SB698: Bill Text

SB698, s. 44 Section 44. 628.36 (4) (b) 3. of the statutes is repealed.

SB698, s. 45 Section 45. 632.87 (5) of the statutes is amended to read:

SB698,17,10 632.87 (5) No insurer or self-insured school district, city or village may, under a policy, plan, or contract covering gynecological services or procedures, exclude or refuse to provide coverage for Papanicolaou tests, pelvic examinations , or associated laboratory fees when the test or examination is performed by a licensed nurse practitioner, as defined in s. 632.895 (8) (a) 3., within the scope of the nurse practitioner's professional license, if the policy, plan, or contract includes coverage for Papanicolaou tests, pelvic examinations, or associated laboratory fees when the test or examination is performed by a physician.

SB698, s. 46 Section 46. 632.895 (8) (f) 4. of the statutes is created to read:

SB698,17,13 632.895 (8) (f) 4. A disability insurance policy providing only health care benefits not provided under the Wisconsin Health Care Plan under ch. 634.

SB698, s. 47 Section 47. 632.895 (9) (d) 4. of the statutes is created to read:

SB698,17,16 632.895 (9) (d) 4. A disability insurance policy providing only health care benefits not provided under the Wisconsin Health Care Plan under ch. 634.

SB698, s. 48 Section 48. 632.895 (10) (a) of the statutes is amended to read:

SB698,17,25 632.895 (10) (a) Except as provided in par. (b), every disability insurance policy and every health care benefits plan provided on a self-insured basis by a county board under s. 59.52 (11), by a city or village under s. 66.0137 (4), by a political subdivision under s. 66.0137 (4m), by a town under s. 60.23 (25), or by a school district under s. 120.13 (2) shall provide coverage for blood lead tests for children under 6 years of age, which shall be conducted in accordance with any recommended lead screening methods and intervals contained in any rules promulgated by the department of health and family services under s. 254.158.

SB698, s. 49 Section 49. 632.895 (10) (b) 6. of the statutes is created to read:

SB698,18,3 632.895 (10) (b) 6. A disability insurance policy providing only health care benefits not provided under the Wisconsin Health Care Plan under ch. 634.

SB698, s. 50 Section 50. 632.895 (11) (a) (intro.) of the statutes is amended to read:

SB698,18,10 632.895 (11) (a) (intro.) Except as provided in par. (e), every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, that provides coverage of any diagnostic or surgical procedure involving a bone, joint, muscle, or tissue shall provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders if all of the following apply:

SB698, s. 51 Section 51. 632.895 (11) (c) 1. of the statutes is amended to read:

SB698,18,14 632.895 (11) (c) 1. The coverage required under this subsection may be subject to any limitations, exclusions, or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan.

SB698, s. 52 Section 52. 632.895 (11) (d) of the statutes is amended to read:

SB698,18,19 632.895 (11) (d) Notwithstanding par. (c) 1., an insurer or a self-insured health plan of the state or a county, city, village, town or school district may require that an insured obtain prior authorization for any medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders.

SB698, s. 53 Section 53. 632.895 (11) (e) 3. of the statutes is created to read:

SB698,18,22 632.895 (11) (e) 3. A disability insurance policy providing only health care benefits not provided under the Wisconsin Health Care Plan under ch. 634.

SB698, s. 54 Section 54. 632.895 (14) (b) of the statutes is amended to read:

SB698,19,3 632.895 (14) (b) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for a dependent who is a child of the insured.

SB698, s. 55 Section 55. 632.895 (14) (d) 7. of the statutes is created to read:

SB698,19,6 632.895 (14) (d) 7. A disability insurance policy providing only health care benefits not provided under the Wisconsin Health Care Plan under ch. 634.

SB698, s. 56 Section 56. Chapter 634 of the statutes is created to read:

SB698,19,8 Chapter 634

SB698,19,9 Wisconsin Health Care Plan

SB698,19,10 634.01 Definitions. In this chapter:

SB698,19,11 (1) "Board" means the Wisconsin health care plan board.

SB698,19,12 (2) "Dependent" means any of the following:

SB698,19,13 (a) A spouse.

