SB451-SSA2,34,2
1b. Care and services for the treatment of an emergency medical condition under
242 USC 1396b (v), as provided in s. 49.45 (27).
SB451-SSA2,34,33 c. Medical assistance under s. 49.46 (1) (a) 15.
SB451-SSA2,34,44 d. Ambulatory prenatal care under s. 49.465.
SB451-SSA2,34,65 e. Medicare premium, coinsurance, and deductible payments under s. 49.46 (2)
6(c) 2. or 3., 49.468 (1) (b) or (c), or 49.47 (6) (a) 6. b. or c.
SB451-SSA2,34,87 f. Medicare premium payments under s. 49.46 (2) (cm), 49.468 (1m) or (2), or
849.47 (6) (a) 6m.
SB451-SSA2, s. 84 9Section 84. 149.12 (2) (g) of the statutes is created to read:
SB451-SSA2,34,1110 149.12 (2) (g) A person is not eligible for coverage under the plan if the person
11is eligible for any of the following:
SB451-SSA2,34,1212 1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.
SB451-SSA2,34,1413 2. Medical assistance provided as part of a family care benefit, as defined in s.
1446.2805 (4).
SB451-SSA2,34,16153. Services provided under a waiver requested under 2001 Wisconsin Act 16,
16section 9123 (16rs), or 2003 Wisconsin Act 33, section 9124 (8c).
SB451-SSA2,34,1817 4. Services provided under the program of all-inclusive care for persons aged
1855 or older authorized under 42 USC 1396u-4.
SB451-SSA2,34,2019 5. Services provided under the demonstration program under a federal waiver
20authorized under 42 USC 1315.
SB451-SSA2,34,2221 6. Health care coverage under the Badger Care health care program under s.
2249.665.
SB451-SSA2, s. 85 23Section 85. 149.12 (3) (a) of the statutes is amended to read:
SB451-SSA2,35,424 149.12 (3) (a) Except as provided in pars. (b) to (c) and (bm), no person is eligible
25for coverage under the plan for whom a premium, deductible, or coinsurance amount

1is paid or reimbursed by a federal, state, county, or municipal government or agency
2as of the first day of any term for which a premium amount is paid or reimbursed and
3as of the day after the last day of any term during which a deductible or coinsurance
4amount is paid or reimbursed.
SB451-SSA2, s. 86 5Section 86. 149.12 (3) (c) of the statutes is repealed.
SB451-SSA2, s. 87 6Section 87. 149.12 (4) and (5) of the statutes are created to read:
SB451-SSA2,35,127 149.12 (4) Subject to subs. (1m), (2), and (3), the authority may establish
8criteria that would enable additional persons to be eligible for coverage under the
9plan. The authority shall ensure that any expansion of eligibility is consistent with
10the purpose of the plan to provide health care coverage for those who are unable to
11obtain health insurance in the private market and does not endanger the solvency
12of the plan.
SB451-SSA2,35,14 13(5) The authority shall establish policies for determining and verifying the
14continued eligibility of an eligible person.
SB451-SSA2, s. 88 15Section 88. 149.13 (1) of the statutes is amended to read:
SB451-SSA2,35,2016 149.13 (1) Every insurer shall participate in the cost of administering the plan,
17except the commissioner may by rule exempt as a class those insurers whose share
18as determined under sub. (2) would be so minimal as to not exceed the estimated cost
19of levying the assessment. The commissioner shall advise the department authority
20of the insurers participating in the cost of administering the plan.
SB451-SSA2, s. 89 21Section 89. 149.13 (3) (a) of the statutes is amended to read:
SB451-SSA2,36,222 149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be
23determined annually by the commissioner based on annual statements and other
24reports filed by the insurer with the commissioner. The commissioner shall assess

1an insurer for the insurer's proportion of participation based on the total
2assessments estimated by the department under s. 149.143 (2) (a) 3. authority.
SB451-SSA2, s. 90 3Section 90. 149.13 (3) (b) of the statutes is amended to read:
SB451-SSA2,36,104 149.13 (3) (b) If the department authority or the commissioner finds that the
5commissioner's authority to require insurers to report under chs. 600 to 646 and 655
6is not adequate to permit the department, the commissioner or the board authority
7to carry out the department's, commissioner's or board's authority's responsibilities
8under this chapter subchapter, the commissioner shall promulgate rules requiring
9insurers to report the information necessary for the department, commissioner and
10board authority to make the determinations required under this chapter subchapter.
SB451-SSA2, s. 91 11Section 91 . 149.13 (4) of the statutes is amended to read:
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:
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