SB451, s. 109
5Section
109. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act ....
6(this act), is repealed and recreated to read:
SB451,40,97
149.14
(5) Deductible and copayment subsidies. (a) The authority shall
8establish and provide subsidies for deductibles paid by eligible persons with coverage
9under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.
SB451,40,1110
(b) The authority may provide subsidies for prescription drug copayment
11amounts paid by eligible persons specified in par. (a).
SB451, s. 110
12Section
110. 149.14 (5) (b) of the statutes is amended to read:
SB451,40,1613
149.14
(5) (b) Except as provided in
pars. (c) and (e) par. (c), if the covered costs
14incurred by the eligible person exceed the deductible for major medical expense
15coverage in a calendar year, the plan shall pay at least 80% of any additional covered
16costs incurred by the person during the calendar year.
SB451, s. 111
17Section
111. 149.14 (5) (c) of the statutes is amended to read:
SB451,40,2318
149.14
(5) (c)
Except as provided in par. (e), if If the aggregate of the covered
19costs not paid by the plan under par. (b) and the deductible exceeds $500 for an
20eligible person receiving medicare, $2,000 for any other eligible person during a
21calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100%
22of all covered costs incurred by the eligible person during the calendar year after the
23payment ceilings under this paragraph are exceeded.
SB451, s. 112
24Section
112. 149.14 (5) (d) of the statutes is repealed.
SB451, s. 113
25Section
113. 149.14 (5) (e) of the statutes is repealed.
SB451, s. 114
1Section
114. 149.14 (5m) of the statutes is repealed.
SB451, s. 115
2Section
115. 149.14 (6) (a) of the statutes is repealed.
SB451, s. 116
3Section
116. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).
SB451, s. 117
4Section
117. 149.14 (7) (b) of the statutes is amended to read:
SB451,41,85
149.14
(7) (b) The
department authority has a cause of action against an
6eligible participant for the recovery of the amount of benefits paid
which that are not
7for covered expenses under the plan. Benefits under the plan may be reduced or
8refused as a setoff against any amount recoverable under this paragraph.
SB451, s. 118
9Section
118. 149.14 (7) (c) of the statutes is amended to read:
SB451,41,1310
149.14
(7) (c) The
department authority is subrogated to the rights of an
11eligible person to recover special damages for illness or injury to the person caused
12by the act of a 3rd person to the extent that benefits are provided under the plan.
13Section 814.03 (3) applies to the department under this paragraph.
SB451, s. 119
14Section
119. 149.14 (8) of the statutes is repealed.
SB451, s. 120
15Section
120. 149.141 of the statutes is created to read:
SB451,41,18
16149.141 Premiums. (1)
Percentage of costs. Except as provided in sub. (2),
17the authority shall set premium rates for coverage under the plan at a level that is
18sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).
SB451,41,20
19(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
20applicable to individual standard risks.
SB451, s. 121
21Section
121. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
22amended to read:
SB451,42,823
149.142
(1) Establishment of rates.
Except as provided in par. (b), the
24department The authority shall establish
provider payment rates for covered
25expenses that consist of the allowable charges paid under s. 49.46 (2) for the services
1and articles provided plus an enhancement determined by the
department authority.
2The rates shall be based on the allowable charges paid under s. 49.46 (2), projected
3plan costs
, and trend factors. Using the same methodology that applies to medical
4assistance under subch. IV of ch. 49, the
department
authority shall establish
5hospital outpatient per visit reimbursement rates and hospital inpatient
6reimbursement rates that are specific to diagnostically related groups of eligible
7persons.
The adjustments to the usual and customary rates shall be sufficient to
8cover 20 percent of plan costs, as provided in s. 149.143 (3).
SB451, s. 122
9Section
122. 149.142 (1) (b) of the statutes is repealed.
SB451, s. 123
10Section
123. 149.142 (2) of the statutes is repealed.
SB451, s. 124
11Section
124. 149.143 of the statutes is repealed and recreated to read:
SB451,42,17
12149.143 Payment of plan costs. (1) Costs excluding subsidies. The
13authority shall pay plan costs, excluding any premium, deductible, and copayment
14subsidies, first from federal funds, if any, that are transferred to the fund under s.
1520.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in
16a policy year. The remainder of the plan costs, excluding premium, deductible, and
17copayment subsidy costs, shall be paid as follows:
SB451,42,1818
(a) Sixty percent from premiums paid by eligible persons.
SB451,42,1919
(b) Twenty percent from insurer assessments under s. 149.13.
SB451,42,2120
(c) Twenty percent from adjustments to provider payment rates under s.
21149.142.
SB451,42,25
22(2) Subsidy costs. The authority shall pay for premium, deductible, and
23copayment subsidies in a policy year first from federal funds, if any, that are
24transferred to the fund under s. 20.145 (5) (m) in that year. The remainder of the
25subsidy costs shall be paid as follows:
SB451,43,1
1(a) Fifty percent from insurer assessments under s. 149.13.