SB698,19,16 (b) An unmarried child under the age of 19 years, including a stepchild of the current marriage if the stepchild is dependent on the stepparent for support and maintenance.

SB698,19,19 (c) An unmarried child over the age of 18 years and under the age of 21 years, including a stepchild of the current marriage, if the child or stepchild is a full-time student and is financially dependent on the parent or stepparent.

SB698,19,22 (d) An unmarried child of any age, including a stepchild of the current marriage, if the child or stepchild is medically certified as disabled and is dependent on the parent or stepparent.

SB698,19,23 (3) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a).

SB698,19,24 (4) "Distributor" has the meaning given in s. 450.01 (9).

SB698,20,4 (5) "Employee" means an individual who is employed in this state by an employer, regardless of whether the individual is a resident. "Employee" does not include a self-employed individual, regardless of whether the self-employed individual has other employees.

SB698,20,9 (6) "Employer" means any person engaged in any activity, enterprise, or business employing one or more individuals within this state. "Employer" includes the state and its political subdivisions and charitable, nonprofit, or tax-exempt organizations or institutions. "Employer" does not include a self-employed individual who has no other employees.

SB698,20,10 (7) "Manufacturer" has the meaning given in s. 450.01 (12).

SB698,20,12 (8) "Medicare" means coverage under part A, part B, or Part D of Title XVIII of the federal Social Security Act, 42 USC 1395 et seq., as amended.

SB698,20,13 (9) "Plan" means the Wisconsin Health Care Plan.

SB698,20,14 (10) "Prescription drug" has the meaning given in s. 450.01 (20).

SB698,20,16 (11) "Resident" means an individual who maintains his or her place of permanent abode in this state.

SB698,20,23 634.10 Plan features. (1) Creation. (a) The board shall develop a health care coverage plan, to be known as the Wisconsin Health Care Plan. Coverage under the plan shall begin on the first day of the 13th month beginning after the effective date of this paragraph .... [revisor inserts date]. The plan shall be considered to be a group or blanket disability insurance policy and is subject to the provisions of chs. 600 to 646 that apply to group or blanket disability insurance policies to the same extent as any other group or blanket disability insurance policy.

SB698,20,25 (2) Covered individuals. (a) Except as provided in par. (c), all of the following shall be covered under the plan:

SB698,21,1 1. An employee.

SB698,21,3 2. An individual who is not employed but who, within the preceding 2 months, was employed in this state by an employer.

SB698,21,5 3. A dependent of an individual specified in subd. 1. or 2., regardless of the dependent's residency.

SB698,21,9 (b) Subject to par. (c), any resident not specified in par. (a) who is under 65 years of age may purchase coverage under the plan, for himself or herself and his or her dependents who are under 65 years of age, at a cost determined by the board under s. 634.25 (1) (a) 2.

SB698,21,11 (c) An individual who is eligible for Medicare is not eligible for coverage under the plan.

SB698,21,14 (3) Care coordinator. Each individual covered under the plan shall select a primary care physician, as defined in s. 609.01 (4m), to coordinate the individual's health care.

SB698,21,22 (4) Benefits and exclusions. (a) Except as provided in par. (b), the plan shall cover all reasonable medical services and prescription drugs necessary to maintain health, enable diagnosis, or provide treatment or rehabilitation for an injury, condition, disability, or disease, including mental health services and alcohol or other drug abuse treatment to the same extent as the plan covers treatment for physical conditions. The plan shall cover wellness programs and chronic disease management, and shall include quality control standards generally accepted in the medical field.

SB698,21,25 (b) The plan shall not cover dental or vision care, long-term care, or reconstructive or cosmetic surgery, unless the care or surgery is determined to be medically necessary under criteria promulgated as rules by the board.

SB698,22,5 (c) Covered expenses under the plan shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, or for which benefits are payable under a worker's compensation or similar law.

SB698,22,9 634.15 Prescription drug purchasing arrangement. (1) Agreements for discounts. The board shall negotiate, or contract with a 3rd party to negotiate, with prescription drug manufacturers and distributors to reach agreements for discounts in the prices of prescription drugs for individuals covered under the plan.

