SB451-SSA1, s. 119
19Section
119. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).
SB451-SSA1,41,2421
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.
SB451-SSA1,42,4
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.
SB451-SSA1,42,9
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).
SB451-SSA1,42,11
10(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
11applicable to individual standard risks.
SB451-SSA1, s. 124
12Section
124. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
13amended to read:
SB451-SSA1,42,2414
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).
SB451-SSA1, s. 127
2Section
127. 149.143 of the statutes is repealed and recreated to read:
SB451-SSA1,43,8
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:
SB451-SSA1,43,99
(a) Sixty percent from premiums paid by eligible persons.
SB451-SSA1,43,1010
(b) Twenty percent from insurer assessments under s. 149.13.
SB451-SSA1,43,1211
(c) Twenty percent from adjustments to provider payment rates under s.
12149.142.
SB451-SSA1,43,16
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:
SB451-SSA1,43,1717
(a) Fifty percent from insurer assessments under s. 149.13.
SB451-SSA1,43,1818
(b) Fifty percent from adjustments to provider payment rates under s. 149.142.
SB451-SSA1, 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:
SB451-SSA1,44,1223
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.
SB451-SSA1, s. 131
13Section
131. 149.146 (2) (a) of the statutes is renumbered 149.14 (2) (c) 2. and
14amended to read:
SB451-SSA1,44,2015
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.
SB451-SSA1,45,4
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).
SB451-SSA1, s. 137
5Section
137. 149.165 (2) (a) (intro.) of the statutes is amended to read:
SB451-SSA1,45,106
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:
SB451-SSA1,45,2012
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).
SB451-SSA1,45,2422
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).
SB451-SSA1, s. 140
25Section
140. 149.165 (3) (b) (intro.) of the statutes is amended to read:
SB451-SSA1,46,4
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:
SB451-SSA1,46,96
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.
SB451-SSA1,46,1312
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.
SB451-SSA1,46,20
18149.18 Chapters 600 to 645 applicable. Except as otherwise provided in this
19chapter subchapter, the plan shall comply and be administered in compliance with
20chs. 600 to 645.
SB451-SSA1, s. 150
23Section
150. Subchapter III of chapter 149 [precedes 149.40] of the statutes
24is created to read:
SB451-SSA1,47,3
1Subchapter III
2
Health Insurance Risk-Sharing
3
Plan Authority
SB451-SSA1,47,4
4149.40 Definitions. In this subchapter:
SB451-SSA1,47,5
5(1) "Authority" means the Health Insurance Risk-Sharing Plan Authority.
SB451-SSA1,47,6
6(2) "Board" means the board of directors of the authority.
SB451-SSA1,47,12
7149.41 Creation and organization of authority. (1) There is created a
8public body corporate and politic to be known as the "Health Insurance Risk-Sharing
9Plan Authority." The board of directors of the authority shall consist of the
10commissioner of insurance, or his or her designee, as a nonvoting member, and the
11following members, who shall be nominated by the governor, and with the advice and
12consent of the senate appointed, for 3-year terms:
SB451-SSA1,47,1313
(a) Four members who represent insurers participating in the plan.
SB451-SSA1,47,1814
(b) Four members who represent health care providers, including one
15representative of the Wisconsin Medical Society, one representative of the Wisconsin
16Hospital Association, Inc., one representative of the Pharmacy Society of Wisconsin,
17and one representative of health care providers that provide services to persons with
18coverage under the plan.
SB451-SSA1,47,2119
(c) Five other members, at least one of whom represents small businesses that
20purchase private health insurance and at least 2 of whom are persons with coverage
21under the plan.
SB451-SSA1,47,23
22(2) A vacancy on the board shall be filled in the same manner as the original
23appointment to the board for the remainder of the unexpired term, if any.
SB451-SSA1,48,3
1(3) A member of the board may not be compensated for his or her services but
2shall be reimbursed for actual and necessary expenses, including travel expenses,
3incurred in the performance of his or her duties.
