AB844-ASA1, s. 96
1Section
96. 149.14 (3) (b) of the statutes is repealed and recreated to read:
AB844-ASA1,38,32
149.14
(3) (b) Professional services for the diagnosis or treatment of injuries,
3illnesses, or conditions, other than mental or dental.
AB844-ASA1, s. 97
4Section
97. 149.14 (3) (c) 1. of the statutes is repealed and recreated to read:
AB844-ASA1,38,85
149.14
(3) (c) 1. Inpatient hospital services, as defined in s. 632.89 (1) (d),
6outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment
7arrangements, as defined in s. 632.89 (1) (f), only to the extent required under s.
8632.89.
AB844-ASA1, s. 99
10Section
99
. 149.14 (3) (c) 3. of the statutes is amended to read:
AB844-ASA1,38,1411
149.14
(3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated
12by the department
of health and family services under s. 149.14 (3) (c) 3., 2003 stats.,
13services for the chronically mentally ill in community support programs operated
14under s. 51.421.
AB844-ASA1, s. 100
15Section
100
. 149.14 (3) (c) 3. of the statutes, as affected by 2005 Wisconsin Act
16.... (this act), is amended to read:
AB844-ASA1,38,2017
149.14
(3) (c) 3. Subject to the limits under subd.
2. and to rules promulgated
18by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats. 191., services for the chronically mentally ill in community support programs operated
20under s. 51.421.
AB844-ASA1,38,2222
149.14
(3) (d) Drugs requiring a physician's prescription
, subject to sub. (4c).
AB844-ASA1,39,524
149.14
(3) (e)
Services For persons eligible for Medicare, services of a licensed
25skilled nursing facility
for eligible persons eligible for medicare, to the extent
1required by s. 632.895 (3) and for not more than an aggregate 120 days during a
2calendar year, if the services are of the type
which
that would qualify as reimbursable
3services under
medicare Medicare. Coverage under this paragraph
which that is not
4required by s. 632.895 (3) is subject to
the any deductible and coinsurance
5requirements
under sub. (5) provided by the authority.
AB844-ASA1,39,87
149.14
(3) (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only
8to the extent required under s. 632.895 (2).
AB844-ASA1,39,1210
149.14
(3) (m) Oral surgery for
excision of partially or completely unerupted,
11impacted teeth and oral surgery with respect to
the gums and other tissues of the
12mouth when not performed in connection with the extraction or repair of teeth.
AB844-ASA1,39,1614
149.14
(3) (o)
Transportation Emergency and other medically necessary
15transportation provided by a licensed ambulance service to the nearest facility
16qualified to treat
the a covered condition.
AB844-ASA1, s. 106
17Section
106. 149.14 (3) (p) of the statutes is renumbered 149.14 (3) (em).
AB844-ASA1, s. 107
18Section
107. 149.14 (4) of the statutes, as affected by 2005 Wisconsin Act ....
19(this act), is repealed and recreated to read:
AB844-ASA1,40,320
149.14
(4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority
21shall establish the plan design, after taking into consideration the levels of health
22insurance coverage provided in the state and medical economic factors, as
23appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit
24levels, deductibles, copayment and coinsurance requirements, exclusions, and
25limitations under the plan that the authority determines generally reflect and are
1commensurate with comprehensive health insurance coverage offered in the private
2individual market in the state. The authority may develop additional benefit designs
3that are responsive to market conditions.
AB844-ASA1,40,85
149.14
(4) (d) That part of any charge for services or articles rendered or
6prescribed by a physician, dentist
, or other health care personnel that exceeds the
7payment rate established by the
department authority under s. 149.142
and reduced
8under ss. 149.143 and 149.144 or any charge not medically necessary.
AB844-ASA1,40,1110
149.14
(4) (m) Experimental treatment, as determined by the
department 11authority.
AB844-ASA1, s. 111
13Section
111. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and
14amended to read:
AB844-ASA1,40,2015
149.142
(2m) Payment is payment in full. Except for copayments, coinsurance
, 16or deductibles required or authorized under the plan, a provider of a covered service
17or article shall accept as payment in full for the covered service or article the payment
18rate determined under
ss. 149.142, 149.143 and 149.144
sub. (1) and may not bill an
19eligible person who receives the service or article for any amount by which the charge
20for the service or article is reduced under
s. 149.142, 149.143 or 149.144 sub. (1).
