SB451-SSA2,36,1712 149.13 (4) Notwithstanding subs. (1) to (3), the department, with the
13agreement of the commissioner, may perform various administrative functions
14related to the assessment of insurers participating in the cost of administering the
15plan. Neither the commissioner nor the department may assess any type of
16insurance that was not being assessed as of December 1, 2005, or any type of insurer
17that was not being assessed as December 1, 2005.
SB451-SSA2, s. 92 18Section 92 . 149.13 (4) of the statutes, as affected by 2005 Wisconsin Act ....
19(this act), is amended to read:
SB451-SSA2,36,2520 149.13 (4) Notwithstanding subs. (1) to (3), the department authority, with the
21agreement of the commissioner, may perform various administrative functions
22related to the assessment of insurers participating in the cost of administering the
23plan. Neither the commissioner nor the department authority may assess any type
24of insurance that was not being assessed as of December 1, 2005, or any type of
25insurer that was not being assessed as December 1, 2005.
SB451-SSA2, s. 93
1Section 93. 149.14 (1) (a) of the statutes is amended to read:
SB451-SSA2,37,82 149.14 (1) (a) The plan shall offer coverage for each eligible person in an
3annually renewable policy the coverage specified in this section for each eligible
4person
. If an eligible person is also eligible for medicare Medicare coverage, the plan
5shall not pay or reimburse any person for expenses paid for by medicare Medicare.
6If an eligible person is eligible for a type of medical assistance specified in s. 149.12
7(2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by
8Medical Assistance
.
SB451-SSA2, s. 94 9Section 94. 149.14 (2) (a) of the statutes is amended to read:
SB451-SSA2,37,1610 149.14 (2) (a) The plan shall provide every eligible person who is not eligible
11for medicare Medicare with major medical expense coverage. Major medical expense
12coverage offered under the plan under this section shall pay an eligible person's
13covered expenses, subject to sub. (3) and deductible, copayment, and coinsurance
14payments authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered
15individual. The maximum limit under this paragraph shall not be altered by the
16board, and no actuarially equivalent benefit may be substituted by the board.
SB451-SSA2, s. 95 17Section 95. 149.14 (3) (intro.) of the statutes is amended to read:
SB451-SSA2,38,618 149.14 (3) Covered expenses. (intro.) Except as provided in sub. (4), except
19as restricted by cost containment provisions under s. 149.17 (4) and except as
20reduced by the department under ss. 149.143 and 149.144, covered
Covered expenses
21for the coverage under this section the plan shall be the payment rates established
22by the department under s. 149.142 authority for the services provided by persons
23licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in
24sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and
25except as reduced by the department under ss. 149.143 and 149.144, covered
Covered

1expenses for the coverage under this section the plan shall also be the payment rates
2established by the department under s. 149.142 authority for, at a minimum, the
3following services and articles if the service or article is prescribed by a physician
4who is licensed under ch. 448 or in another state and who is certified under s. 49.45
5(2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45
6(2) (a) 11.:
SB451-SSA2, s. 96 7Section 96. 149.14 (3) (b) of the statutes is repealed and recreated to read:
SB451-SSA2,38,98 149.14 (3) (b) Professional services for the diagnosis or treatment of injuries,
9illnesses, or conditions, other than mental or dental.
SB451-SSA2, s. 97 10Section 97. 149.14 (3) (c) 1. of the statutes is repealed and recreated to read:
SB451-SSA2,38,1411 149.14 (3) (c) 1. Inpatient hospital services, as defined in s. 632.89 (1) (d),
12outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment
13arrangements, as defined in s. 632.89 (1) (f), at least to the extent required under s.
14632.89.
SB451-SSA2, s. 98 15Section 98. 149.14 (3) (c) 2. of the statutes is repealed.
SB451-SSA2, s. 99 16Section 99 . 149.14 (3) (c) 3. of the statutes is amended to read:
SB451-SSA2,38,2017 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.,
19services for the chronically mentally ill in community support programs operated
20under s. 51.421.
SB451-SSA2, s. 100 21Section 100 . 149.14 (3) (c) 3. of the statutes, as affected by 2005 Wisconsin Act
22.... (this act), is amended to read:
SB451-SSA2,39,223 149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated
24by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats.