SB451-SSA1,48,10
4(4) Annually, the governor shall appoint one member other than the
5commissioner as chairperson, and the members of the board may elect other officers
6as they consider appropriate. Seven voting members of the board constitute a
7quorum for the purpose of conducting the business and exercising the powers of the
8authority, notwithstanding the existence of any vacancy. The board may take action
9upon a vote of a majority of the members present, unless the bylaws of the authority
10require a larger number.
SB451-SSA1,48,22
11(5) The board may appoint an executive director who shall not be a member of
12the board and who shall serve at the pleasure of the board. The authority may
13delegate by resolution to one or more of its members or its executive director any
14powers and duties that it considers proper. The executive director shall receive such
15compensation as may be determined by the board. The executive director or other
16person designated by resolution of the board shall keep a record of the proceedings
17of the authority and shall be custodian of all books, documents, and papers filed with
18the authority, the minute book or journal of the authority, and its official seal. The
19executive director or other person may cause copies to be made of all minutes and
20other records and documents of the authority and may give certificates under the
21official seal of the authority to the effect that such copies are true copies, and all
22persons dealing with the authority may rely upon such certificates.
SB451-SSA1,48,24
23149.43 Duties of authority. In addition to all other duties imposed under this
24chapter, the authority shall do all of the following:
SB451-SSA1,48,25
25(1) Adopt policies for the administration of this chapter.
SB451-SSA1,49,3
1(2) Contract with the plan administrator under s. 149.16, 2003 stats., in the
2manner required under 2005 Wisconsin Act .... (this act), section 165 (1) (b) until the
3end of the contract term.
SB451-SSA1,49,5
4(3) Establish the authority's annual budget and monitor the fiscal
5management of the authority.
SB451-SSA1,49,7
6(4) Beginning on July 1, 2006, do, or contract with another person to do, all of
7the following:
SB451-SSA1,49,98
(a) Perform all eligibility and administrative claims payment functions
9relating to the plan.
SB451-SSA1,49,1210
(b) Establish a premium billing procedure for collection of premiums from
11insured persons. Billings shall be made on a periodic basis as determined by the
12authority.
SB451-SSA1,49,1413
(c) Perform all necessary functions to assure timely payment of benefits to
14covered persons under the plan, including:
SB451-SSA1,49,1715
1. Making available information relating to the proper manner of submitting
16a claim for benefits under the plan and distributing forms upon which submissions
17shall be made.
SB451-SSA1,49,1818
2. Evaluating the eligibility of each claim for payment under the plan.
SB451-SSA1,49,2019
3. Notifying each claimant within 30 days after receiving a properly completed
20and executed proof of loss whether the claim is accepted, rejected, or compromised.
SB451-SSA1,49,22
21(5) Seek to qualify or maintain the plan as a state pharmacy assistance
22program, as defined in
42 CFR 423.464.
SB451-SSA1,49,24
23(6) Annually submit a report to the legislature under s. 13.172 (2) and to the
24governor on the operation of the plan.
SB451-SSA1,50,4
1149.45 Powers of authority. (1) Except as restricted under sub. (2), the
2authority shall have all the powers necessary or convenient to carry out the purposes
3and provisions of this chapter. In addition to all other powers granted by this chapter,
4the authority may:
SB451-SSA1,50,65
(a) Adopt bylaws and policies and procedures for the regulation of its affairs
6and the conduct of its business.
SB451-SSA1,50,87
(b) Have a seal and alter the seal at pleasure; have perpetual existence; and
8maintain an office.
SB451-SSA1,50,99
(c) Hire employees, define their duties, and fix their rate of compensation.
SB451-SSA1,50,1010
(d) Incur debt, except as restricted under sub. (2).
SB451-SSA1,50,1211
(e) Contract for any professional services required for the authority, subject to
12ss. 149.43 (2) and 149.47.
SB451-SSA1,50,1613
(f) Appoint any technical or professional advisory committee that the authority
14finds necessary to assist the authority in exercising its duties and powers. The
15authority shall define the duties of the committee, and provide reimbursement for
16the expenses of the committee.
