Amendment SA1-SSA1-SB40

SB40-SSA1-SA1,244,19 (a) Establish and administer a health care system in this state that ensures that all eligible persons have access to high quality, timely, and affordable health care. In establishing and administering the health care system, except as otherwise provided by law, the board shall seek to attain all of the following goals:

SB40-SSA1-SA1,244,21 1. Every resident of this state shall have access to affordable, comprehensive health care services.

SB40-SSA1-SA1,244,23 2. Health care reform shall maintain and improve choice of health care providers and high quality health care services in this state.

SB40-SSA1-SA1,244,25 3. Health care reform shall implement cost containment strategies that retain and assure affordable coverage for all residents of this state.

SB40-SSA1-SA1,245,1 (b) Establish, fund, and manage the plan as provided in this chapter.

SB40-SSA1-SA1,245,5 (c) Appoint an executive director, who shall serve at the pleasure of the board. The board may delegate to one or more of its members or its executive director any powers and duties the board considers proper. The executive director shall receive such compensation as may be determined by the board.

SB40-SSA1-SA1,245,9 (d) Provide for mechanisms to enroll every eligible resident in this state under the plan. Contracts entered into by the board with providers shall include provisions to enroll all eligible persons at the point of service, and outreach programs to assure every eligible person becomes enrolled in the plan.

SB40-SSA1-SA1,245,11 (e) Create a program for consumer protection and a process to resolve disputes with providers.

SB40-SSA1-SA1,245,15 (f) Establish an independent and binding appeals process for resolving disputes over eligibility and other determinations made by the board. Any person who is adversely affected by a board eligibility determination or any other determination is entitled to judicial review of the determination.

SB40-SSA1-SA1,245,17 (g) Submit an annual report on its activities to the governor and chief clerk of each house of the legislature, for distribution under s. 13.172 (2).

SB40-SSA1-SA1,245,21 (h) Contract for annual, independent, program evaluations and financial audits that measure the extent to which the plan is achieving the goals under par. (a) 1. to 3. The board may not enter into a contract with the same auditor for more than 6 years.

SB40-SSA1-SA1,245,25 (i) Accept bids from health care networks in accordance with the criteria set out in s. 260.30, or make payments to fee-for-service providers in accordance with s. 260.30. The board shall consult with the department of employee trust funds in determining the most effective and efficient way of purchasing health care benefits.

SB40-SSA1-SA1,246,2 (j) Audit health care networks and providers to determine if their services meet the plan objectives and criteria under this chapter.

SB40-SSA1-SA1,246,5 (5) Powers. The board shall have all the powers necessary or convenient to carry out the purposes and provisions of this chapter. In addition to all other powers granted the board under this chapter, the board may:

SB40-SSA1-SA1,246,7 (a) Adopt, amend, and repeal bylaws and policies and procedures for the regulation of its affairs and the conduct of its business.

SB40-SSA1-SA1,246,8 (b) Have a seal and alter the seal at pleasure.

SB40-SSA1-SA1,246,9 (c) Maintain an office.

SB40-SSA1-SA1,246,10 (d) Sue and be sued.

SB40-SSA1-SA1,246,12 (e) Accept gifts, grants, loans, or other contributions from private or public sources.

SB40-SSA1-SA1,246,14 (f) Establish the authority's annual budget and monitor the fiscal management of the authority.

SB40-SSA1-SA1,246,16 (g) Execute contracts and other instruments, including contracts for any professional services required for the authority.

SB40-SSA1-SA1,246,18 (h) Employ any officers, agents, and employees that it may require and determine their qualifications and compensation.

SB40-SSA1-SA1,246,19 (i) Procure liability insurance.

SB40-SSA1-SA1,246,21 (j) Contract for studies on issues, as identified by the board or by the advisory committee under s. 260.49, that relate to the plan.

SB40-SSA1-SA1,246,23 (k) Borrow money, as necessary on a short-term basis, to address cash flow issues.

SB40-SSA1-SA1,246,25 (L) Compel witnesses to attend meetings and to testify upon any necessary matter concerning the plan.

SB40-SSA1-SA1,247,3 260.10 Eligibility. (1) Covered persons. Except as provided in subs. (2) to (5) and subject to sub. (6), a person is eligible to participate in the plan if the person satisfies all of the following criteria:

SB40-SSA1-SA1,247,5 (a) The person has maintained his or her place of permanent abode, as defined by the board, in this state for at least 12 months.

