Amendment ASA1-AB100

AB100-ASA1,805,17 149.12 (3) (a) Except as provided in pars. (b) to (c) and (bm), no person is eligible for coverage under the plan for whom a premium, deductible, or coinsurance amount is paid or reimbursed by a federal, state, county, or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.

AB100-ASA1, s. 2041c Section 2041c. 149.12 (3) (c) of the statutes is repealed.

AB100-ASA1, s. 2041m Section 2041m. 149.12 (4) and (5) of the statutes are created to read:

AB100-ASA1,805,24 149.12 (4) Subject to subs. (1m), (2), and (3), the board may establish criteria that would enable additional persons to be eligible for coverage under the plan. The board shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.

AB100-ASA1,806,2 (5) The board shall establish policies for determining and verifying the continued eligibility of an eligible person.

AB100-ASA1, s. 2042c Section 2042c. 149.13 (1) of the statutes is amended to read:

AB100-ASA1,806,8 149.13 (1) Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department board of the insurers participating in the cost of administering the plan.

AB100-ASA1, s. 2042m Section 2042m. 149.13 (3) (a) of the statutes is amended to read:

AB100-ASA1,806,14 149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the department under s. 149.143 (2) (a) 3. board.

AB100-ASA1, s. 2043c Section 2043c. 149.13 (3) (b) of the statutes is amended to read:

AB100-ASA1,806,22 149.13 (3) (b) If the department board or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600 to 646 and 655 is not adequate to permit the department, the commissioner or the board to carry out the department's, commissioner's or board's responsibilities under this chapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and board to make the determinations required under this chapter.

AB100-ASA1, s. 2043m Section 2043m. 149.13 (4) of the statutes is amended to read:

AB100-ASA1,807,2 149.13 (4) Notwithstanding subs. (1) to (3), the department board, with the agreement of the commissioner, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan.

AB100-ASA1, s. 2044c Section 2044c. 149.14 (1) (a) of the statutes is amended to read:

AB100-ASA1,807,7 149.14 (1) (a) The plan shall offer coverage for each eligible person in an annually renewable policy the coverage specified in this section for each eligible person. If an eligible person is also eligible for medicare Medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by medicare Medicare.

AB100-ASA1, s. 2044m Section 2044m. 149.14 (2) (a) of the statutes is amended to read:

AB100-ASA1,807,15 149.14 (2) (a) The plan shall provide every eligible person who is not eligible for medicare Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to sub. (3) and deductible, copayment, and coinsurance payments authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.

AB100-ASA1, s. 2045c Section 2045c. 149.14 (3) (intro.) of the statutes is renumbered 149.14 (3) and amended to read:

AB100-ASA1,808,5 149.14 (3) Covered expenses. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department under ss. 149.143 and 149.144, covered Covered expenses for the coverage under this section the plan shall be the payment rates established by the department under s. 149.142 board for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department under ss. 149.143 and 149.144, covered Covered expenses for the coverage under this section the plan shall also be the payment rates established by the department under s. 149.142 board for the following services and articles if the service or article is prescribed by a physician who is licensed under ch. 448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45 (2) (a) 11.:

AB100-ASA1, s. 2045m Section 2045m. 149.14 (3) (a) to (r) of the statutes are repealed.

AB100-ASA1, s. 2046c Section 2046c. 149.14 (4) of the statutes is repealed and recreated to read:

AB100-ASA1,808,13 149.14 (4) Benefit design. Except as provided in subs. (2) (a) and (6), the board shall determine the benefit design of the plan, including the covered expenses, expenses excluded from coverage, deductibles, copayments, coinsurance, out-of-pocket limits, and coverage limitations. The board may establish more than one benefit design under the plan. All benefit designs shall be comparable to typical individual health insurance policies offered in the private sector market in this state.

AB100-ASA1, s. 2046m Section 2046m. 149.14 (4c) of the statutes is repealed.

AB100-ASA1, s. 2047c Section 2047c. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and amended to read:

AB100-ASA1,808,22 149.142 (2m) Payment is payment in full. Except for copayments, coinsurance, or deductibles required or authorized under the plan, a provider of a covered service or article shall accept as payment in full for the covered service or article the payment rate determined under ss. 149.142, 149.143 and 149.144 sub. (1) and may not bill an eligible person who receives the service or article for any amount by which the charge for the service or article is reduced under s. 149.142, 149.143 or 149.144 sub. (1).

AB100-ASA1, s. 2047m Section 2047m. 149.14 (5) of the statutes is repealed.

AB100-ASA1, s. 2048c Section 2048c. 149.14 (5m) of the statutes is repealed.

AB100-ASA1, s. 2048m Section 2048m. 149.14 (6) (a) of the statutes is repealed.

AB100-ASA1, s. 2049c Section 2049c. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).

AB100-ASA1, s. 2049m Section 2049m. 149.14 (7) (b) of the statutes is amended to read:

AB100-ASA1,809,6 149.14 (7) (b) The department organization has a cause of action against an eligible participant for the recovery of the amount of benefits paid which are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.