AB844-ASA1, s. 112
21Section
112. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act ....
22(this act), is repealed and recreated to read:
AB844-ASA1,40,2523
149.14
(5) Deductible and copayment subsidies. (a) The authority shall
24establish and provide subsidies for deductibles paid by eligible persons with coverage
25under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.
AB844-ASA1,41,2
1(b) The authority may provide subsidies for prescription drug copayment
2amounts paid by eligible persons specified in par. (a).
AB844-ASA1,41,74
149.14
(5) (b) Except as provided in
pars. (c) and (e) par. (c), if the covered costs
5incurred by the eligible person exceed the deductible for major medical expense
6coverage in a calendar year, the plan shall pay at least 80% of any additional covered
7costs incurred by the person during the calendar year.
AB844-ASA1,41,149
149.14
(5) (c)
Except as provided in par. (e), if If the aggregate of the covered
10costs not paid by the plan under par. (b) and the deductible exceeds $500 for an
11eligible person receiving medicare, $2,000 for any other eligible person during a
12calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100%
13of all covered costs incurred by the eligible person during the calendar year after the
14payment ceilings under this paragraph are exceeded.
AB844-ASA1, s. 119
19Section
119. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).
AB844-ASA1,41,2421
149.14
(7) (b) The
department authority has a cause of action against an
22eligible participant for the recovery of the amount of benefits paid
which that are not
23for covered expenses under the plan. Benefits under the plan may be reduced or
24refused as a setoff against any amount recoverable under this paragraph.
AB844-ASA1,42,4
1149.14
(7) (c) The
department
authority is subrogated to the rights of an
2eligible person to recover special damages for illness or injury to the person caused
3by the act of a 3rd person to the extent that benefits are provided under the plan.
4Section 814.03 (3) applies to the department under this paragraph.
AB844-ASA1,42,9
7149.141 Premiums. (1)
Percentage of costs. Except as provided in sub. (2),
8the authority shall set premium rates for coverage under the plan at a level that is
9sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).
AB844-ASA1,42,11
10(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
11applicable to individual standard risks.
AB844-ASA1, s. 124
12Section
124. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
13amended to read:
AB844-ASA1,42,2414
149.142
(1) Establishment of rates.
Except as provided in par. (b), the
15department The authority shall establish
provider payment rates for covered
16expenses that consist of the allowable charges paid under s. 49.46 (2) for the services
17and articles provided plus an enhancement determined by the
department authority.
18The rates shall be based on the allowable charges paid under s. 49.46 (2), projected
19plan costs
, and trend factors. Using the same methodology that applies to medical
20assistance under subch. IV of ch. 49, the
department
authority shall establish
21hospital outpatient per visit reimbursement rates and hospital inpatient
22reimbursement rates that are specific to diagnostically related groups of eligible
23persons.
The adjustments to the usual and customary rates shall be sufficient to
24cover 20 percent of plan costs, as provided in s. 149.143 (3).
AB844-ASA1, s. 127
2Section
127. 149.143 of the statutes is repealed and recreated to read:
AB844-ASA1,43,8
3149.143 Payment of plan costs. (1) Costs excluding subsidies. The
4authority shall pay plan costs, excluding any premium, deductible, and copayment
5subsidies, first from federal funds, if any, that are transferred to the fund under s.
620.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in
7a policy year. The remainder of the plan costs, excluding premium, deductible, and
8copayment subsidy costs, shall be paid as follows:
AB844-ASA1,43,99
(a) Sixty percent from premiums paid by eligible persons.
AB844-ASA1,43,1010
(b) Twenty percent from insurer assessments under s. 149.13.
AB844-ASA1,43,1211
(c) Twenty percent from adjustments to provider payment rates under s.
12149.142.
AB844-ASA1,43,16
13(2) Subsidy costs. The authority shall pay for premium, deductible, and
14copayment subsidies in a policy year first from federal funds, if any, that are
15transferred to the fund under s. 20.145 (5) (m) in that year. The remainder of the
16subsidy costs shall be paid as follows:
AB844-ASA1,43,1717
(a) Fifty percent from insurer assessments under s. 149.13.
AB844-ASA1,43,1818
(b) Fifty percent from adjustments to provider payment rates under s. 149.142.