SB40-SSA1-SA1,247,7 (b) The person maintains a substantial presence in this state, as defined by the board.

SB40-SSA1-SA1,247,8 (c) The person is under 65 years of age.

SB40-SSA1-SA1,247,12 (d) The person is not eligible for health care coverage from the federal government or a foreign government, is not an inmate of a penal facility, as defined in s. 19.32 (1e), and is not placed or confined in, or committed to, an institution for the mentally ill or developmentally disabled.

SB40-SSA1-SA1,247,15 (e) Unless a waiver requested under sub. (6) (b) has been granted and is in effect, the person is not eligible for Medical Assistance under subch. IV of ch. 49 or for health care coverage under the Badger Care health care program under s. 49.665.

SB40-SSA1-SA1,247,20 (2) Gainfully employed. If a person and the members of the person's immediate family do not meet the criteria under sub. (1) (a) and (b), but do meet the criteria under sub. (1) (c) to (e) and the person is gainfully employed in this state, as defined by the board, the person and the members of the person's immediate family are eligible to participate in the plan.

SB40-SSA1-SA1,247,24 (3) Dependent children. If a child under age 18 resides with his or her parent in this state but the parent does not yet meet the residency requirement under sub. (1) (a), the child is eligible to participate in the plan regardless of the length of time the child has resided in this state.

SB40-SSA1-SA1,248,4 (4) Pregnant women. A pregnant woman who resides in this state who does not yet meet the residency requirement under sub. (1) (a) is eligible to participate in the plan regardless of the length of time the pregnant woman has resided in this state.

SB40-SSA1-SA1,248,10 (5) Collective bargaining agreement. A person who is eligible to participate in the plan under sub. (1), (2), (3), or (4) and who receives health care coverage under a collective bargaining agreement that is in effect on January 1, 2009, is not eligible to participate in the plan until the day on which the collective bargaining agreement expires or the day on which the collective bargaining agreement is extended, modified, or renewed.

SB40-SSA1-SA1,248,12 (6) Waiver request. (a) In this subsection, "department" means the department of health and family services.

SB40-SSA1-SA1,248,20 (b) 1. The department shall develop a request for a waiver from the secretary of the federal department of health and human services to provide coverage under the plan to individuals who are eligible for Medical Assistance under subch. IV of ch. 49 in the low-income families category, as determined by the department, and to individuals who are eligible for health care coverage under the Badger Care health care program under s. 49.665. The waiver request shall be written so as to allow the use of federal financial participation to fund, to the maximum extent possible, health care coverage under the plan for the individuals specified in this subdivision.

SB40-SSA1-SA1,249,2 2. The department shall, not later than July 1, 2008, submit the waiver request developed under subd. 1. to a special legislative committee that shall be comprised of the members of the joint committee on finance and the members of the standing committees of the senate and the assembly with subject matter jurisdiction over health issues. The special legislative committee shall have 60 days to review and comment to the department on the waiver request.

SB40-SSA1-SA1,249,5 (c) Except as required under par. (b), the department may develop waiver requests to the appropriate federal agencies to permit funds from federal health care services programs to be used for health care coverage for persons under the plan.

SB40-SSA1-SA1,249,7 (7) Definitions of terms. For purposes of this chapter, the board shall define all of the following terms:

SB40-SSA1-SA1,249,8 (a) Place of permanent abode.

SB40-SSA1-SA1,249,19 (b) Substantial presence this state. In defining "substantial presence in this state," the board shall consider such factors as the amount of time per year that an individual is actually present in the state and the amount of taxes that an individual pays in this state, except that, if the individual attends school outside of this state and is under 23 years of age, the factors shall include the amount of time that the individual's parent or guardian is actually present in the state and the amount of taxes that the individual's parent or guardian pays in this state, and if the individual is in active service with the U.S. armed forces outside of this state, the factors shall include the amount of time that the individual's parent, guardian, or spouse is actually present in the state and the amount of taxes that the individual's parent, guardian, or spouse pays in this state.

SB40-SSA1-SA1,249,20 (c) Immediate family.

SB40-SSA1-SA1,249,22 (d) Gainfully employed. The definition shall include employment by persons who are self-employed and persons who work on farms.

SB40-SSA1-SA1,250,6 260.12 Office of outreach, enrollment, and advocacy. (1) Establishment. The board shall establish an office of outreach, enrollment, and advocacy. The office shall contract with nonprofit organizations to perform the outreach, enrollment, and advocacy functions specified in this section, and to review the health care payment and services records of persons who are participating, or who are eligible to participate, in the plan and who have provided the office with informed consent for the review. The office may not contract with any organization under this subsection that provides services under the plan or that has any other conflict of interest, as described in sub. (3).