SB451,43,22
(b) Fifty percent from adjustments to provider payment rates under s. 149.142.
SB451, s. 127
5Section
127. 149.146 (1) (a) and (b) of the statutes are consolidated,
6renumbered 149.14 (2) (c) 1. and amended to read:
SB451,43,217
149.14
(2) (c) 1.
Beginning on January 1, 1998, in In addition to the coverage
8required under
s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons
9who are not eligible for
medicare Medicare a choice of coverage, as described in
10section 2744 (a) (1) (
C), P.L.
104-191. Any such choice of coverage shall be major
11medical expense coverage.
(b) An eligible person
under par. (a) who is not eligible
12for Medicare may elect once each year, at the time and according to procedures
13established by the
department authority, among the coverages offered under this
14section and s. 149.14 paragraph and par. (a). If an eligible person elects new
15coverage, any preexisting condition exclusion imposed under the new coverage is met
16to the extent that the eligible person has been previously and continuously covered
17under
this chapter the plan. No preexisting condition exclusion may be imposed on
18an eligible person who elects new coverage if the person was an eligible individual
19when first covered under
this chapter the plan and the person remained
20continuously covered under
this chapter the plan up to the time of electing the new
21coverage.
SB451, s. 128
22Section
128. 149.146 (2) (a) of the statutes is renumbered 149.14 (2) (c) 2. and
23amended to read:
SB451,44,424
149.14
(2) (c) 2.
Except as specified by the department, the terms of coverage
25under s. 149.14, including deductible reductions under s. 149.14 (5) (a) and
1prescription drug copayment reductions under s. 149.14 (5) (e), do not apply to the
2coverage offered under this section. Premium reductions under s. 149.165
and
3deductible subsidies and prescription drug copayment subsidies under s. 149.14 (5) 4do not apply to the coverage offered under this
section paragraph.
SB451, s. 129
5Section
129. 149.146 (2) (am) of the statutes is repealed.
SB451, s. 130
6Section
130. 149.146 (2) (b) of the statutes is repealed.
SB451, s. 133
9Section
133. 149.165 (1) of the statutes is amended to read:
SB451,44,1310
149.165
(1) Except as provided in s. 149.146 (2) (a), the department The
11authority shall reduce the premiums established under
s. 149.11 in conformity with
12ss. 149.14 (5m), 149.143 and 149.17 s. 149.141 for the eligible persons and in the
13manner set forth in subs. (2) and (3).
SB451, s. 134
14Section
134. 149.165 (2) (a) (intro.) of the statutes is amended to read:
SB451,44,1915
149.165
(2) (a) (intro.) Subject to sub. (3m), if the household income, as defined
16in s. 71.52 (5) and as determined under sub. (3), of an eligible person with coverage
17under s. 149.14 (2) (a) is equal to or greater than the first amount and less than the
182nd amount listed in any of the following, the
department authority shall reduce the
19premium for the eligible person to the rate shown after the amounts:
SB451, s. 135
20Section
135. 149.165 (2) (bc) of the statutes is amended to read:
SB451,45,421
149.165
(2) (bc) Subject to sub. (3m), if the household income, as defined in s.
2271.52 (5) and as determined under sub. (3), of an eligible person with coverage under
23s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd
24amount listed in par. (a) 1., 2., 3., 4.
, or 5., the
department authority shall reduce the
25premium established for the eligible person by the same percentage as the
1department authority reduces, under par. (a), the premium established for an
2eligible person with coverage under s. 149.14 (2) (a) who has a household income
3specified in the same subdivision under par. (a) as the household income of the
4eligible person with coverage under s. 149.14 (2) (b).
SB451, s. 136
5Section
136. 149.165 (3) (a) of the statutes is amended to read:
SB451,45,86
149.165
(3) (a) Subject to par. (b), the
department authority shall establish and
7implement the method for determining the household income of an eligible person
8under sub. (2).
SB451, s. 137
9Section
137. 149.165 (3) (b) (intro.) of the statutes is amended to read:
SB451,45,1310
149.165
(3) (b) (intro.) In determining household income under sub. (2), the
11department authority shall consider information submitted by an eligible person on
12a completed federal profit or loss from farming form, schedule F, if all of the following
13apply:
SB451, s. 138
14Section
138. 149.165 (3m) of the statutes is amended to read:
SB451,45,1815
149.165
(3m) The
board authority may approve adjustment of the household
16income dollar amounts listed in sub. (2) (a) 1. to 5., except for the first dollar amount
17listed in sub. (2) (a) 1., to reflect changes in the consumer price index for all urban
18consumers, U.S. city average, as determined by the U.S. department of labor.
SB451, s. 139
19Section
139. 149.165 (4) of the statutes is repealed.
