AB94: Bill Text

AB94, s. 14 Section 14. Chapter 152 of the statutes is created to read:

AB94,8,7 Chapter 152 health plan

AB94,8,8 152.01 Definitions. In this chapter:

AB94,8,9 (1) "Block grant" has the meaning given in s. 16.54 (2) (a) 3.

AB94,8,10 (2) "Board" means the health policy board.

AB94,8,11 (3) "Department" means the department of health planning and finance.

AB94,8,12 (4) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a).

AB94,8,21 (5) "Health care facility" means a facility, as defined in s. 647.01 (4), or any hospital, nursing home, community-based residential facility, county home, county infirmary, county hospital, county mental health center, community health center, primary health center, tuberculosis sanatorium, adult family home, assisted living facility, rural medical center, hospice, or other place licensed, certified, or approved by the department of health and family services under s. 49.70, 49.71, 49.72, 50.02, 50.03, 50.032, 50.033, 50.034, 50.35, 50.52, 50.92 (2), 51.08, or 51.09 or a facility under s. 45.50, 51.05, 51.06, or 252.10 or ch. 233, or licensed or certified by a county department under s. 50.032 or 50.033.

AB94,8,23 (6) "Health care provider" means a provider of health care services or other benefits in this state that are specified under s. 152.10 (4).

AB94,8,25 (7) "Medicare" means coverage under part A or part B of Title XVIII of the federal Social Security Act, 42 USC 1395 to 1395hhh.

AB94,9,2 (8) "Reimbursement" means payment for the provision of services and other benefits that are specified under s. 152.10 (4).

AB94,9,3 (9) "Secretary" means the secretary of health planning and finance.

AB94,9,5 (10) "Veteran", except as otherwise provided, has the meaning given in 38 USC 101 (2).

AB94,9,13 152.10 Health plan. (1) There is created a health plan in this state, under which, beginning on July 1, 2010, each eligible person, regardless of any preexisting condition, shall receive reasonable medical service necessary to maintain health, enable diagnosis, or provide treatment or rehabilitation for an injury, condition, disability, or disease, for which reimbursement shall be made by the department. Coverage is provided under the health plan for orthodontia or for the performance of reconstructive or cosmetic surgery that is determined to be necessary under criteria that are promulgated as rules by the department.

AB94,9,17 (2) Each individual in this state who is not excluded from residency, as specified in sub. (3) (c), is eligible for coverage under the health plan, except as provided in sub. (5), and except that all of the following may be phased in for eligibility under this subsection, beginning no later than July 1, 2011:

AB94,9,19 (a) Individuals, other than those specified in par. (b), who have no coverage under disability insurance policies.

AB94,9,23 (b) Individuals who have no coverage under disability insurance policies and who receive health care, treatment for nervous or mental disorders, or treatment or prevention services for alcohol and other drug abuse that are funded by state or local funding.

AB94,9,25 (c) Individuals who are employees of the state or any county, city, village, or town, and who, as a benefit of the employment, have coverage for themselves and family members under provisions of group disability insurance policies or under self-insured health plans.

AB94,10,5 (d) Individuals, other than those specified in par. (c) or (h), who, by reason of their employment or as family members of individuals who are employed, have coverage under group disability insurance policies.

AB94,10,7 (e) Individuals who have coverage under individual disability insurance policies.

AB94,10,9 (f) Individuals who have coverage under the health insurance risk-sharing plan under subch. II of ch. 149.

AB94,10,12 (g) Individuals who are eligible for benefits or services under s. 49.46, 49.468, 49.47, 49.473, or 49.665, waiver programs under medical assistance, Medicare, or block grants that provide health care services.

AB94,10,15 (h) Individuals who are employees of self-insured employers, other than those specified in par. (c), and who receive health care benefits for themselves and family members under self-insured health plans.

AB94,10,16 (i) Individuals who receive medical benefits under worker's compensation.

