c. One or more members of the individual's family were eligible for other health insurance coverage or Medical Assistance at the time the employee failed to enroll in the health insurance coverage under par. (b) 1. and no member of the family was eligible for coverage under this section at that time.
d. The individual's access to health insurance coverage has ended due to the death or change in marital status of the subscriber.
e. Any other reason that the department determines is a good cause reason.
(e) If a pregnant woman has health insurance coverage and her family income exceeds 200 percent of the poverty line, the woman is required, as a condition of eligibility, to maintain the health insurance coverage.
(f) If an individual with a family income that exceeds 150 percent of the poverty line had the health insurance coverage specified in par. (b) 1. but no longer has the coverage, if an individual who is an unborn child or an unborn child's mother, regardless of family income, had health insurance coverage but no longer has the coverage, or if a pregnant woman specified in par. (e) has health insurance coverage and does not maintain the coverage, the individual or pregnant woman is not eligible for BadgerCare Plus for the 3 calendar months following the month in which the insurance coverage ended without a good cause reason specified in par. (g).
(g) Any of the following is a good cause reason for purposes of par. (f):
1. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employment ended for a reason other than voluntary termination, unless the voluntary termination was a result of the incapacitation of the subscriber or because on an immediate family member's health condition.
2. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, the subscriber changed employers, and the new employer does not offer health insurance coverage.
3. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employer discontinued health plan coverage for all employees.
4. The pregnant woman's coverage was continuation coverage and the continuation coverage was exhausted in accordance with 29 CFR 2590.701-2 (4).
5. The individual's or pregnant woman's coverage terminated due to the death or change in marital status of the subscriber.
6. Any other reason determined by the department to be a good cause reason.
(9) EMPLOYER VERIFICATION OF INSURANCE COVERAGE. (a) 1. Except as provided in subd. 2., for an applicant or recipient with a family income that exceeds 150 percent of the poverty line, the department shall verify insurance coverage and access information directly with the employer through which the applicant or recipient may have health insurance coverage or access to coverage.
2. Subdivision 1. does not apply to any of the following:
a. A pregnant woman.
b. A child described in sub. (4) (a) 2. or (b) 2.
c. An individual described in sub. (4) (a) 5.
(b) An employer that receives a request from the department for insurance coverage and access to coverage information shall supply the information requested by the department in the format specified by the department within 30 calendar days after receiving the request.
(c) 1. Subject to subds. 2. and 3., an employer that does not comply with the requirements under par. (b) shall be required to pay, within 45 days after the requested information was due, a penalty equal to the full per member per month cost of coverage under BadgerCare Plus for the individual about whom the information is requested, and for each of the individual's family members with coverage under BadgerCare Plus, for each month in which the individual and the individual's family members are covered before the employer provides the information.
2. An employer with fewer than 250 employees may not be required to pay more than $1,000 in penalties under this paragraph that are attributable to any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in penalties under this paragraph that are attributable to any 6-month period.
3. Notwithstanding subd. 1., an employer shall not be subject to any penalties if the employer, at least once per year, timely provides to the department, in the manner and format specified by the department, information from which the department may determine whether the employer provides its employees with access to health insurance coverage.
4. All penalty assessments collected under this paragraph shall be credited to the appropriation accounts under s. 20.435 (4) (jw) and (jz).
(d) An employer may contest a penalty assessment under par. (c) by sending a written request for hearing to the division of hearings and appeals in the department of administration. Proceedings before the division are governed by ch. 227.
(10) COST SHARING. (a) Copayments. Except as provided in s. 49.45 (18) (am), all cost-sharing provisions under s. 49.45 (18) apply to a recipient with coverage of the benefits described in s. 49.46 (2) (a) and (b) to the same extent as they apply to a person eligible for medical assistance under s. 49.46, 49.468, or 49.47.
(b) Premiums. 1. Except as provided in subd. 4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income. If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted.