11., services for the chronically mentally ill in community support programs operated
2under s. 51.421.
SB451-SSA2, s. 101 3Section 101. 149.14 (3) (d) of the statutes is amended to read:
SB451-SSA2,39,44 149.14 (3) (d) Drugs requiring a physician's prescription, subject to sub. (4c).
SB451-SSA2, s. 102 5Section 102. 149.14 (3) (e) of the statutes is amended to read:
SB451-SSA2,39,126 149.14 (3) (e) Services For persons eligible for Medicare, services of a licensed
7skilled nursing facility for eligible persons eligible for medicare, to the extent
8required by s. 632.895 (3) and for not more than an aggregate 120 days during a
9calendar year, if the services are of the type which that would qualify as reimbursable
10services under medicare Medicare. Coverage under this paragraph which that is not
11required by s. 632.895 (3) is subject to the any deductible and coinsurance
12requirements under sub. (5) provided by the authority.
SB451-SSA2, s. 103 13Section 103. 149.14 (3) (f) of the statutes is created to read:
SB451-SSA2,39,1514 149.14 (3) (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only
15to the extent required under s. 632.895 (2).
SB451-SSA2, s. 104 16Section 104. 149.14 (3) (m) of the statutes is amended to read:
SB451-SSA2,39,1917 149.14 (3) (m) Oral surgery for excision of partially or completely unerupted,
18impacted teeth and oral surgery with respect to the gums and other tissues of the
19mouth when not performed in connection with the extraction or repair of teeth.
SB451-SSA2, s. 105 20Section 105. 149.14 (3) (o) of the statutes is amended to read:
SB451-SSA2,39,2321 149.14 (3) (o) Transportation Emergency and other medically necessary
22transportation
provided by a licensed ambulance service to the nearest facility
23qualified to treat the a covered condition.
SB451-SSA2, s. 106 24Section 106. 149.14 (3) (p) of the statutes is renumbered 149.14 (3) (em).
SB451-SSA2, s. 107
1Section 107. 149.14 (4) of the statutes, as affected by 2005 Wisconsin Act ....
2(this act), is repealed and recreated to read:
SB451-SSA2,40,113 149.14 (4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority
4shall establish the plan design, after taking into consideration the levels of health
5insurance coverage provided in the state and medical economic factors, as
6appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit
7levels, deductibles, copayment and coinsurance requirements, exclusions, and
8limitations under the plan that the authority determines generally reflect and are
9commensurate with comprehensive health insurance coverage offered in the private
10individual market in the state. The authority may develop additional benefit designs
11that are responsive to market conditions.
SB451-SSA2, s. 108 12Section 108. 149.14 (4) (d) of the statutes is amended to read:
SB451-SSA2,40,1613 149.14 (4) (d) That part of any charge for services or articles rendered or
14prescribed by a physician, dentist, or other health care personnel that exceeds the
15payment rate established by the department authority under s. 149.142 and reduced
16under ss. 149.143 and 149.144
or any charge not medically necessary.
SB451-SSA2, s. 109 17Section 109. 149.14 (4) (m) of the statutes is amended to read:
SB451-SSA2,40,1918 149.14 (4) (m) Experimental treatment, as determined by the department
19authority.
SB451-SSA2, s. 110 20Section 110. 149.14 (4c) of the statutes is repealed.
SB451-SSA2, s. 111 21Section 111. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and
22amended to read:
SB451-SSA2,41,323 149.142 (2m) Payment is payment in full. Except for copayments, coinsurance,
24or deductibles required or authorized under the plan, a provider of a covered service
25or article shall accept as payment in full for the covered service or article the payment