SB698,22,14 (2) Joining with other states. The board may join the prescription drug purchasing arrangement under the plan with similar arrangements or programs in other states to form a multistate purchasing group to negotiate, or contract with a 3rd party to negotiate, with prescription drug manufacturers and distributors for reduced prescription drug prices.

SB698,22,19 (3) Application to other health-related programs. The board may seek to extend the application of the agreements for discounted prescription drug prices negotiated under sub. (1) or (2) to other health care programs under which residents are covered, such as Medical Assistance, the Badger Care health care program, and Worker's Compensation.

SB698,22,22 634.25 Financing. (1) Cost-sharing requirements. (a) 1. Subject to pars. (b) to (e), the board shall determine the deductibles, copayments, coinsurance, and any other cost sharing that individuals with coverage under the plan must pay.

SB698,23,2 2. The board shall determine the premium amounts that must be paid by individuals who purchase coverage under the plan under s. 634.10 (2) (b). The premium amounts shall reflect the actual cost of coverage for those individuals. Any individual who purchases coverage under s. 634.10 (2) (b) and who fails to pay a premium when due loses coverage.

SB698,23,4 (b) Except as provided in par. (d), during the first year of the plan's operation all of the following apply:

SB698,23,8 1. The total amount of cost sharing, excluding prescription drug copayments under subd. 2., health care services copayments and coinsurance under subds. 3. and 4., and premiums determined under par. (a) 2., may not exceed $300 for a single individual or $600 for a family.

SB698,23,10 2. Copayments for prescription drugs may not exceed $15 per prescription for a generic drug or $20 per prescription for a brand name drug.

SB698,23,14 3. A covered individual shall pay a copayment of $15 each time the individual receives services from the individual's care coordinator under s. 634.10 (3) or any other health care provider to whom the individual has been referred by his or her care coordinator.

SB698,23,17 4. Subject to par. (c), a covered individual who receives health care services from a specialist provider without a referral from his or her care coordinator under s. 634.10 (3) shall be required to pay 25 percent of the cost of the services provided.

SB698,23,20 (c) The board shall establish guidelines for obtaining emergency treatment from a specialist provider without a referral and without the cost-sharing requirement under par. (b) 4.

SB698,23,24 (d) The board may modify the maximum cost-sharing amounts specified in par. (b) 1. and the copayment and coinsurance amounts specified in par. (b) 2. to 4. as long as any modification does not have a substantial effect on the total cost for covered individuals.

SB698,24,3 (e) After the first year of the plan's operation, the board annually may increase the maximum cost-sharing amounts and the copayment and coinsurance amounts under the plan by not more than a percentage equal to medical inflation.

SB698,24,9 (2) Employer assessment. (a) Subject to pars. (b), (c), and (d), each employer shall pay a monthly assessment at a flat rate for each of the employer's employees. The board shall determine the basis for calculating the assessments and, taking into consideration the reductions under par. (c), shall set the flat rate per employee at a level that is sufficient to cover the administrative and operating costs of the plan that are not covered by the cost sharing under sub. (1).

SB698,24,13 (b) An employer may pay, at the employer's discretion, the per employee assessment amount determined under par. (a) for an employee who leaves the employer's employment, for the period, or for any portion of the period, during which the former employee is not employed by another employer.

SB698,24,17 (c) If an employer has fewer than 10 employees and the average gross income of all of the employer's employees is not more than $20,000, the assessment amount that the employer would be required to pay under par. (a) or may pay under par. (b) shall be reduced by 50 percent.

SB698,24,20 (d) For an employee who is a member of a labor union, the employer assessments under pars. (a) to (c) may be paid through a Taft-Hartley Trust established by the labor union.

SB698,24,25 (3) Federal funds. The board shall seek to obtain federal funds for paying plan costs related to individuals covered under the plan who would otherwise be eligible for coverage under Medical Assistance, the Badger Care health care program, or any other health care program other than Medicare financed at least in part with federal funds.