AB94,10,21 (j) Veterans who receive medical benefits under 38 USC 1701 to 1754 and certain spouses and dependents of veterans who receive benefits under 38 USC 1781 to 1785 or 38 USC 1802 to 1834; and veterans, as defined in s. 45.01 (12), who receive medical benefits under s. 45.40 (2) and certain spouses and dependents of these veterans who receive medical benefits under s. 45.40 (2m).

AB94,10,23 (k) Members of federally-recognized American Indian tribes or bands who receive health and other services under 25 USC 1621 to 1683.

AB94,11,3 (3) (a) Any individual who is eligible under sub. (2) may receive services that are available under the health plan from any participating health care provider in this state. Services that correspond to those that are available under the health plan and that are provided to the individual in another state are reimbursable at rates under the health plan that are current at the time of service provision.

AB94,11,6 (b) No individual who is eligible under sub. (2) may under this section be required to pay an amount as a deductible or copayment as a condition for receipt of services under this section from a health care facility or health care provider.

AB94,11,10 (c) An individual who has a fixed habitation outside the state but not inside the state is not a resident for purposes of this chapter. Any reimbursement paid under the health plan for health care services rendered to an individual who is determined not to be a resident is a liability of the individual.

AB94,11,12 (4) Health care services and other benefits provided under the health plan shall include all of the following:

AB94,11,14 (a) Services of all persons licensed, certified, registered, or permitted to treat the sick under chs. 441, 446, 447, 448, 449, 450, 451, 455, 457, and 459.

AB94,11,16 (b) Health care services that are provided by health care facilities and the offices and clinics of persons under par. (a).

AB94,11,18 (c) Preventive health care services and health promotional programs, including well-child care, immunizations, screening, outreach, and education.

AB94,11,21 (d) Medical or surgical supplies and durable medical or surgical equipment, supplies and appliances, including valves, pacemakers, prostheses, eyeglasses, and hearing aids.

AB94,11,24 (e) Prescription drugs specified in the listing of approved medicinal substances and formulae under s. 152.40 (5) (n) and any other drugs specified by the department by rule.

AB94,11,25 (f) Blood and blood products.

AB94,12,5 (g) Long-term care services that are necessary for the physical health, mental and emotional well-being, and social and personal needs of individuals who have limited self-care capabilities, including services of health care facilities; home health care; hospice care; home-based and community-based services, including personal assistance and attendant care; and periodic needs assessments.

AB94,12,7 (h) Mental health treatment and services, including substance abuse and brain injury treatment.

AB94,12,8 (i) Dental services, as specified under s. 49.46 (2) (b) 1.

AB94,12,11 (5) The health plan is the payer of last resort, and coverage under the health plan is supplemental to any health care coverage in force that is held by an individual.

AB94,12,15 (6) As a condition of participation by a health care provider in the health plan, the health care provider shall accept reimbursement only under the health plan for all services or other benefits that the health care provider provides under the health plan.

AB94,12,18 152.20 Health policy board; powers and duties. (1) The board shall approve and continually evaluate the listing of approved medicinal substances and formulae that is required under s. 152.40 (5) (n).

AB94,12,21 (2) The board shall biennially evaluate and oversee cost containment guidelines and policies, including the evaluation of mechanisms used to contain costs of providing services, and shall revise the guidelines and policies as necessary.

AB94,12,23 (3) The board shall review all of the following issues and formulate or revise policies, as appropriate, with respect to the issues:

AB94,12,24 (a) Duties of the department that require policy determinations.

AB94,13,3 (b) The sources and amounts of revenues for the administration of the department and the board and for financing the payment of health care services that are provided to residents under the health plan.

AB94,13,4 (c) Information provided by the regional consumer health councils.

AB94,13,8 (d) Development of a system for determination and periodic review of areas in this state, and specific populations within those areas, that are medically underserved; and development of plans for providing health care services to those areas and populations, including the establishment of community health centers.

AB94,13,12 (e) Development of a system for periodic reviews and evaluations of all aspects of the operation of the health plan, including the adequacy, cost, effectiveness, and quality of health care services provided. These reviews and evaluations shall be made available to the public by the board.

AB94,13,14 (f) Development of a notice and hearing procedure for review of complaints of residents about the health plan, in accordance with the requirements of ch. 227.

AB94,13,15 (g) Other issues that the board determines are relevant to the health plan.

AB94,13,16 (h) State statutory changes that may be necessary to effect pars. (a) to (g).

AB94,13,20 (4) By January 1, April 1, July 1, and October 1 of each year, the board shall report to the governor on the revenues and expenditures of the health plan for the calendar quarter immediately preceding the most recently completed calendar quarter.

AB94,14,2 (5) (a) The board may appoint up to 2 advisory committees, each with not more than 12 members, that shall be advisory to the secretary. Appointees shall reflect as much as possible a balance of gender, race, age, sexual orientation, ethnicity, religion, disability, and geographic area. The board may determine the length of terms of advisory committee members and the frequency of meetings, and may terminate the committees.

AB94,14,3 (b) If appointed under par. (a), all of the following apply:

AB94,14,6 1. Only one advisory committee shall reflect the interests and concerns of consumer advocacy and may not include a health care provider or representative of a health care provider or the agency or organization of a health care provider.

AB94,14,9 2. Only one advisory committee shall reflect the interests and concerns of health care providers and agencies and organizations of health care providers and may not include a representative of a consumer advocacy agency or organization.

AB94,14,13 3. An advisory committee shall report annually to the board and the secretary concerning the committee's activities in the immediately preceding fiscal year, shall provide advice relative to health policy issues, and shall make recommendations concerning departmental policies and procedures.

AB94,14,15 152.30 Regional consumer health councils. (1) Each regional consumer health council shall do all of the following:

AB94,14,20 (a) Elect one member of the regional consumer health council to serve as a member of the board under s. 15.20 (1). If the term of the member who is so elected expires with respect to the regional consumer health council or with respect to the board under s. 15.20 (1), the regional consumer health council shall elect a current member of the council to serve as a member of the board in his or her stead.

AB94,14,24 (b) Study and continuously monitor the delivery and quality of and access to health care services in the region of the regional consumer health council and recommend to the board and regional office ways to improve the quality of and help ensure access to health care services.

AB94,15,3 (c) Recommend to the board payment rates and conditions appropriate to specific regional needs and advise on regional health care policy issues and administrative policies and procedures.

AB94,15,6 (d) Study and continuously monitor the unmet health care service needs in the region of the regional consumer health council and recommend to the board ways by which the needs may be met.

AB94,15,10 (e) Report at least annually to the board with respect to the health care needs, problems, and concerns of the region, including any issues elicited at public hearings under par. (g), and provide to the board recommendations to alleviate these needs, problems, and concerns.

AB94,15,13 (f) Require reports from and advise the member of the staff of the appropriate regional office whose duties are specified under s. 152.40 (1), concerning issues that arise under pars. (b) to (e).

AB94,15,17 (g) In at least 2 localities of the region, hold public hearings at least annually to elicit public opinion concerning the health plan under this chapter. The council shall give notice of each hearing by publishing a class 1 notice, under ch. 985, at least 15 days before the hearing in a newspaper covering the affected area.

AB94,15,18 (h) Perform other duties as required by the board.

AB94,15,21 (2) Each regional consumer health council may, for cause, recall the member elected under sub. (1) (a) and may elect another member to fulfill that term on the board if all of the following are done:

AB94,15,24 (a) The elected member of the board for whom recall is sought receives notice of the recall at least 10 working days before the meeting at which the recall is voted upon.

AB94,16,3 (b) Notice of the vote to recall the elected member is made on the agenda of the meeting of the regional consumer health council that is immediately prior to the meeting at which recall is voted upon.

AB94,16,9 (2m) The regional consumer health council may appoint a regional advisory committee. If appointed, the regional advisory committee shall consist of 18 members who reflect as much as possible a balance of gender, race, age, sexual orientation, ethnicity, religion, geographic area, and the interests of management, labor, and individuals with disabilities, and may consist of consumer advocates and health care providers.

AB94,16,12 (3) The staff of the appropriate regional office shall provide services to each regional consumer health council to deal with issues of health consumer advocacy and health ombudsman functions.

AB94,16,17 152.40 Department of health planning and finance. (1) The department shall administer the health plan under this chapter, including establishing a regional office in each of the regions specified under s. 15.207 (1) (a) 1. to 6. Each regional office shall have at least one staff member who acts in a full-time capacity as a regional consumer advocate and health care ombudsman.

AB94,16,20 (2) The department shall establish provider payment rates, taking into consideration regional, rural, and urban differences, and conditions of payment for the provision of health care services under the health plan.

AB94,16,22 (3) The department shall, after review and approval by the board, promulgate as rules all of the following:

AB94,16,24 (a) Guidelines for cost containment under the health plan, including the purchasing and distribution of major diagnostic, medical, and surgical equipment.

AB94,17,4 (b) Criteria, as recommended by the medical advisory committee appointed by the secretary under sub. (7), for determining necessity for orthodontia and for the performance of reconstructive or cosmetic surgery for coverage under the health plan.

AB94,17,6 (4) The department shall biennially evaluate and recommend to the board cost control measures for the health plan.

AB94,17,9 (5) The department shall, by July 1, 2009, begin implementation of processes, in light of policies formulated or revised under s. 152.20 (3), to effect all of the following:

AB94,17,13 (a) Specification of the amounts and sources of revenues to finance payment to providers under the health plan, which may not include any premiums, copayments, deductibles, and other forms of direct payment by patients, and which shall include all of the following:

AB94,17,19 1. Use of federal, state, and local moneys that fund, as of July 1, 2010, health care services, including medicare, medical assistance, health care services funded by a relief block grant under s. 49.02, 49.025, or 49.029; health care services under s. 49.665; veterans medical benefits; services specified in s. 152.10 (2) (k); services provided under federal block grants; alcohol and other drug abuse services; and services provided by local health departments.

AB94,17,24 2. Use of revenues from a tax on employers, based on the amount of wages that they pay, that generates, in the aggregate, revenues that are at least equal to amounts that employers contribute, as of the effective date of this subdivision .... [revisor inserts date], for employee health care benefit costs, including the costs of worker's compensation attributable to health care for injured employees.

AB94,18,4 3. Use of revenues from a graduated income tax on individuals that generates, in the aggregate, revenues that are not greater than expenditures that individuals make, as of July 1, 2010, for health care costs for which coverage under disability insurance policies is not obtained.

AB94,18,7 4. An indexing of the sources of revenues under this paragraph that provides for revenue growth that is equivalent to the anticipated growth of health care costs under the health plan.

AB94,18,10 (b) Application for waivers to 42 USC 1396 to 1396v or consideration of the feasibility of statutory changes to 42 USC 1396 to 1396v in order to effect all of the following:

AB94,18,12 1. Administration of the Medical Assistance program in this state by the department, rather than by the department of health and family services.

AB94,18,14 2. Use of federal financial participation to fund a portion of the administrative costs, after June 30, 2010, of the department.

AB94,18,19 3. Use of federal financial participation, after June 30, 2010, to fund, under the health plan, the health care services received by a percentage of the residents that corresponds to the percentage of the residents, as determined by the board, that is eligible to receive health care services under the Medical Assistance program on July 1, 2010.

AB94,18,21 4. The formulation of criteria and procedures for payment of out-of-state health care costs incurred by residents specified in subd. 3.