SB451, s. 140
20Section
140. 149.17 (1) of the statutes is amended to read:
SB451,45,2221
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.
SB451, s. 141
23Section
141. 149.17 (2) of the statutes is repealed.
SB451, s. 142
24Section
142. 149.17 (4) of the statutes is repealed.
SB451, s. 143
25Section
143. 149.175 of the statutes is repealed.
SB451, s. 144
1Section
144. 149.18 of the statutes is amended to read:
SB451,46,4
2149.18 Chapters 600 to 645 applicable. Except as otherwise provided in this
3chapter subchapter, the plan shall comply and be administered in compliance with
4chs. 600 to 645.
SB451, s. 147
7Section
147. Subchapter III of chapter 149 [precedes 149.40] of the statutes
8is created to read:
SB451,46,1210
Subchapter III
11
Health Insurance Risk-Sharing
12
Plan Authority
SB451,46,13
13149.40 Definitions. In this subchapter:
SB451,46,14
14(1) "Authority" means the Health Insurance Risk-Sharing Plan Authority.
SB451,46,15
15(2) "Board" means the board of directors of the authority.
SB451,46,21
16149.41 Creation and organization of authority. (1) There is created a
17public body corporate and politic to be known as the "Health Insurance Risk-Sharing
18Plan Authority." The board of directors of the authority shall consist of the
19commissioner of insurance, or his or her designee, as a nonvoting member, and the
20following members, who shall be nominated by the governor, and with the advice and
21consent of the senate appointed, for 3-year terms:
SB451,46,2222
(a) Four members who represent insurers participating in the plan.
SB451,47,223
(b) Four members who represent health care providers, including one
24representative of the Wisconsin Medical Society, one representative of the Wisconsin
25Hospital Association, Inc., one representative of the Pharmacy Society of Wisconsin,
1and one representative of health care providers that provide services to persons with
2coverage under the plan.
SB451,47,53
(c) Five other members, at least one of whom represents small businesses that
4purchase private health insurance and at least 2 of whom are persons with coverage
5under the plan.
SB451,47,7
6(2) A vacancy on the board shall be filled in the same manner as the original
7appointment to the board for the remainder of the unexpired term, if any.
SB451,47,10
8(3) A member of the board may not be compensated for his or her services but
9shall be reimbursed for actual and necessary expenses, including travel expenses,
10incurred in the performance of his or her duties.
SB451,47,17
11(4) Annually, the governor shall appoint one member other than the
12commissioner as chairperson, and the members of the board may elect other officers
13as they consider appropriate. Seven voting members of the board constitute a
14quorum for the purpose of conducting the business and exercising the powers of the
15authority, notwithstanding the existence of any vacancy. The board may take action
16upon a vote of a majority of the members present, unless the bylaws of the authority
17require a larger number.
SB451,48,4
18(5) The board may appoint an executive director who shall not be a member of
19the board and who shall serve at the pleasure of the board. The authority may
20delegate by resolution to one or more of its members or its executive director any
21powers and duties that it considers proper. The executive director shall receive such
22compensation as may be determined by the board. The executive director or other
23person designated by resolution of the board shall keep a record of the proceedings
24of the authority and shall be custodian of all books, documents, and papers filed with
25the authority, the minute book or journal of the authority, and its official seal. The
1executive director or other person may cause copies to be made of all minutes and
2other records and documents of the authority and may give certificates under the
3official seal of the authority to the effect that such copies are true copies, and all
4persons dealing with the authority may rely upon such certificates.
SB451,48,6
5149.43 Duties of authority. In addition to all other duties imposed under this
6chapter, the authority shall do all of the following:
SB451,48,7
7(1) Adopt policies for the administration of this chapter.
SB451,48,10
8(2) Contract with the plan administrator under s. 149.16, 2003 stats., in the
9manner required under 2005 Wisconsin Act .... (this act), section 162 (1) (b) until the
10end of the contract term.
SB451,48,12
11(3) Establish the authority's annual budget and monitor the fiscal
12management of the authority.
SB451,48,14
13(4) Beginning on July 1, 2006, do, or contract with another person to do, all of
14the following:
SB451,48,1615
(a) Perform all eligibility and administrative claims payment functions
16relating to the plan.
SB451,48,1917
(b) Establish a premium billing procedure for collection of premiums from
18insured persons. Billings shall be made on a periodic basis as determined by the
19authority.
SB451,48,2120
(c) Perform all necessary functions to assure timely payment of benefits to
21covered persons under the plan, including:
SB451,48,2422
1. Making available information relating to the proper manner of submitting
23a claim for benefits under the plan and distributing forms upon which submissions
24shall be made.
SB451,48,2525
2. Evaluating the eligibility of each claim for payment under the plan.
SB451,49,2
13. Notifying each claimant within 30 days after receiving a properly completed
2and executed proof of loss whether the claim is accepted, rejected, or compromised.