AB844-ASA1, s. 130
21Section
130. 149.146 (1) (a) and (b) of the statutes are consolidated,
22renumbered 149.14 (2) (c) 1. and amended to read:
AB844-ASA1,44,1223
149.14
(2) (c) 1.
Beginning on January 1, 1998, in In addition to the coverage
24required under
s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons
25who are not eligible for
medicare Medicare a choice of coverage, as described in
1section 2744 (a) (1) (
C), P.L.
104-191. Any such choice of coverage shall be major
2medical expense coverage.
(b) An eligible person
under par. (a) who is not eligible
3for Medicare may elect once each year, at the time and according to procedures
4established by the
department authority, among the coverages offered under this
5section and s. 149.14 paragraph and par. (a). If an eligible person elects new
6coverage, any preexisting condition exclusion imposed under the new coverage is met
7to the extent that the eligible person has been previously and continuously covered
8under
this chapter the plan. No preexisting condition exclusion may be imposed on
9an eligible person who elects new coverage if the person was an eligible individual
10when first covered under
this chapter the plan and the person remained
11continuously covered under
this chapter the plan up to the time of electing the new
12coverage.
AB844-ASA1, s. 131
13Section
131. 149.146 (2) (a) of the statutes is renumbered 149.14 (2) (c) 2. and
14amended to read:
AB844-ASA1,44,2015
149.14
(2) (c) 2.
Except as specified by the department, the terms of coverage
16under s. 149.14, including deductible reductions under s. 149.14 (5) (a) and
17prescription drug copayment reductions under s. 149.14 (5) (e), do not apply to the
18coverage offered under this section. Premium reductions under s. 149.165
and
19deductible subsidies and prescription drug copayment subsidies under s. 149.14 (5) 20do not apply to the coverage offered under this
section paragraph.
AB844-ASA1,45,4
1149.165
(1) Except as provided in s. 149.146 (2) (a), the department The
2authority shall reduce the premiums established under
s. 149.11 in conformity with
3ss. 149.14 (5m), 149.143 and 149.17 s. 149.141 for the eligible persons and in the
4manner set forth in subs. (2) and (3).
AB844-ASA1, s. 137
5Section
137. 149.165 (2) (a) (intro.) of the statutes is amended to read:
AB844-ASA1,45,106
149.165
(2) (a) (intro.) Subject to sub. (3m), if the household income, as defined
7in s. 71.52 (5) and as determined under sub. (3), of an eligible person with coverage
8under s. 149.14 (2) (a) is equal to or greater than the first amount and less than the
92nd amount listed in any of the following, the
department authority shall reduce the
10premium for the eligible person to the rate shown after the amounts:
AB844-ASA1,45,2012
149.165
(2) (bc) Subject to sub. (3m), if the household income, as defined in s.
1371.52 (5) and as determined under sub. (3), of an eligible person with coverage under
14s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd
15amount listed in par. (a) 1., 2., 3., 4.
, or 5., the
department authority shall reduce the
16premium established for the eligible person by the same percentage as the
17department authority reduces, under par. (a), the premium established for an
18eligible person with coverage under s. 149.14 (2) (a) who has a household income
19specified in the same subdivision under par. (a) as the household income of the
20eligible person with coverage under s. 149.14 (2) (b).
AB844-ASA1,45,2422
149.165
(3) (a) Subject to par. (b), the
department authority shall establish and
23implement the method for determining the household income of an eligible person
24under sub. (2).
AB844-ASA1, s. 140
25Section
140. 149.165 (3) (b) (intro.) of the statutes is amended to read:
AB844-ASA1,46,4
1149.165
(3) (b) (intro.) In determining household income under sub. (2), the
2department authority shall consider information submitted by an eligible person on
3a completed federal profit or loss from farming form, schedule F, if all of the following
4apply:
AB844-ASA1,46,96
149.165
(3m) The
board authority may approve adjustment of the household
7income dollar amounts listed in sub. (2) (a) 1. to 5., except for the first dollar amount
8listed in sub. (2) (a) 1., to reflect changes in the consumer price index for all urban
9consumers, U.S. city average, as determined by the U.S. department of labor.
AB844-ASA1,46,1312
149.17
(1) Subject to
ss. 149.14 (5m),
s. 149.143
and 149.146 (2) (b), a rating
13plan calculated in accordance with generally accepted actuarial principles.