1rate determined under ss. 149.142, 149.143 and 149.144 sub. (1) and may not bill an
2eligible person who receives the service or article for any amount by which the charge
3for the service or article is reduced under s. 149.142, 149.143 or 149.144 sub. (1).
SB451-SSA2, s. 112 4Section 112. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act ....
5(this act), is repealed and recreated to read:
SB451-SSA2,41,86 149.14 (5) Deductible and copayment subsidies. (a) The authority shall
7establish and provide subsidies for deductibles paid by eligible persons with coverage
8under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.
SB451-SSA2,41,109 (b) The authority may provide subsidies for prescription drug copayment
10amounts paid by eligible persons specified in par. (a).
SB451-SSA2, s. 113 11Section 113. 149.14 (5) (b) of the statutes is amended to read:
SB451-SSA2,41,1512 149.14 (5) (b) Except as provided in pars. (c) and (e) par. (c), if the covered costs
13incurred by the eligible person exceed the deductible for major medical expense
14coverage in a calendar year, the plan shall pay at least 80% of any additional covered
15costs incurred by the person during the calendar year.
SB451-SSA2, s. 114 16Section 114. 149.14 (5) (c) of the statutes is amended to read:
SB451-SSA2,41,2217 149.14 (5) (c) Except as provided in par. (e), if If the aggregate of the covered
18costs not paid by the plan under par. (b) and the deductible exceeds $500 for an
19eligible person receiving medicare, $2,000 for any other eligible person during a
20calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100%
21of all covered costs incurred by the eligible person during the calendar year after the
22payment ceilings under this paragraph are exceeded.
SB451-SSA2, s. 115 23Section 115. 149.14 (5) (d) of the statutes is repealed.
SB451-SSA2, s. 116 24Section 116. 149.14 (5) (e) of the statutes is repealed.
SB451-SSA2, s. 117 25Section 117. 149.14 (5m) of the statutes is repealed.
SB451-SSA2, s. 118
1Section 118. 149.14 (6) (a) of the statutes is repealed.
SB451-SSA2, s. 119 2Section 119. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).
SB451-SSA2, s. 120 3Section 120. 149.14 (7) (b) of the statutes is amended to read:
SB451-SSA2,42,74 149.14 (7) (b) The department authority has a cause of action against an
5eligible participant for the recovery of the amount of benefits paid which that are not
6for covered expenses under the plan. Benefits under the plan may be reduced or
7refused as a setoff against any amount recoverable under this paragraph.
SB451-SSA2, s. 121 8Section 121. 149.14 (7) (c) of the statutes is amended to read:
SB451-SSA2,42,129 149.14 (7) (c) The department authority is subrogated to the rights of an
10eligible person to recover special damages for illness or injury to the person caused
11by the act of a 3rd person to the extent that benefits are provided under the plan.
12Section 814.03 (3) applies to the department under this paragraph.
SB451-SSA2, s. 122 13Section 122. 149.14 (8) of the statutes is repealed.
SB451-SSA2, s. 123 14Section 123. 149.141 of the statutes is created to read:
SB451-SSA2,42,17 15149.141 Premiums. (1) Percentage of costs. Except as provided in sub. (2),
16the authority shall set premium rates for coverage under the plan at a level that is
17sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).
SB451-SSA2,42,19 18(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
19applicable to individual standard risks.
SB451-SSA2, s. 124 20Section 124. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
21amended to read:
SB451-SSA2,43,722 149.142 (1) Establishment of rates. Except as provided in par. (b), the
23department
The authority shall establish provider payment rates for covered
24expenses that consist of the allowable charges paid under s. 49.46 (2) for the services
25and articles provided plus an enhancement determined by the department authority.

1The rates shall be based on the allowable charges paid under s. 49.46 (2), projected
2plan costs, and trend factors. Using the same methodology that applies to medical
3assistance under subch. IV of ch. 49, the department authority shall establish
4hospital outpatient per visit reimbursement rates and hospital inpatient
5reimbursement rates that are specific to diagnostically related groups of eligible
6persons. The adjustments to the usual and customary rates shall be sufficient to
7cover the portion of plan costs specified in s. 149.143 (1) (c) and (2) (b).
SB451-SSA2, s. 125 8Section 125. 149.142 (1) (b) of the statutes is repealed.
SB451-SSA2, s. 126 9Section 126. 149.142 (2) of the statutes is repealed.
SB451-SSA2, s. 127 10Section 127. 149.143 of the statutes is repealed and recreated to read:
SB451-SSA2,43,16 11149.143 Payment of plan costs. (1) Costs excluding subsidies. The
12authority shall pay plan costs, excluding any premium, deductible, and copayment
13subsidies, first from federal funds, if any, that are transferred to the fund under s.
1420.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in
15a policy year. The remainder of the plan costs, excluding premium, deductible, and
16copayment subsidy costs, shall be paid as follows:
SB451-SSA2,43,1717 (a) Sixty percent from premiums paid by eligible persons.
SB451-SSA2,43,1818 (b) Twenty percent from insurer assessments under s. 149.13.
SB451-SSA2,43,2019 (c) Twenty percent from adjustments to provider payment rates under s.
20149.142.
SB451-SSA2,43,24 21(2) Subsidy costs. The authority shall pay for premium, deductible, and
22copayment subsidies in a policy year first from federal funds, if any, that are
23transferred to the fund under s. 20.145 (5) (m) in that year. The remainder of the
24subsidy costs shall be paid as follows:
SB451-SSA2,43,2525 (a) Fifty percent from insurer assessments under s. 149.13.
SB451-SSA2,44,1
1(b) Fifty percent from adjustments to provider payment rates under s. 149.142.
SB451-SSA2, s. 128 2Section 128. 149.144 of the statutes is repealed.
SB451-SSA2, s. 129 3Section 129. 149.145 of the statutes is repealed.
SB451-SSA2, s. 130 4Section 130. 149.146 (1) (a) and (b) of the statutes are consolidated,
5renumbered 149.14 (2) (c) 1. and amended to read:
SB451-SSA2,44,206 149.14 (2) (c) 1. Beginning on January 1, 1998, in In addition to the coverage
7required under s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons
8who are not eligible for medicare Medicare a choice of coverage, as described in
9section 2744 (a) (1) (C), P.L. 104-191. Any such choice of coverage shall be major
10medical expense coverage. (b) An eligible person under par. (a) who is not eligible
11for Medicare
may elect once each year, at the time and according to procedures
12established by the department authority, among the coverages offered under this
13section and s. 149.14 paragraph and par. (a). If an eligible person elects new
14coverage, any preexisting condition exclusion imposed under the new coverage is met
15to the extent that the eligible person has been previously and continuously covered
16under this chapter the plan. No preexisting condition exclusion may be imposed on
17an eligible person who elects new coverage if the person was an eligible individual
18when first covered under this chapter the plan and the person remained
19continuously covered under this chapter the plan up to the time of electing the new
20coverage.
SB451-SSA2, s. 131 21Section 131. 149.146 (2) (a) of the statutes is renumbered 149.14 (2) (c) 2. and
22amended to read:
SB451-SSA2,45,323 149.14 (2) (c) 2. Except as specified by the department, the terms of coverage
24under s. 149.14, including deductible reductions under s. 149.14 (5) (a) and
25prescription drug copayment reductions under s. 149.14 (5) (e), do not apply to the

