AB807,10,25 21(3) (a) Any individual who is eligible under sub. (2) may receive services that
22are available under the health plan from any participating health care provider in
23this state. Services that correspond to those that are available under the health plan
24and that are provided to the individual in another state are reimbursable at rates
25under the health plan that are current at the time of service provision.
AB807,11,3
1(b) No individual who is eligible under sub. (2) may under this section be
2required to pay an amount as a deductible or copayment as a condition for receipt of
3services under this section from a health care facility or health care provider.
AB807,11,74 (c) An individual who has a fixed habitation outside the state but not inside the
5state is not a resident for purposes of this chapter. Any reimbursement paid under
6the health plan for health care services rendered to an individual who is determined
7not to be a resident is a liability of the individual.
AB807,11,9 8(4) Health care services and other benefits provided under the health plan shall
9include all of the following:
AB807,11,1110 (a) Services of all persons licensed, certified, registered, or permitted to treat
11the sick under chs. 441, 446, 447, 448, 449, 450, 451, 455, 457, and 459.
AB807,11,1312 (b) Health care services that are provided by health care facilities and the
13offices and clinics of persons under par. (a).
AB807,11,1514 (c) Preventive health care services and health promotional programs, including
15well-child care, immunizations, screening, outreach, and education.
AB807,11,1816 (d) Medical or surgical supplies and durable medical or surgical equipment,
17supplies and appliances, including valves, pacemakers, prostheses, eyeglasses, and
18hearing aids.
AB807,11,2119 (e) Prescription drugs specified in the listing of approved medicinal substances
20and formulae under s. 152.40 (5) (m) and any other drugs specified by the department
21by rule.
AB807,11,2222 (f) Blood and blood products.
AB807,12,223 (g) Long-term care services that are necessary for the physical health, mental
24and emotional well-being, and social and personal needs of individuals who have
25limited self-care capabilities, including services of health care facilities; home

1health care; hospice care; home-based and community-based services, including
2personal assistance and attendant care; and periodic needs assessments.
AB807,12,43 (h) Mental health treatment and services, including substance abuse and brain
4injury treatment.
AB807,12,55 (i) Dental services, as specified under s. 49.46 (2) (b) 1.
AB807,12,8 6(5) The health plan is the payer of last resort, and coverage under the health
7plan is supplemental to any health care coverage in force that is held by an
8individual.
AB807,12,12 9(6) As a condition of participation by a health care provider in the health plan,
10the health care provider shall accept reimbursement only under the health plan for
11all services or other benefits that the health care provider provides under the health
12plan.
AB807,12,15 13152.20 Health policy board; powers and duties. (1) The board shall
14approve and continually evaluate the listing of approved medicinal substances and
15formulae that is required under s. 152.40 (5) (n).
AB807,12,18 16(2) The board shall biennially evaluate and oversee cost containment
17guidelines and policies, including the evaluation of mechanisms used to contain costs
18of providing services, and shall revise the guidelines and policies as necessary.
AB807,12,20 19(3) The board shall review all of the following issues and formulate or revise
20policies, as appropriate, with respect to the issues:
AB807,12,2121 (a) Duties of the department that require policy determinations.
AB807,12,2422 (b) The sources and amounts of revenues for the administration of the
23department and the board and for financing the payment of health care services that
24are provided to residents under the health plan.
AB807,12,2525 (c) Information provided by the regional consumer health councils.
AB807,13,4
1(d) Development of a system for determination and periodic review of areas in
2this state, and specific populations within those areas, that are medically
3underserved; and development of plans for providing health care services to those
4areas and populations, including the establishment of community health centers.
AB807,13,85 (e) Development of a system for periodic reviews and evaluations of all aspects
6of the operation of the health plan, including the adequacy, cost, effectiveness, and
7quality of health care services provided. These reviews and evaluations shall be
8made available to the public by the board.
AB807,13,109 (f) Development of a notice and hearing procedure for review of complaints of
10residents about the health plan, in accordance with the requirements of ch. 227.
AB807,13,1111 (g) Other issues that the board determines are relevant to the health plan.
AB807,13,1212 (h) State statutory changes that may be necessary to effect pars. (a) to (g).
