AB100-engrossed,815,1811
149.12
(1) (intro.) Except as provided in subs. (1m)
and, (2)
, and (3), the board
12or plan administrator shall certify as eligible a person who is covered by
medicare 13Medicare because he or she is disabled under
42 USC 423, a person who submits
14evidence that he or she has tested positive for the presence of HIV, antigen or
15nonantigenic products of HIV
, or an antibody to HIV, a person who is an eligible
16individual, and any person who receives and submits any of the following based
17wholly or partially on medical underwriting considerations within 9 months prior to
18making application for coverage by the plan:
AB100-engrossed,815,2020
149.12
(1) (a) A notice of rejection of coverage from
one 2 or more insurers.
AB100-engrossed,815,2522
149.12
(1m) The board
or plan administrator may not certify a person as
23eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required
24notices were issued by an insurance intermediary who is not acting as an
25administrator, as defined in s. 633.01.
AB100-engrossed,816,32
149.12
(2) (g) A person is not eligible for coverage under the plan if the person
3is eligible for any of the following:
AB100-engrossed,816,44
1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.
AB100-engrossed,816,65
2. Medical assistance provided as part of a family care benefit, as defined in s.
646.2805 (4).
AB100-engrossed,816,873. Services provided under a waiver requested under
2001 Wisconsin Act 16,
8section
9123 (16rs), or
2003 Wisconsin Act 33, section
9124 (8c).
AB100-engrossed,816,109
4. Services provided under the program of all-inclusive care for persons aged
1055 or older authorized under
42 USC 1396u-4.
AB100-engrossed,816,1211
5. Services provided under the demonstration program under a federal waiver
12authorized under
42 USC 1315.
AB100-engrossed,816,1413
6. Health care coverage under the Badger Care health care program under s.
1449.665.
AB100-engrossed,816,2116
149.12
(3) (a) Except as provided in pars. (b)
to (c) and (bm), no person is eligible
17for coverage under the plan for whom a premium, deductible
, or coinsurance amount
18is paid or reimbursed by a federal, state, county
, or municipal government or agency
19as of the first day of any term for which a premium amount is paid or reimbursed and
20as of the day after the last day of any term during which a deductible or coinsurance
21amount is paid or reimbursed.
AB100-engrossed,817,324
149.12
(4) Subject to subs. (1m), (2), and (3), the board may establish criteria
25that would enable additional persons to be eligible for coverage under the plan. The
1board shall ensure that any expansion of eligibility is consistent with the purpose of
2the plan to provide health care coverage for those who are unable to obtain health
3insurance in the private market and does not endanger the solvency of the plan.
AB100-engrossed,817,5
4(5) The board shall establish policies for determining and verifying the
5continued eligibility of an eligible person.
AB100-engrossed,817,117
149.13
(1) Every insurer shall participate in the cost of administering the plan,
8except the commissioner may by rule exempt as a class those insurers whose share
9as determined under sub. (2) would be so minimal as to not exceed the estimated cost
10of levying the assessment. The commissioner shall advise the
department board of
11the insurers participating in the cost of administering the plan.
AB100-engrossed,817,1713
149.13
(3) (a) Each insurer's proportion of participation under sub. (2) shall be
14determined annually by the commissioner based on annual statements and other
15reports filed by the insurer with the commissioner. The commissioner shall assess
16an insurer for the insurer's proportion of participation based on the total
17assessments estimated by the
department under s. 149.143 (2) (a) 3. board.
AB100-engrossed,817,2519
149.13
(3) (b) If the
department
board or the commissioner finds that the
20commissioner's authority to require insurers to report under chs. 600 to 646 and 655
21is not adequate to permit
the department, the commissioner or the board to carry out
22the
department's, commissioner's or board's responsibilities under this chapter, the
23commissioner shall promulgate rules requiring insurers to report the information
24necessary for the
department, commissioner and board to make the determinations
25required under this chapter.