1coverage offered under this section.
Premium reductions under s. 149.165 and
2deductible subsidies and prescription drug copayment subsidies under s. 149.14 (5)

3do not apply to the coverage offered under this section paragraph.
SB451-SSA2, s. 132 4Section 132. 149.146 (2) (am) of the statutes is repealed.
SB451-SSA2, s. 133 5Section 133. 149.146 (2) (b) of the statutes is repealed.
SB451-SSA2, s. 134 6Section 134. 149.15 of the statutes is repealed.
SB451-SSA2, s. 135 7Section 135. 149.16 of the statutes is repealed.
SB451-SSA2, s. 136 8Section 136. 149.165 (1) of the statutes is amended to read:
SB451-SSA2,45,129 149.165 (1) Except as provided in s. 149.146 (2) (a), the department The
10authority
shall reduce the premiums established under s. 149.11 in conformity with
11ss. 149.14 (5m), 149.143 and 149.17
s. 149.141 for the eligible persons and in the
12manner set forth in subs. (2) and (3).
SB451-SSA2, s. 137 13Section 137. 149.165 (2) (a) (intro.) of the statutes is amended to read:
SB451-SSA2,45,1814 149.165 (2) (a) (intro.) Subject to sub. (3m), if the household income, as defined
15in s. 71.52 (5) and as determined under sub. (3), of an eligible person with coverage
16under s. 149.14 (2) (a) is equal to or greater than the first amount and less than the
172nd amount listed in any of the following, the department authority shall reduce the
18premium for the eligible person to the rate shown after the amounts:
SB451-SSA2, s. 138 19Section 138. 149.165 (2) (bc) of the statutes is amended to read:
SB451-SSA2,46,320 149.165 (2) (bc) Subject to sub. (3m), if the household income, as defined in s.
2171.52 (5) and as determined under sub. (3), of an eligible person with coverage under
22s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd
23amount listed in par. (a) 1., 2., 3., 4., or 5., the department authority shall reduce the
24premium established for the eligible person by the same percentage as the
25department authority reduces, under par. (a), the premium established for an

1eligible person with coverage under s. 149.14 (2) (a) who has a household income
2specified in the same subdivision under par. (a) as the household income of the
3eligible person with coverage under s. 149.14 (2) (b).
SB451-SSA2, s. 139 4Section 139. 149.165 (3) (a) of the statutes is amended to read:
SB451-SSA2,46,75 149.165 (3) (a) Subject to par. (b), the department authority shall establish and
6implement the method for determining the household income of an eligible person
7under sub. (2).
SB451-SSA2, s. 140 8Section 140. 149.165 (3) (b) (intro.) of the statutes is amended to read:
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