AB807,13,16 13(4) By January 1, April 1, July 1, and October 1 of each year, the board shall
14report to the governor on the revenues and expenditures of the health plan for the
15calendar quarter immediately preceding the most recently completed calendar
16quarter.
AB807,13,22 17(5) (a) The board may appoint up to 2 advisory committees, each with not more
18than 12 members, that shall be advisory to the secretary. Appointees shall reflect
19as much as possible a balance of gender, race, age, sexual orientation, ethnicity,
20religion, disability, and geographic area. The board may determine the length of
21terms of advisory committee members and the frequency of meetings, and may
22terminate the committees.
AB807,13,2323 (b) If appointed under par. (a), all of the following apply:
AB807,14,3
11. Only one advisory committee shall reflect the interests and concerns of
2consumer advocacy and may not include a health care provider or representative of
3a health care provider or the agency or organization of a health care provider.
AB807,14,64 2. Only one advisory committee shall reflect the interests and concerns of
5health care providers and agencies and organizations of health care providers and
6may not include a representative of a consumer advocacy agency or organization.
AB807,14,107 3. An advisory committee shall report annually to the board and the secretary
8concerning the committee's activities in the immediately preceding fiscal year, shall
9provide advice relative to health policy issues, and shall make recommendations
10concerning departmental policies and procedures.
AB807,14,12 11152.30 Regional consumer health councils. (1) Each regional consumer
12health council shall do all of the following:
AB807,14,1713 (a) Elect one member of the regional consumer health council to serve as a
14member of the board under s. 15.20 (1). If the term of the member who is so elected
15expires with respect to the regional consumer health council or with respect to the
16board under s. 15.20 (1), the regional consumer health council shall elect a current
17member of the council to serve as a member of the board in his or her stead.
AB807,14,2118 (b) Study and continuously monitor the delivery and quality of and access to
19health care services in the region of the regional consumer health council and
20recommend to the board and regional office ways to improve the quality of and help
21ensure access to health care services.
AB807,14,2422 (c) Recommend to the board payment rates and conditions appropriate to
23specific regional needs and advise on regional health care policy issues and
24administrative policies and procedures.
AB807,15,3
1(d) Study and continuously monitor the unmet health care service needs in the
2region of the regional consumer health council and recommend to the board ways by
3which the needs may be met.
AB807,15,74 (e) Report at least annually to the board with respect to the health care needs,
5problems, and concerns of the region, including any issues elicited at public hearings
6under par. (g), and provide to the board recommendations to alleviate these needs,
7problems, and concerns.
AB807,15,108 (f) Require reports from and advise the member of the staff of the appropriate
9regional office whose duties are specified under s. 152.40 (1), concerning issues that
10arise under pars. (b) to (e).
AB807,15,1411 (g) In at least 2 localities of the region, hold public hearings at least annually
12to elicit public opinion concerning the health plan under this chapter. The council
13shall give notice of each hearing by publishing a class 1 notice, under ch. 985, at least
1415 days before the hearing in a newspaper covering the affected area.
AB807,15,1515 (h) Perform other duties as required by the board.
AB807,15,18 16(2) Each regional consumer health council may, for cause, recall the member
17elected under sub. (1) (a) and may elect another member to fulfill that term on the
18board if all of the following are done:
AB807,15,2019 (a) The elected member of the board for whom recall is sought receives notice
20of the recall at least 10 working days before the meeting at which recall is voted upon.
AB807,15,2321 (b) Notice of the vote to recall the elected member is made on the agenda of the
22meeting of the regional consumer health council that is immediately prior to the
23meeting at which recall is voted upon.
AB807,16,4 24(2m) The regional consumer health council may appoint a regional advisory
25committee. If appointed, the regional advisory committee shall consist of 18

1members who reflect as much as possible a balance of gender, race, age, sexual
2orientation, ethnicity, religion, geographic area, and the interests of management,
3labor, and individuals with disabilities, and may consist of consumer advocates and
4health care providers.
AB807,16,7 5(3) The staff of the appropriate regional office shall provide services to each
6regional consumer health council to deal with issues of health consumer advocacy
7and health ombudsman functions.