AB100-engrossed,818,52
149.13
(4) Notwithstanding subs. (1) to (3), the
department board, with the
3agreement of the commissioner, may perform various administrative functions
4related to the assessment of insurers participating in the cost of administering the
5plan.
AB100-engrossed,818,107
149.14
(1) (a) The plan shall offer
coverage for each eligible person in an
8annually renewable policy
the coverage specified in this section for each eligible
9person. If an eligible person is also eligible for
medicare Medicare coverage, the plan
10shall not pay or reimburse any person for expenses paid for by
medicare Medicare.
AB100-engrossed,818,1812
149.14
(2) (a) The plan shall provide every eligible person who is not eligible
13for
medicare Medicare with major medical expense coverage. Major medical expense
14coverage offered under the plan under this section shall pay an eligible person's
15covered expenses, subject to
sub. (3) and deductible, copayment
, and coinsurance
16payments
authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered
17individual.
The maximum limit under this paragraph shall not be altered by the
18board, and no actuarially equivalent benefit may be substituted by the board.
AB100-engrossed, s. 2045c
19Section 2045c. 149.14 (3) (intro.) of the statutes is renumbered 149.14 (3) and
20amended to read:
AB100-engrossed,819,821
149.14
(3) Covered expenses. Except as provided in sub. (4), except as
22restricted by cost containment provisions under s. 149.17 (4) and except as reduced
23by the department under ss. 149.143 and 149.144, covered Covered expenses for
the 24coverage under
this section the plan shall be the payment rates established by the
25department under s. 149.142 board for
the services provided by persons licensed
1under ch. 446 and certified under s. 49.45 (2) (a) 11.
Except as provided in sub. (4),
2except as restricted by cost containment provisions under s. 149.17 (4) and except as
3reduced by the department under ss. 149.143 and 149.144, covered
Covered expenses
4for
the coverage under
this section
the plan shall also be the payment rates
5established by the
department under s. 149.142 board for
the following services and
6articles if the service or article is prescribed by a physician who is licensed under ch.
7448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service
8or article is provided by a provider certified under s. 49.45 (2) (a) 11.
:
AB100-engrossed,819,1611
149.14
(4) Benefit design. Except as provided in subs. (2) (a) and (6), the board
12shall determine the benefit design of the plan, including the covered expenses,
13expenses excluded from coverage, deductibles, copayments, coinsurance,
14out-of-pocket limits, and coverage limitations. The board may establish more than
15one benefit design under the plan. All benefit designs shall be comparable to typical
16individual health insurance policies offered in the private sector market in this state.
AB100-engrossed,819,2520
149.142
(2m) Payment is payment in full. Except for copayments, coinsurance
, 21or deductibles required or authorized under the plan, a provider of a covered service
22or article shall accept as payment in full for the covered service or article the payment
23rate determined under
ss. 149.142, 149.143 and 149.144
sub. (1) and may not bill an
24eligible person who receives the service or article for any amount by which the charge
25for the service or article is reduced under
s. 149.142, 149.143 or 149.144 sub. (1).
AB100-engrossed,820,96
149.14
(7) (b) The
department organization has a cause of action against an
7eligible participant for the recovery of the amount of benefits paid which are not for
8covered expenses under the plan. Benefits under the plan may be reduced or refused
9as a setoff against any amount recoverable under this paragraph.
AB100-engrossed,820,1411
149.14
(7) (c) The
department organization is subrogated to the rights of an
12eligible person to recover special damages for illness or injury to the person caused
13by the act of a 3rd person to the extent that benefits are provided under the plan.
14Section 814.03 (3) applies to the
department organization under this paragraph.
AB100-engrossed,820,1816
149.14
(8) Subsidies. The board shall provide for subsidies for premiums,
17deductibles, and copayments for eligible persons with household incomes below a
18level established by the board.
AB100-engrossed,820,22
20149.141 Premiums. The board shall set premiums for coverage under the
21plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s.
