Amendment SA1-SSA1-SB40

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:

SB40-SSA1-SA1,255,23 (a) Subject to par. (b), a participant who is 18 years of age or older on January 1 of a year may not be required to pay more than $2,000 during that year in total cost sharing under subs. (2) and (3).

SB40-SSA1-SA1,255,25 (b) A family consisting of 2 or more participants may not be required to pay more than $3,000 during a year in total cost sharing under subs. (2) and (3).

SB40-SSA1-SA1,256,7 260.30 Service areas; selection and payment of health care providers and health care networks. (1) Establishment of areas where services will be provided. The board may establish areas in the state, which may be counties, multicounty regions, or other areas, for the purpose of receiving bids from health care networks. These areas shall be established so as to maximize the level and quality of competition among health care networks or to increase the number of provider choices available to eligible persons and participants in the areas.

SB40-SSA1-SA1,256,10 (2) Options available in each area. In each area designated by the board under sub. (1), the board shall offer both of the following options for delivery of health care services under the plan:

SB40-SSA1-SA1,256,19 (a) An option, known as the "fee-for-service option," under which participants must choose a primary care provider, may be referred by the primary care provider to any medical specialist, and may be admitted by the primary care provider or specialist to any hospital or other facility, for the purpose of receiving the benefits provided under this chapter. Under this option, the board, with the assistance of one or more administrators chosen by a competitive bidding process and with whom the board has contracted, shall pay directly, at the provider payment rates established by the board under sub. (7) (b) 1., for all health care services and articles that are covered under the plan.

SB40-SSA1-SA1,256,24 (b) An option under which one or more health care networks that meet the qualifying criteria in sub. (4) and are certified under sub. (5) provide health care services to participants. The board is required to offer this option in each area designated by the board to the extent that qualifying health care networks exist in the area.

SB40-SSA1-SA1,257,5 (3) Solicitation of bids from health care networks. The board shall annually solicit sealed risk-adjusted premium bids from competing health care networks for the purpose of offering health care coverage to participants. The board shall request each bidder to submit information pertaining to whether the bidder is a qualifying health care network, as described in sub. (4).

SB40-SSA1-SA1,257,7 (4) Qualifying health care networks. A health care network is qualifying if it does all of the following:

SB40-SSA1-SA1,257,13 (a) Demonstrates to the satisfaction of the board that the fixed monthly risk-adjusted amount that it bids to provide participants with the health care benefits specified in this chapter reasonably reflects its estimated actual costs for providing participants with such benefits in light of its underlying efficiency as a network, and has not been artificially underbid for the predatory purpose of gaining market share.

SB40-SSA1-SA1,257,15 (b) Will spend at least 92 percent of the revenue it receives under this chapter on one of the following:

SB40-SSA1-SA1,257,17 1. Payments to health care providers in order to provide the health care benefits specified in this chapter to participants who choose the health care network.

SB40-SSA1-SA1,257,19 2. Investments that the health care network has reasonably determined will improve the overall quality or lower the overall cost of patient care.

SB40-SSA1-SA1,257,20 (c) Ensures all of the following:

SB40-SSA1-SA1,257,24 1. That participants living in an area that a health care network serves shall not be required to drive more than 30 minutes, or, in a metropolitan area served by mass transit, spend more than 60 minutes using mass transit facilities, in order to reach the offices of at least 2 primary care providers, as defined by the board.

SB40-SSA1-SA1,258,5 2. That physicians, physician assistants, nurses, clinics, hospitals, and other health care providers and facilities, including providers and facilities that specialize in mental health services and alcohol or other drug abuse treatment, are conveniently available, as defined by the board, to participants living in every part of the area that the health care network serves.

SB40-SSA1-SA1,258,9 (d) Ensures that participants have access, 24 hours a day, 7 days a week, to a toll-free hotline and help desk that is staffed by persons who live in the area and who have been fully trained to communicate the benefits provided under this chapter and the choices of providers that participants have in using the health care network.

SB40-SSA1-SA1,258,11 (e) Ensures that each participant who chooses the health care network selects a primary care provider who is responsible for overseeing all of the participant's care.

SB40-SSA1-SA1,258,14 (f) Will provide each participant with medically appropriate and high-quality health care, including mental health services and alcohol or other drug abuse treatment, in a highly coordinated manner.

SB40-SSA1-SA1,258,21 (g) Emphasizes, in its policies and operations, the promotion of healthy lifestyles; preventive care, including early identification of and response to high-risk individuals and groups, early identification of and response to health disorders, disease management, including chronic care management, and best practices, including the appropriate use of primary care, medical specialists, medications, and hospital emergency rooms; and the utilization of continuous quality improvement standards and practices that are generally accepted in the medical field.

SB40-SSA1-SA1,259,2 (h) Has developed and is implementing a program, including providing incentives to providers when appropriate, to promote health care quality, increase the transparency of health care cost and quality information, ensure the confidentiality of medical information, and advance the appropriate use of technology.

SB40-SSA1-SA1,259,10 (i) Has entered into shared service agreements with out-of-network medical specialists, hospitals, and other facilities, including medical centers of excellence in the state, through which participants can obtain, at no additional expense to participants beyond the normally required level of cost sharing, the services of out-of-network providers that the network's primary care physicians selected by participants have determined is necessary to ensure medically appropriate and high-quality health care, to facilitate the best outcome, or, without reducing the quality of care, to lower costs.

SB40-SSA1-SA1,259,12 (j) Has in place a comprehensive, shared, electronic patient records and treatment tracking system and an electronic provider payment system.

SB40-SSA1-SA1,259,14 (k) Has adopted and implemented a strong policy to safeguard against conflicts of interest.

SB40-SSA1-SA1,259,20 (L) Has been organized by physicians or other health care providers, a cooperative, or an entity whose mission includes improving the quality and lowering the cost of health care, including the avoidance of unnecessary operating and capital costs arising from inappropriate utilization or inefficient delivery of health care services, unwarranted duplication of services and infrastructure, or creation of excess capacity.

SB40-SSA1-SA1,259,25 (m) Agrees to enroll and provide the benefits specified in this chapter to all participants who choose the network, regardless of the participant's age, sex, race, religion, national origin, sexual orientation, health status, marital status, disability status, or employment status, except that a health care network may do one of the following:

SB40-SSA1-SA1,260,6 1. Limit the number of new enrollees it accepts if the health care network certifies to the board that accepting more than a specified number of enrollees would make it impossible to provide all enrollees with the benefits specified in this chapter at the level of quality that the network is committed to maintaining, provided that the health care network uses a random method for deciding which new enrollees it accepts.

SB40-SSA1-SA1,260,12 2. Limit the participants that it serves to a specific affinity group, such as farmers or teachers, that the health care network has certified to the board, provided that the limitation does not involve discrimination based on any of the factors described in this paragraph and has neither been created for the purpose, nor will have the effect, of screening out higher-risk enrollees. This subdivision applies only to affinity groups that are in existence as of December 31, 2007.

SB40-SSA1-SA1,260,17 (5) Certification of health care networks and classification of bids. (a) The board shall review the bids submitted under sub. (3), the information submitted by bidders pertaining to whether the bidders are qualifying health care networks, and other evidence provided to the board as to whether a particular bidder is a qualifying health care network.