SB40-SSA1-SA1,250,8 (2) Duties. The office of outreach, enrollment, and advocacy shall do all of the following:

SB40-SSA1-SA1,250,10 (a) Engage in aggressive outreach to enroll eligible persons and participants in their choice of health care coverage under the plan.

SB40-SSA1-SA1,250,13 (b) Assist eligible persons in choosing health care coverage by examining cost, quality, and geographic coverage information regarding their choice of available networks or providers.

SB40-SSA1-SA1,250,18 (c) Inform plan participants of the role they can play in holding down health care costs by taking advantage of preventive care, enrolling in chronic disease management programs if appropriate, responsibly utilizing medical services, and engaging in healthy lifestyles. The office shall inform participants of networks or workplaces where healthy lifestyle incentives are in place.

SB40-SSA1-SA1,250,20 (d) At the direction of the board, establish a process for resolving disputes with providers.

SB40-SSA1-SA1,250,25 (e) Act as an advocate for plan participants having questions, difficulties, or complaints about their health care services or coverage, including investigating and attempting to resolve the complaint. Investigation should include, when appropriate, consulting with the health care advisory committee under s. 260.49 regarding best practice guidelines.

SB40-SSA1-SA1,251,4 (f) If a participant's complaint cannot be successfully resolved, inform the participant of any legal or other means of recourse for his or her complaint. If the complaint involves a dispute over eligibility or other determinations made by the board, the participant shall be directed to the appeals process for board decisions.

SB40-SSA1-SA1,251,8 (g) Provide information to the public, agencies, legislators, and others regarding problems and concerns of plan participants and, in consultation with the health care advisory committee under s. 260.49, make recommendations for resolving those problems and concerns.

SB40-SSA1-SA1,251,10 (h) Ensure that plan participants have timely access to the services provided by the office.

SB40-SSA1-SA1,251,15 (3) Conflict of interest limitation. The office and its employees and contractors shall not have any conflict of interest relating to the performance of their duties. There is a conflict of interest if, with respect to the office's director, employees, or contractors, or a person affiliated with the office's director, employees, or contractors, any of the following exists:

SB40-SSA1-SA1,251,17 (a) Direct involvement in the licensing, certification, or accreditation of a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,251,19 (b) Direct ownership interest or investment interest in a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,251,21 (c) Employment by, or participation in, the management of a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,251,24 (d) Receipt of, or having the right to receive, directly or indirectly, remuneration under a compensation arrangement with a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,252,7 260.15 Benefits. (1) Generally. The board shall establish a health care plan that will take effect on January 1, 2009. The plan shall provide the same benefits as those that were in effect as of January 1, 2007, under the state employee health plan under s. 40.51 (6). The board may adjust the plan benefits to provide additional cost-effective treatment options if there is evidence-based research that the options are likely to reduce health care costs, avoid health risks, or result in better health outcomes.

SB40-SSA1-SA1,252,11 (2) Additional benefits. In addition to the benefit requirements under sub. (1), the plan shall provide coverage for mental health services and alcohol or other drug abuse treatment to the same extent as the plan covers treatment for physical conditions and coverage for preventive dental care for children up to 18 years of age.

SB40-SSA1-SA1,252,13 260.20 Cost sharing. (1) No cost sharing. The plan shall cover the following preventive services without any cost-sharing requirement:

SB40-SSA1-SA1,252,14 (a) Prenatal care for pregnant women.

SB40-SSA1-SA1,252,15 (b) Well-baby care.

SB40-SSA1-SA1,252,17 (c) Medically appropriate examinations and immunizations for children up to 18 years of age.

SB40-SSA1-SA1,252,19 (d) Medically appropriate gynecological exams, Papanicolaou tests, and mammograms.

SB40-SSA1-SA1,252,21 (e) Medically appropriate regular medical examinations for adults, as determined by best practices.

SB40-SSA1-SA1,252,22 (f) Medically appropriate colonoscopies.

SB40-SSA1-SA1,252,23 (g) Preventive dental care for children up to 18 years of age.

SB40-SSA1-SA1,253,3 (h) Other preventive services or procedures, as determined by the board, for which there is scientific evidence that exemption from cost sharing is likely to reduce health care costs or avoid health risks.