AB100-ASA1, s. 2050c Section 2050c. 149.14 (7) (c) of the statutes is amended to read:

AB100-ASA1,809,11 149.14 (7) (c) The department organization is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan. Section 814.03 (3) applies to the department organization under this paragraph.

AB100-ASA1, s. 2050m Section 2050m. 149.14 (8) of the statutes is repealed and recreated to read:

AB100-ASA1,809,15 149.14 (8) Subsidies. The board shall provide for subsidies for premiums, deductibles, and copayments for eligible persons with household incomes below a level established by the board.

AB100-ASA1, s. 2051c Section 2051c. 149.141 of the statutes is created to read:

AB100-ASA1,809,19 149.141 Premiums. The board shall set premiums for coverage under the plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).

AB100-ASA1, s. 2051m Section 2051m. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and amended to read:

AB100-ASA1,810,7 149.142 (1) Establishment of rates. Except as provided in par. (b), the department The board shall establish provider payment rates for covered expenses that consist of the allowable charges paid under s. 49.46 (2) for the services and articles provided plus an enhancement determined by the department board. The rates shall be based on the allowable charges paid under s. 49.46 (2), projected plan costs, and trend factors. Using the same methodology that applies to medical assistance under subch. IV of ch. 49, the department board shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons. The adjustments to the usual and customary rates shall be sufficient to cover 20 percent of plan costs, as provided in s. 149.143 (3).

AB100-ASA1, s. 2052c Section 2052c. 149.142 (1) (b) of the statutes is repealed.

AB100-ASA1, s. 2052m Section 2052m. 149.142 (2) of the statutes is repealed.

AB100-ASA1, s. 2053c Section 2053c. 149.143 of the statutes is repealed and recreated to read:

AB100-ASA1,810,12 149.143 Payment of plan costs. The board shall pay plan costs, including any premium, deductible, and copayment subsidies, as follows:

AB100-ASA1,810,13 (1) Sixty percent from premiums paid by eligible persons.

AB100-ASA1,810,14 (2) Twenty percent from insurer assessments under s. 149.13.

AB100-ASA1,810,16 (3) Twenty percent from adjustments to provider payment rates under s. 149.142.

AB100-ASA1, s. 2053m Section 2053m. 149.144 of the statutes is repealed.

AB100-ASA1, s. 2054c Section 2054c. 149.145 of the statutes is repealed.

AB100-ASA1, s. 2054m Section 2054m. 149.146 (1) (a) and (b) of the statutes are consolidated, renumbered 149.14 (2) (c) and amended to read:

AB100-ASA1,811,9 149.14 (2) (c) Beginning on January 1, 1998, in In addition to the coverage required under s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons who are not eligible for medicare Medicare a choice of coverage, as described in section 2744 (a) (1) (C), P.L. 104-191. Any such choice of coverage shall be major medical expense coverage. (b) An eligible person under par. (a) who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the department board, among the coverages offered under this section and s. 149.14. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under this chapter. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under this chapter and the person remained continuously covered under this chapter up to the time of electing the new coverage paragraph and par. (a).

AB100-ASA1, s. 2055c Section 2055c. 149.146 (2) of the statutes is repealed.

AB100-ASA1, s. 2055m Section 2055m. 149.15 of the statutes is repealed.

AB100-ASA1, s. 2056c Section 2056c. 149.155 of the statutes is created to read:

AB100-ASA1,811,13 149.155 Additional duties of board. The board shall do all of the following:

AB100-ASA1,811,15 (1) Adopt policies for the administration of this chapter, including delegation of any part of its powers and its own procedures.

AB100-ASA1,811,17 (5) Seek to qualify the plan as a state pharmacy assistance program, as defined in 42 CFR 423.464.

AB100-ASA1,811,19 (6) Annually submit a report to the legislature under s. 13.172 (2) and to the governor on the operation of the plan.

AB100-ASA1, s. 2056m Section 2056m. 149.16 (title) of the statutes is repealed.

AB100-ASA1, s. 2057c Section 2057c. 149.16 (1m) of the statutes is repealed.

AB100-ASA1, s. 2057m Section 2057m. 149.16 (3) (a) of the statutes is renumbered 149.155 (2) and amended to read:

AB100-ASA1,811,25 149.155 (2) The plan administrator shall perform Perform all eligibility and administrative claims payment functions relating to the plan.

AB100-ASA1, s. 2058c Section 2058c. 149.16 (3) (b) of the statutes is renumbered 149.155 (3) and amended to read:

AB100-ASA1,812,5 149.155 (3) The plan administrator shall establish Establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the department board.

AB100-ASA1, s. 2058m Section 2058m. 149.16 (3) (c) of the statutes is renumbered 149.155 (4), and 149.155 (4) (intro.), as renumbered, is amended to read:

AB100-ASA1,812,10 149.155 (4) (intro.) The plan administrator shall perform Perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:

AB100-ASA1, s. 2059c Section 2059c. 149.16 (3) (e) of the statutes is repealed.

AB100-ASA1, s. 2059m Section 2059m. 149.16 (4) of the statutes is repealed.

AB100-ASA1, s. 2060c Section 2060c. 149.16 (5) of the statutes is repealed.

AB100-ASA1, s. 2060m Section 2060m. 149.165 of the statutes is repealed.

AB100-ASA1, s. 2061c Section 2061c. 149.17 (1) of the statutes is amended to read:

AB100-ASA1,812,17 149.17 (1) Subject to ss. 149.14 (5m), s. 149.143 and 149.146 (2) (b), a rating plan calculated in accordance with generally accepted actuarial principles.

AB100-ASA1, s. 2061m Section 2061m. 149.17 (2) of the statutes is repealed.

AB100-ASA1, s. 2062c Section 2062c. 149.17 (4) of the statutes is repealed.

AB100-ASA1, s. 2062m Section 2062m. 149.175 of the statutes is repealed.

AB100-ASA1, s. 2063c Section 2063c. 149.20 of the statutes is repealed.

AB100-ASA1, s. 2065 Section 2065. 149.25 of the statutes is repealed.

AB100-ASA1, s. 2067 Section 2067. 153.05 (6m) of the statutes is amended to read:

AB100-ASA1,813,4 153.05 (6m) The department may contract with the group insurance board for the provision of data collection and analysis services related to health maintenance organizations and insurance companies that provide health insurance for state employees. The department shall establish contract fees for the provision of the services. All moneys collected under this subsection shall be credited to the appropriation under s. 20.435 (4) (1) (hg).

AB100-ASA1, s. 2067g Section 2067g. 153.05 (14) of the statutes is created to read:

AB100-ASA1,813,8 153.05 (14) With respect to health care information required to be collected under this section from health care providers that are not hospitals or ambulatory surgery centers, the department shall do all of the following:

AB100-ASA1,813,11 (a) Develop procedures to ensure that data are submitted consistently and accurately, including clarifying the place-of-service codes and types of ancillary services that are required to be reported.

AB100-ASA1,813,13 (b) Work directly with individual physician practice groups to identify and correct data submission errors.

AB100-ASA1,813,15 (c) Develop and publish standard reports under s. 153.45 (1) (a) that are understandable by individuals other than medical professionals.

AB100-ASA1,813,16 (d) Make program data available in a timely fashion.

AB100-ASA1,813,19 (e) Enter into a memorandum of understanding with the department of regulation and licensing to improve the timeliness of updating physician information and to improve the assessment process under s. 153.60 (1).

AB100-ASA1, s. 2074 Section 2074. 153.60 (1) of the statutes is amended to read:

AB100-ASA1,814,17 153.60 (1) The department shall, by the first October 1 after the commencement of each fiscal year, estimate the total amount of expenditures under this chapter for the department and the board for that fiscal year for data collection, database development and maintenance, generation of data files and standard reports, orientation and training provided under s. 153.05 (9) (a) and maintaining the board. The department shall assess the estimated total amount for that fiscal year, less the estimated total amount to be received for purposes of administration of this chapter under s. 20.435 (4) (1) (hi) during the fiscal year, and the unencumbered balance of the amount received for purposes of administration of this chapter under s. 20.435 (4) (1) (hi) from the prior fiscal year and the amount in the appropriation account under s. 20.435 (1) (dg), 1997 stats., for the fiscal year, to health care providers, other than hospitals and ambulatory surgery centers, who are in a class of health care providers from whom the department collects data under this chapter in a manner specified by the department by rule. The department shall obtain approval from the board for the amounts of assessments for health care providers other than hospitals and ambulatory surgery centers. The department shall work together with the department of regulation and licensing to develop a mechanism for collecting assessments from health care providers other than hospitals and ambulatory surgery centers. No health care provider that is not a facility may be assessed under this subsection an amount that exceeds $75 per fiscal year. All payments of assessments shall be credited to the appropriation under s. 20.435 (4) (1) (hg).

AB100-ASA1, s. 2075 Section 2075. 153.60 (3) of the statutes is amended to read:

AB100-ASA1,815,4 153.60 (3) The department shall, by the first October 1 after the commencement of each fiscal year, estimate the total amount of expenditures required for the collection, database development and maintenance and generation of public data files and standard reports for health care plans that voluntarily agree to supply health care data under s. 153.05 (6r). The department shall assess the estimated total amount for that fiscal year to health care plans in a manner specified by the department by rule and may enter into an agreement with the office of the commissioner of insurance for collection of the assessments. Each health plan that voluntarily agrees to supply this information shall pay the assessments on or before December 1. All payments of assessments shall be deposited in the appropriation under s. 20.435 (4) (1) (hg) and may be used solely for the purposes of s. 153.05 (6r).