SB698,25,7 634.30 Provider payment rates. (1) Establishment and increases. The board shall establish the provider payment rates for services and articles covered under the plan. The provider payment rates established shall be fair and adequate to ensure that this state is able to retain the highest quality of medical practitioners. The board shall limit increases in the provider payment rate for each service or article such that any increase in per person spending under the plan does not exceed medical inflation.

SB698,25,13 (2) Payment is payment in full. Except for deductibles, copayments, coinsurance, and any other cost sharing 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 sub. (1) and may not bill a covered individual who receives the service or article for any amount by which the charge for the service or article is reduced under sub. (1).

SB698,25,16 634.35 Administration. The plan may be administered on either a statewide or a regional basis. The board shall select one or more administrators of the plan using a competitive bidding process.

SB698,25,20 634.40 Other employer-provided health care benefits. Nothing in this chapter prevents an employer, or a Taft-Hartly Trust on behalf of an employer, from paying all or part of any employee cost sharing under s. 634.25 (1) or from providing for the employer's employees any health care benefits not provided under the plan.

SB698, s. 57 Section 57 . Nonstatutory provisions.

SB698,25,25 (1) Terms of initial members of health plan board. Notwithstanding the length of terms specified for the members of the Wisconsin health plan board under section 15.735 (1) (c) of the statutes, as created by this act, the initial members of the Wisconsin health plan board shall be appointed for the following terms:

SB698,26,3 (a) Two members specified under section 15.735 (1) (a) 1. of the statutes, as created by this act, and one member specified under section 15.735 (1) (a) 2. of the statutes, as created by this act, for terms expiring on May 1, 2010.

SB698,26,6 (b) One member specified under section 15.735 (1) (a) 1. of the statutes, as created by this act, and 2 members specified under section 15.735 (1) (a) 2. of the statutes, as created by this act, for terms expiring on May 1, 2011.

SB698,26,9 (c) Two members specified under section 15.735 (1) (a) 1. of the statutes, as created by this act, and 2 members specified under section 15.735 (1) (a) 2. of the statutes, as created by this act, for terms expiring on May 1, 2012.

SB698,26,12 (2) Waivers. The office of the commissioner of insurance shall, no later than the first day of the 7th month beginning after the effective date of this subsection, do all of the following:

SB698,26,14 (a) Request waivers from the secretary of the federal department of health and human services for all of the following purposes:

SB698,26,19 1. To allow the use of federal financial participation to fund the benefits provided under the Wisconsin Health Care Plan to individuals who are eligible to receive health care services under Medical Assistance, the Badger Care health care program, or any other health care program other than Medicare financed at least in part with federal funds.

SB698,26,23 2. To allow individuals who are eligible for coverage under Medical Assistance, the Badger Care health care program, or any other health care program other than Medicare financed at least in part with federal funds to be covered under the Wisconsin Health Care Plan.

SB698,27,3 3. To allow individuals with coverage under Medical Assistance or the Badger Care health care program to purchase prescription drugs at discounted prices under agreements negotiated for Wisconsin Health Care Plan participants.

SB698,27,8 (b) Request a waiver of federal laws related to a program providing benefits comparable to state worker's compensation benefits to allow individuals paying for prescription drugs under the federal program to purchase prescription drugs at discounted prices under agreements negotiated for Wisconsin Health Care Plan participants.

SB698, s. 58 Section 58 . Initial applicability.

SB698,27,15 (1) If a comprehensive health insurance policy covering an employee is in effect on the effective date of this subsection and has a term that extends beyond the first day of the 13th month beginning after effective date of this subsection, this act first applies to that employee, with respect to coverage and cost sharing under the Wisconsin Health Care Plan, and to the employee's employer, with respect to paying an assessment for the employee, on the day on which the policy terminates.

SB698,27,22 (2) If compliance with the requirements of this act would impair any provision of a contract to which an employer is a party, that is related to providing health care benefits to the employer's employees on a self-insured basis, and that is in effect on the effective date of this subsection, this act first applies to that employer, with respect to paying assessments for the employer's employees, and to the employer's employees, with respect to coverage and cost sharing under the Wisconsin Health Care Plan, on the day on which the contract terminates.