SB40-SSA1-SA1,253,6 (i) Chronic care services, provided that the participant receiving the services is participating in, and complying with, a chronic disease management program as defined by the board.

SB40-SSA1-SA1,253,10 (2) Deductibles. (a) Maximum amounts and who must pay. 1. Subject to subd. 2., during any year, a participant who is 18 years of age or older on January 1 of that year shall pay a deductible of $300, which shall apply to all covered services and articles.

SB40-SSA1-SA1,253,13 2. During any year, a family consisting of 2 or more participants who are 18 years of age or older on January 1 of that year shall pay a deductible of $600, which shall apply to all covered services and articles.

SB40-SSA1-SA1,253,15 3. During any year, a participant who is under 18 years of age on January 1 of that year shall not be required to pay a deductible.

SB40-SSA1-SA1,253,20 4. Except for copayments and coinsurance, the plan shall provide a participant with full coverage for all covered services and articles after the participant has received covered services and articles totaling the applicable deductible amount under this paragraph, regardless of whether the participant has paid the deductible amount.

SB40-SSA1-SA1,254,6 (b) Provider requirements. 1. A provider that provides to a participant a covered service or article to which a deductible applies shall charge for the service or article the payment rate established by the board under s. 260.30 (7) (b) 1. if the participant's coverage is under the fee-for-service option under s. 260.30 (2) (a) or the applicable network rate for the service or article, as determined by the board, if the participant's coverage is under the health care network option under s. 260.30 (2) (b). Except as provided in subd. 3., a provider of a covered service or article to which a deductible applies shall accept as payment in full for the covered service or article the payment rate specified in this subdivision and may not bill a participant who receives the service or article for any amount by which the charge for the service or article is reduced under this subdivision.

SB40-SSA1-SA1,254,10 2. Except for prescription drugs, a provider may not refuse to provide to a participant a covered service or article to which a deductible applies on the basis that the participant does not pay, or has not paid, any applicable deductible amount before the service or article is provided.

SB40-SSA1-SA1,254,17 3. A provider may not charge any interest, penalty, or late fee on any deductible amount owed by a participant unless the deductible amount owed is at least 6 months past due and the provider has provided the participant with notice of the interest, penalty, or late fee at least 90 days before the interest, penalty, or late fee payment is due. Interest may not exceed 1 percent per month, and any penalty or late fee may not exceed the provider's reasonable cost of administering the unpaid bill.

SB40-SSA1-SA1,254,20 (c) Adjustments by board. Notwithstanding par. (a) 1. and 2., the board may adjust the deductible amounts specified in par. (a) 1. and 2., but only to reduce those amounts.

SB40-SSA1-SA1,254,24 (3) Copayments and coinsurance. (a) General copayments. During any year, a participant who is 18 years of age or older on January 1 of that year shall pay a copayment of $20 for medical, hospital, and related health care services, as determined by the board.

SB40-SSA1-SA1,255,4 (b) Specialist provider services without referral. A participant, regardless of age, who receives health care services from a specialist provider without a referral from his or her primary care provider under the plan shall be required to pay 25 percent of the cost of the services provided.

SB40-SSA1-SA1,255,7 (c) Inappropriate emergency room use. Notwithstanding par. (a), a participant who is 18 years of age or older shall pay a copayment of $60 for inappropriate emergency room use, as determined by the board.

SB40-SSA1-SA1,255,9 (d) Prescription drugs. 1. All participants, regardless of age, shall pay $5 for each prescription of a generic drug that is on the formulary determined by the board.

SB40-SSA1-SA1,255,11 2. All participants, regardless of age, shall pay $15 for each prescription of a brand-name drug that is on the formulary determined by the board.

SB40-SSA1-SA1,255,13 3. All participants, regardless of age, shall pay $40 for each prescription of a brand-name drug that is not on the formulary determined by the board.

SB40-SSA1-SA1,255,16 4. Notwithstanding subds. 1. to 3., no participant shall pay more for a prescription drug than the actual cost of the prescription drug plus the negotiated dispensing fee.

SB40-SSA1-SA1,255,18 (e) Adjustments by board. Notwithstanding pars. (a) to (d), the board may adjust the copayment and coinsurance amounts specified in pars. (a) to (d).

SB40-SSA1-SA1,255,20 (4) Maximum amounts. Notwithstanding the deductible, coinsurance, and copayment amounts in subs. (2) and (3), all of the following apply: