Amendment SSA2-SB451

SB451-SSA2,31,23 subchapter II Health insurance risk-sharing plan provisions

SB451-SSA2, s. 77 Section 77. 149.11 of the statutes is repealed and recreated to read:

SB451-SSA2,32,3 149.11 Administration of plan. (1) Authority. The authority shall be responsible for the operation of the plan and, subject to ss. 149.43 (2) and 149.47, may enter into contracts for the plan's administration.

SB451-SSA2,32,6 (2) Fund. (a) The authority shall pay the operating and administrative expenses of the plan from the fund, which shall be outside the state treasury and which shall consist of all of the following:

SB451-SSA2,32,7 3. Federal moneys paid to the authority under s. 20.145 (5) (m).

SB451-SSA2,32,9 4. The moneys transferred under 2005 Wisconsin Act .... (this act), section 166 (1).

SB451-SSA2,32,10 5. The earnings resulting from investments under par. (b).

SB451-SSA2,32,11 6. Any other moneys received by the authority from time to time.

SB451-SSA2,32,15 (b) The authority controls the assets of the fund and shall select regulated financial institutions in this state that receive deposits in which to establish and maintain accounts for assets needed on a current basis. If practicable, the accounts shall earn interest.

SB451-SSA2,32,17 (c) Moneys in the fund may be expended only for the purposes specified in par. (a).

SB451-SSA2, s. 78 Section 78. 149.115 of the statutes is amended to read:

SB451-SSA2,32,23 149.115 Rules relating to creditable coverage. The commissioner, in consultation with the department, shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.

SB451-SSA2, s. 79 Section 79. 149.12 (1) (intro.) of the statutes is amended to read:

SB451-SSA2,33,8 149.12 (1) (intro.) Except as provided in subs. (1m) and, (2), and (3), the board or plan administrator authority shall certify as eligible a person who is covered by medicare Medicare because he or she is disabled under 42 USC 423, a person who submits evidence that he or she has tested positive for the presence of HIV, antigen or nonantigenic products of HIV, or an antibody to HIV, a person who is an eligible individual, and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:

SB451-SSA2, s. 80 Section 80. 149.12 (1) (a) of the statutes is amended to read:

SB451-SSA2,33,10 149.12 (1) (a) A notice of rejection of coverage from one 2 or more insurers.

SB451-SSA2, s. 81 Section 81. 149.12 (1m) of the statutes is amended to read:

SB451-SSA2,33,15 149.12 (1m) The board or plan administrator authority may not certify a person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required notices were issued by an insurance intermediary who is not acting as an administrator, as defined in s. 633.01.

SB451-SSA2, s. 82 Section 82. 149.12 (2) (f) of the statutes is renumbered 149.12 (2) (f) 1. and amended to read:

SB451-SSA2,33,19 149.12 (2) (f) 1. No Except as provided in subd. 2., no person who is eligible for medical assistance is eligible for coverage under the plan.

SB451-SSA2, s. 83 Section 83. 149.12 (2) (f) 2. of the statutes is created to read:

SB451-SSA2,33,23 149.12 (2) (f) 2. Subdivision 1. does not apply to a person who is otherwise eligible for coverage under the plan and who is eligible for only any of the following types of medical assistance:

SB451-SSA2,33,24 a. Family planning services under s. 49.45 (24r).

SB451-SSA2,34,2 b. Care and services for the treatment of an emergency medical condition under 42 USC 1396b (v), as provided in s. 49.45 (27).

SB451-SSA2,34,3 c. Medical assistance under s. 49.46 (1) (a) 15.

SB451-SSA2,34,4 d. Ambulatory prenatal care under s. 49.465.

SB451-SSA2,34,6 e. Medicare premium, coinsurance, and deductible payments under s. 49.46 (2) (c) 2. or 3., 49.468 (1) (b) or (c), or 49.47 (6) (a) 6. b. or c.

SB451-SSA2,34,8 f. Medicare premium payments under s. 49.46 (2) (cm), 49.468 (1m) or (2), or 49.47 (6) (a) 6m.