2. Except as provided in subds. 3. and 4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line.
3. Except as provided in subd. 4., a recipient who is an unborn child, or a pregnant woman eligible under sub. (4) (b) 1., whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for an adult with a family income of 300 percent of the poverty line.
4. None of the following shall pay a premium:
a. A child who is a Native American or an Alaskan Native with a family income that does not exceed 300 percent of the poverty line.
b. A child who is eligible under sub. (4) (a) 2. or (b) 2.
c. A child whose family income does not exceed 200 percent of the poverty line.
d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.
e. A child who obtains eligibility under sub. (7) (b) 2.
f. An individual who is eligible under sub. (4) (a) 5.
5. If a recipient who is required to pay a premium under this paragraph or under sub. (4) (c) does not pay a premium when due, the recipient's coverage terminates and the recipient is not eligible for BadgerCare Plus for 6 calendar months following the date on which the recipient's coverage terminated.
(11) BENCHMARK PLAN BENEFITS AND COPAYMENTS. Recipients who are not eligible for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following benefits and pay the following copayments:
(a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and subject to the Badger Rx Gold program discounts.
(b) Physicians' services, including one annual routine physical examination, with a copayment of no more than $15 per visit.
(c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.
(d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall require a copayment of no more than $75.
(e) Laboratory and X-ray services, including mammography.
(f) Home health services, limited to 60 visits per year.
(g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6).
(L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided.
(m) Transportation to obtain emergency medical care only, as medically necessary, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.
(o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.
(p) Early childhood developmental services, for children under 6 years of age.
(q) Smoking cessation treatment, for pregnant women only.
(r) Prenatal care coordination, for pregnant women at high risk only.
(11m) PROVIDER PAYMENTS AND REQUIREMENTS. The provider of a service or equipment under sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under sub. (11) to a recipient who is unable to share costs as specified in sub. (11), the recipient is not relieved of liability for those costs.
(12) RULES; NOTICE OF EFFECTIVE DATE. (a) 1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.
2. The department may promulgate emergency rules under s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.
(b) If the amendments to the state plan submitted under sub. (2) are approved and a waiver that is consistent with all of the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.
SECTION 57. 49.473 (2) (a) of the statutes is amended to read:
49.473 (2) (a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health care coverage under s. 49.665.
SECTION 58. 49.49 (3m) (a) (intro.) of the statutes is amended to read:
49.49 (3m) (a) (intro.) No provider may knowingly impose upon a recipient charges in addition to payments received for services under ss. 49.45 to 49.47 49.471 or knowingly impose direct charges upon a recipient in lieu of obtaining payment under ss. 49.45 to 49.47 49.471 except under the following conditions:
SECTION 59. 49.49 (3m) (a) 1. of the statutes is amended to read:
49.49 (3m) (a) 1. Benefits or services are not provided under s. 49.46 (2) or 49.471 (11) and the recipient is advised of this fact prior to receiving the service.
SECTION 60. 49.49 (3m) (a) 2. of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:
49.49 (3m) (a) 2. If an applicant is determined to be eligible retroactively under s. 49.46 (1) (b) or, 49.47 (4) (d), or 49.471 and a provider bills the applicant directly for services and benefits rendered during the retroactive period, the provider shall, upon notification of the applicant's retroactive eligibility, submit claims for payment under s. 49.45 for covered services or benefits rendered to the recipient during the retroactive period. Upon receipt of payment under s. 49.45, the provider shall reimburse the recipient or other person who has made prior payment to the provider for services provided to the recipient during the retroactive eligibility period, by the amount of the prior payment made.
****NOTE: This is reconciled s. 49.49 (3m) (a) 2. This SECTION has been affected by LRB-0250 and LRB-0905.
SECTION 61. 49.49 (3m) (a) 3. of the statutes is amended to read:
49.49 (3m) (a) 3. Benefits or services for which recipient copayment, coinsurance, or deductible is required under s. 49.45 (18), not to exceed maximum amounts allowable under 42 CFR 447.53 to 447.58, or for which recipient copayment or coinsurance is required under s. 49.471 (11).