22149.143 (1).
AB100-engrossed,821,11
1149.142
(1) Establishment of rates. Except as provided in par. (b), the
2department The board shall establish
provider payment rates for covered expenses
3that consist of the allowable charges paid under s. 49.46 (2) for the services and
4articles provided plus an enhancement determined by the
department board. The
5rates shall be based on the allowable charges paid under s. 49.46 (2), projected plan
6costs
, and trend factors. Using the same methodology that applies to medical
7assistance under subch. IV of ch. 49, the
department
board shall establish hospital
8outpatient per visit reimbursement rates and hospital inpatient reimbursement
9rates that are specific to diagnostically related groups of eligible persons.
The
10adjustments to the usual and customary rates shall be sufficient to cover 20 percent
11of plan costs, as provided in s. 149.143 (3).
AB100-engrossed,821,16
15149.143 Payment of plan costs. The board shall pay plan costs, including
16any premium, deductible, and copayment subsidies, as follows:
AB100-engrossed,821,17
17(1) Sixty percent from premiums paid by eligible persons.
AB100-engrossed,821,18
18(2) Twenty percent from insurer assessments under s. 149.13.
AB100-engrossed,821,20
19(3) Twenty percent from adjustments to provider payment rates under s.
20149.142.
AB100-engrossed, s. 2054m
23Section 2054m. 149.146 (1) (a) and (b) of the statutes are consolidated,
24renumbered 149.14 (2) (c) and amended to read:
AB100-engrossed,822,14
1149.14
(2) (c)
Beginning on January 1, 1998, in In addition to the coverage
2required under
s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons
3who are not eligible for
medicare Medicare a choice of coverage, as described in
4section 2744 (a) (1) (C), P.L.
104-191. Any such choice of coverage shall be major
5medical expense coverage.
(b) An eligible person
under par. (a) who is not eligible
6for Medicare may elect once each year, at the time and according to procedures
7established by the
department board, among the coverages offered under this
section
8and s. 149.14. If an eligible person elects new coverage, any preexisting condition
9exclusion imposed under the new coverage is met to the extent that the eligible
10person has been previously and continuously covered under this chapter. No
11preexisting condition exclusion may be imposed on an eligible person who elects new
12coverage if the person was an eligible individual when first covered under this
13chapter and the person remained continuously covered under this chapter up to the
14time of electing the new coverage paragraph and par. (a).
AB100-engrossed,822,18
18149.155 Additional duties of board. The board shall do all of the following:
AB100-engrossed,822,20
19(1) Adopt policies for the administration of this chapter, including delegation
20of any part of its powers and its own procedures.
AB100-engrossed,822,22
21(5) Seek to qualify the plan as a state pharmacy assistance program, as defined
22in
42 CFR 423.464.
AB100-engrossed,822,24
23(6) Annually submit a report to the legislature under s. 13.172 (2) and to the
24governor on the operation of the plan.
AB100-engrossed,823,54
149.155
(2) The plan administrator shall perform Perform all eligibility and
5administrative claims payment functions relating to the plan.
AB100-engrossed,823,108
149.155
(3) The plan administrator shall establish Establish a premium billing
9procedure for collection of premiums from insured persons. Billings shall be made
10on a periodic basis as determined by the
department
board.
AB100-engrossed, s. 2058m
11Section 2058m. 149.16 (3) (c) of the statutes is renumbered 149.155 (4), and
12149.155 (4) (intro.), as renumbered, is amended to read:
AB100-engrossed,823,1513
149.155
(4) (intro.)
The plan administrator shall perform Perform all necessary
14functions to assure timely payment of benefits to covered persons under the plan,
15including:
AB100-engrossed,823,2221
149.17
(1) Subject to
ss. 149.14 (5m),
s. 149.143
and 149.146 (2) (b), a rating
22plan calculated in accordance with generally accepted actuarial principles.