SB451-SSA2, s. 84 Section 84. 149.12 (2) (g) of the statutes is created to read:

SB451-SSA2,34,11 149.12 (2) (g) A person is not eligible for coverage under the plan if the person is eligible for any of the following:

SB451-SSA2,34,12 1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.

SB451-SSA2,34,14 2. Medical assistance provided as part of a family care benefit, as defined in s. 46.2805 (4).

SB451-SSA2,34,16 3. Services provided under a waiver requested under 2001 Wisconsin Act 16, section 9123 (16rs), or 2003 Wisconsin Act 33, section 9124 (8c).

SB451-SSA2,34,18 4. Services provided under the program of all-inclusive care for persons aged 55 or older authorized under 42 USC 1396u-4.

SB451-SSA2,34,20 5. Services provided under the demonstration program under a federal waiver authorized under 42 USC 1315.

SB451-SSA2,34,22 6. Health care coverage under the Badger Care health care program under s. 49.665.

SB451-SSA2, s. 85 Section 85. 149.12 (3) (a) of the statutes is amended to read:

SB451-SSA2,35,4 149.12 (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.

SB451-SSA2, s. 86 Section 86. 149.12 (3) (c) of the statutes is repealed.

SB451-SSA2, s. 87 Section 87. 149.12 (4) and (5) of the statutes are created to read:

SB451-SSA2,35,12 149.12 (4) Subject to subs. (1m), (2), and (3), the authority may establish criteria that would enable additional persons to be eligible for coverage under the plan. The authority 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.

SB451-SSA2,35,14 (5) The authority shall establish policies for determining and verifying the continued eligibility of an eligible person.

SB451-SSA2, s. 88 Section 88. 149.13 (1) of the statutes is amended to read:

SB451-SSA2,35,20 149.13 (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 authority of the insurers participating in the cost of administering the plan.

SB451-SSA2, s. 89 Section 89. 149.13 (3) (a) of the statutes is amended to read:

SB451-SSA2,36,2 149.13 (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. authority.

SB451-SSA2, s. 90 Section 90. 149.13 (3) (b) of the statutes is amended to read:

SB451-SSA2,36,10 149.13 (3) (b) If the department authority 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 authority to carry out the department's, commissioner's or board's authority's responsibilities under this chapter subchapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and board authority to make the determinations required under this chapter subchapter.

SB451-SSA2, s. 91 Section 91 . 149.13 (4) of the statutes is amended to read:

SB451-SSA2,36,17 149.13 (4) Notwithstanding subs. (1) to (3), the department, 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. Neither the commissioner nor the department may assess any type of insurance that was not being assessed as of December 1, 2005, or any type of insurer that was not being assessed as December 1, 2005.

SB451-SSA2, s. 92 Section 92 . 149.13 (4) of the statutes, as affected by 2005 Wisconsin Act .... (this act), is amended to read:

SB451-SSA2,36,25 149.13 (4) Notwithstanding subs. (1) to (3), the department authority, 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. Neither the commissioner nor the department authority may assess any type of insurance that was not being assessed as of December 1, 2005, or any type of insurer that was not being assessed as December 1, 2005.

SB451-SSA2, s. 93 Section 93. 149.14 (1) (a) of the statutes is amended to read:

SB451-SSA2,37,8 149.14 (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. If an eligible person is eligible for a type of medical assistance specified in s. 149.12 (2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by Medical Assistance.

SB451-SSA2, s. 94 Section 94. 149.14 (2) (a) of the statutes is amended to read:

SB451-SSA2,37,16 149.14 (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.

SB451-SSA2, s. 95 Section 95. 149.14 (3) (intro.) of the statutes is amended to read:

SB451-SSA2,38,6 149.14 (3) Covered expenses. (intro.) 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 authority 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 authority for, at a minimum, 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.:

SB451-SSA2, s. 96 Section 96. 149.14 (3) (b) of the statutes is repealed and recreated to read:

SB451-SSA2,38,9 149.14 (3) (b) Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental.