SECTION 62. 49.497 (title) of the statutes is amended to read:
49.497 (title) Recovery of incorrect Medical Assistance or Badger Care payments and of unpaid employer penalties.
SECTION 63. 49.497 (1r) of the statutes is created to read:
49.497 (1r) (a) The department may recover any penalty assessment not paid under s. 49.471 (9) (c) from the employer against which the penalty was assessed. If, after notice that payment of a penalty is overdue, the employer who is liable fails to pay the penalty amount, or enter into or comply with an agreement for payment, the department may bring an action to enforce the liability or may issue an order to compel payment of the liability. Any person aggrieved by an order issued by the department under this paragraph may appeal the order as a contested case under ch. 227 by filing with the department a request for a hearing within 30 days after the date of the order. The only issue at the hearing shall be the determination by the department that the person has not paid the penalty or entered into, or complied with, an agreement for payment.
(b) If any employer named in an order to compel payment issued under par. (a) fails to pay the department any amount due under the terms of the order and no contested case to review the order is pending and the time for filing for a contested case review has expired, the department may present a certified copy of the order to the circuit court for any county. The sworn statement of the secretary shall be evidence of the failure to pay the penalty. The circuit court shall, without notice, render judgment in accordance with the order. A judgment rendered under this paragraph shall have the same effect and shall be entered in the judgment and lien docket and may be enforced in the same manner as if the judgment had been rendered in an action tried and determined by the circuit court.
(c) The recovery procedure under this subsection is in addition to any other recovery procedure authorized by law.
SECTION 64. 49.497 (4) of the statutes is amended to read:
49.497 (4) The department may appear for the state in any and all collection matters under this section, and may commence suit in the name of the department to recover an incorrect payment from the recipient to whom or on whose behalf it was made or to recover an unpaid penalty from the employer against which the penalty was assessed.
SECTION 65. 49.665 (4) (ap) 2. of the statutes is repealed.
SECTION 66. 49.665 (7) (a) 1. of the statutes is amended to read:
49.665 (7) (a) 1. Notwithstanding sub. (4) (a) 3m. and (ap) 2., the department shall mail information verification forms to the employers of the individuals required to provide the verifications under sub. (4) (a) 3m. and (ap) 2. to obtain the information specified.
SECTION 67. 49.688 (5) (a) (intro.) of the statutes is amended to read:
49.688 (5) (a) (intro.) Beginning on September 1, 2002, except as provided in sub. (7) (b), as a condition of participation by a pharmacy or pharmacist in the program under s. 49.45, 49.46, or 49.47, or 49.471, the pharmacy or pharmacist may not charge a person who presents a valid prescription order and a card indicating that he or she meets eligibility requirements under sub. (2) an amount for a prescription drug under the order that exceeds the following:
SECTION 68. 49.785 (1) (intro.) of the statutes is amended to read:
49.785 (1) (intro.) Except as provided in sub. (1m), if any recipient of benefits under s. 49.148, 49.46 or 49.77, or under 42 USC 1381 to 1385 in effect on May 8, 1980, specified in sub. (1c) dies and the estate of the deceased recipient is insufficient to pay the funeral, burial, and cemetery expenses of the deceased recipient, the county or applicable tribal governing body or organization responsible for burial of the recipient shall pay, to the person designated by the county department under s. 46.215, 46.22, or 46.23 or applicable tribal governing body or organization responsible for the burial of the recipient, all of the following:
SECTION 69. 49.785 (1c) of the statutes is created to read:
49.785 (1c) All of the following are eligible recipients under this section:
(a) A recipient of benefits under s. 49.148, 49.46, or 49.77, or under 42 USC 1381 to 1385 in effect on May 8, 1980.
(b) A recipient of benefits under s. 49.471 who is any of the following:
1. A pregnant woman or a child under 6 years of age with a family income not exceeding 185 percent of the poverty line at the time of death.
2. A child at least 6 years of age but less than 19 years of age with a family income not exceeding 100 percent of the poverty line at the time of death.