AB807,16,12 8152.40 Department of health planning and finance. (1) The department
9shall administer the health plan under this chapter, including establishing a
10regional office in each of the regions specified under s. 15.207 (1) (a) 1. to 6. Each
11regional office shall have at least one staff member who acts in a full-time capacity
12as a regional consumer advocate and health care ombudsman.
AB807,16,15 13(2) The department shall establish provider payment rates, taking into
14consideration regional, rural, and urban differences, and conditions of payment for
15the provision of health care services under the health plan.
AB807,16,17 16(3) The department shall, after review and approval by the board, promulgate
17as rules all of the following:
AB807,16,1918 (a) Guidelines for cost containment under the health plan, including the
19purchasing and distribution of major diagnostic, medical, and surgical equipment.
AB807,16,2320 (b) Criteria, as recommended by the medical advisory committee appointed by
21the secretary under sub. (7), for determining necessity for orthodontia and for the
22performance of reconstructive or cosmetic surgery for coverage under the health
23plan.
AB807,16,25 24(4) The department shall biennially evaluate and recommend to the board cost
25control measures for the health plan.
AB807,17,3
1(5) The department shall, by July 1, 2007, begin implementation of processes,
2in light of policies formulated or revised under s. 152.20 (3), to effect all of the
3following:
AB807,17,74 (a) Specification of the amounts and sources of revenues to finance payment to
5providers under the health plan, which may not include any premiums, copayments,
6deductibles, and other forms of direct payment by patients, and which shall include
7all of the following:
AB807,17,138 1. Use of federal, state, and local moneys that fund, as of July 1, 2008, health
9care services, including medicare, medical assistance, health care services funded by
10a relief block grant under s. 49.02 or 49.025, health care services under s. 49.665,
11veterans medical benefits, services specified in s. 152.10 (2) (k), services provided
12under federal block grants, alcohol and other drug abuse services, and services
13provided by local health departments.
AB807,17,1814 2. Use of revenues from a tax on employers, based on the amount of wages that
15they pay, that generates, in the aggregate, revenues that are at least equal to
16amounts that employers contribute, as of the effective date of this subdivision ....
17[revisor inserts date], for employee health care benefit costs, including the costs of
18worker's compensation attributable to health care for injured employees.
AB807,17,2219 3. Use of revenues from a graduated income tax on individuals that generates,
20in the aggregate, revenues that are not greater than expenditures that individuals
21make, as of July 1, 2008, for health care costs for which coverage under disability
22insurance policies is not obtained.
AB807,17,2523 4. An indexing of the sources of revenues under this paragraph that provides
24for revenue growth that is equivalent to the anticipated growth of health care costs
25under the health plan.
AB807,18,3
1(b) Application for waivers to 42 USC 1396 to 1396v or consideration of the
2feasibility of statutory changes to 42 USC 1396 to 1396v in order to effect all of the
3following:
AB807,18,54 1. Administration of the Medical Assistance program in this state by the
5department, rather than by the department of health and family services.
AB807,18,76 2. Use of federal financial participation to fund a portion of the administrative
7costs, after June 30, 2008, of the department.
AB807,18,128 3. Use of federal financial participation, after June 30, 2008, to fund, under the
9health plan, the health care services received by a percentage of the residents that
10corresponds to the percentage of the residents, as determined by the board, that is
11eligible to receive health care services under the Medical Assistance program on July
121, 2008.
AB807,18,1413 4. The formulation of criteria and procedures for payment of out-of-state
14health care costs incurred by residents specified in subd. 3.
AB807,18,1615 5. Use of federal financial participation to fund the scope, or a portion of the
16scope, of medical services to be provided under the health plan.
AB807,18,1817 (c) Application for waivers to Medicare or consideration of the feasibility of
18statutory changes to 42 USC 1395 to 1395ddd in order to effect all of the following:
AB807,18,2019 1. Administration of the Medicare program in this state by the department,
20rather than by private insurers.
AB807,18,2221 2. Use of federal Medicare funds to fund a portion of the administrative costs,
22after June 30, 2008, of the department.