SB451-SSA2, s. 97 Section 97. 149.14 (3) (c) 1. of the statutes is repealed and recreated to read:

SB451-SSA2,38,14 149.14 (3) (c) 1. Inpatient hospital services, as defined in s. 632.89 (1) (d), outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment arrangements, as defined in s. 632.89 (1) (f), at least to the extent required under s. 632.89.

SB451-SSA2, s. 98 Section 98. 149.14 (3) (c) 2. of the statutes is repealed.

SB451-SSA2, s. 99 Section 99 . 149.14 (3) (c) 3. of the statutes is amended to read:

SB451-SSA2,38,20 149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats., services for the chronically mentally ill in community support programs operated under s. 51.421.

SB451-SSA2, s. 100 Section 100 . 149.14 (3) (c) 3. of the statutes, as affected by 2005 Wisconsin Act .... (this act), is amended to read:

SB451-SSA2,39,2 149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats. 1., services for the chronically mentally ill in community support programs operated under s. 51.421.

SB451-SSA2, s. 101 Section 101. 149.14 (3) (d) of the statutes is amended to read:

SB451-SSA2,39,4 149.14 (3) (d) Drugs requiring a physician's prescription, subject to sub. (4c).

SB451-SSA2, s. 102 Section 102. 149.14 (3) (e) of the statutes is amended to read:

SB451-SSA2,39,12 149.14 (3) (e) Services For persons eligible for Medicare, services of a licensed skilled nursing facility for eligible persons eligible for medicare, to the extent required by s. 632.895 (3) and for not more than an aggregate 120 days during a calendar year, if the services are of the type which that would qualify as reimbursable services under medicare Medicare. Coverage under this paragraph which that is not required by s. 632.895 (3) is subject to the any deductible and coinsurance requirements under sub. (5) provided by the authority.

SB451-SSA2, s. 103 Section 103. 149.14 (3) (f) of the statutes is created to read:

SB451-SSA2,39,15 149.14 (3) (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only to the extent required under s. 632.895 (2).

SB451-SSA2, s. 104 Section 104. 149.14 (3) (m) of the statutes is amended to read:

SB451-SSA2,39,19 149.14 (3) (m) Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth.

SB451-SSA2, s. 105 Section 105. 149.14 (3) (o) of the statutes is amended to read:

SB451-SSA2,39,23 149.14 (3) (o) Transportation Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat the a covered condition.

SB451-SSA2, s. 106 Section 106. 149.14 (3) (p) of the statutes is renumbered 149.14 (3) (em).

SB451-SSA2, s. 107 Section 107. 149.14 (4) of the statutes, as affected by 2005 Wisconsin Act .... (this act), is repealed and recreated to read:

SB451-SSA2,40,11 149.14 (4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority shall establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state. The authority may develop additional benefit designs that are responsive to market conditions.

SB451-SSA2, s. 108 Section 108. 149.14 (4) (d) of the statutes is amended to read:

SB451-SSA2,40,16 149.14 (4) (d) That part of any charge for services or articles rendered or prescribed by a physician, dentist, or other health care personnel that exceeds the payment rate established by the department authority under s. 149.142 and reduced under ss. 149.143 and 149.144 or any charge not medically necessary.

SB451-SSA2, s. 109 Section 109. 149.14 (4) (m) of the statutes is amended to read:

SB451-SSA2,40,19 149.14 (4) (m) Experimental treatment, as determined by the department authority.

SB451-SSA2, s. 110 Section 110. 149.14 (4c) of the statutes is repealed.

SB451-SSA2, s. 111 Section 111. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and amended to read:

SB451-SSA2,41,3 149.142 (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).

SB451-SSA2, s. 112 Section 112. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act .... (this act), is repealed and recreated to read:

SB451-SSA2,41,8 149.14 (5) Deductible and copayment subsidies. (a) The authority shall establish and provide subsidies for deductibles paid by eligible persons with coverage under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.