AB807,18,2523 3. Use of federal Medicare funds to fund, under the health plan, the health care
24services received by residents who are eligible to receive services under Medicare
25beginning on July 1, 2008.
AB807,19,2
14. The formulation of criteria and procedures for payment of out-of-state
2health care costs incurred by residents specified in subd. 3.
AB807,19,43 5. Use of federal Medicare funds to fund the scope, or a portion of the scope, of
4medical services to be provided under the health plan.
AB807,19,65 6. The assignment to the state, as represented by the department, of rights of
6an individual to payment for medical care from any 3rd party.
AB807,19,107 (d) Application for waivers or consideration of the feasibility of statutory
8changes to federal laws, other than those specified in pars. (b) and (c), in order to use
9moneys available under those federal laws for payment of health care services under
10the health plan or in order to provide services to all residents under the health plan.
AB807,19,1311 (e) The establishment and maintenance, with reserves of no less than 5 percent
12of the total annual amount appropriated under s. 20.430 (1) (b), of a health trust fund
13in the department, for receipt of revenues specified in par. (a).
AB807,19,2114 (f) The formulation of criteria for determining payment and the formulation of
15procedures for determining payment and negotiating applicable rates to be used for
16payment for health care providers, including health care facilities, under the health
17plan. The criteria and procedures for determining payment shall include periodic
18overall budgeting, including separately budgeting for operational costs; for health
19care facilities and services; for negotiations with professional groups or associations
20of practitioners; for consideration of inflation costs and increased patient
21populations; and for research and teaching.
AB807,19,2522 (g) The development and implementation of a system to provide an electronic
23or other identification card, bearing a unique number that is not a social security
24number, to each health plan participant, for receipt of benefits under the plan, and
25to each health care provider, for receipt of reimbursement.
AB807,20,4
1(h) The formulation of criteria and procedures to review and to provide funding
2for capital expenditures, from an account separate from that from which health care
3services are paid, for the establishment, maintenance, or expansion of health care
4facilities.
AB807,20,65 (i) The formulation of criteria and procedures for recovery of overpayments
6made to health care providers under the health plan.
AB807,20,87 (j) The determination and use of factors requisite to establishing an annual
8state health budget for the provision of services under the health plan.
AB807,20,119(k) Application for waivers of 29 USC 1144 (a) or consideration of the feasibility
10of statutory change to 29 USC 1144 (a) or the means by which operation of the health
11plan may avoid conflict with 29 USC 1144 (a).
AB807,20,1412 (L) Investigation of the feasibility of providing the state with subrogation
13rights to payments for injury or disease to residents that are provided under motor
14vehicle or other liability insurance policies or plans.
AB807,20,1615 (m) Formulation of criteria and procedures for payment under the health plan
16of out-of-state health care costs incurred by residents.
AB807,20,1817 (n) Establishment of a listing of approved medicinal substances and formulae,
18including all of the following:
AB807,20,2219 1. Negotiation with pharmaceutical manufacturers or distributors to obtain
20the lowest possible cost for each medicinal substance. The negotiation shall include
21as parties on behalf of the health plan the secretary of the department and the
22chairperson of the board.
AB807,20,2423 2. Establishment of a single statewide price, under the health plan, for each
24medicinal substance.
AB807,21,2
13. Monitoring the listing to oversee its currency and revising the listing by
2January 1 and July 1 annually.
AB807,21,43 4. Negotiating a statewide uniform dispensing fee with representatives of
4pharmacists or pharmacies.
AB807,21,55 (p) Exemption of operation of the health plan from ch. 133, if necessary.
AB807,21,66 (q) Other issues relevant to the health plan, as determined by the board.
AB807,21,15 7(6) From the appropriation under s. 20.430 (1) (c), the department shall, in
8cooperation with the department of workforce development and any other applicable
9state agency, as defined in s. 20.001 (1), provide job retraining or job placement
10services to individuals employed by insurers, as defined in s. 600.03 (27) and by
11health care providers whose employment is or will be terminated because of
12implementation of the health plan under this chapter. The department may award
13moneys as grants to applying organizations, under the department's
14request-for-proposal procedures, for the provision of job retraining or placement
15services under this subsection.
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