SB1,741,1716 b. The individual's employer discontinued health insurance coverage for all
17employees.
SB1,741,2118 c. One or more members of the individual's family were eligible for other health
19insurance coverage or Medical Assistance at the time the employee failed to enroll
20in the health insurance coverage under par. (b) 1. and no member of the family was
21eligible for coverage under this section at that time.
SB1,741,2322 d. The individual's access to health insurance coverage has ended due to the
23death or change in marital status of the subscriber.
SB1,741,2424 e. Any other reason that the department determines is a good cause reason.
SB1,742,3
1(e) If a pregnant woman has health insurance coverage and her family income
2exceeds 200 percent of the poverty line, the woman is required, as a condition of
3eligibility, to maintain the health insurance coverage.
SB1,742,114 (f) If an individual with a family income that exceeds 150 percent of the poverty
5line had the health insurance coverage specified in par. (b) 1. but no longer has the
6coverage, if an individual who is an unborn child or an unborn child's mother,
7regardless of family income, had health insurance coverage but no longer has the
8coverage, or if a pregnant woman specified in par. (e) has health insurance coverage
9and does not maintain the coverage, the individual or pregnant woman is not eligible
10for BadgerCare Plus for the 3 calendar months following the month in which the
11insurance coverage ended without a good cause reason specified in par. (g).
SB1,742,1212 (g) Any of the following is a good cause reason for purposes of par. (f):
SB1,742,1713 1. The individual or pregnant woman was covered by a group health plan that
14was provided by a subscriber through his or her employer, and the subscriber's
15employment ended for a reason other than voluntary termination, unless the
16voluntary termination was a result of the incapacitation of the subscriber or because
17on an immediate family member's health condition.
SB1,742,2018 2. The individual or pregnant woman was covered by a group health plan that
19was provided by a subscriber through his or her employer, the subscriber changed
20employers, and the new employer does not offer health insurance coverage.
SB1,742,2321 3. The individual or pregnant woman was covered by a group health plan that
22was provided by a subscriber through his or her employer, and the subscriber's
23employer discontinued health plan coverage for all employees.
SB1,742,2524 4. The pregnant woman's coverage was continuation coverage and the
25continuation coverage was exhausted in accordance with 29 CFR 2590.701-2 (4).
SB1,743,2
15. The individual's or pregnant woman's coverage terminated due to the death
2or change in marital status of the subscriber.
SB1,743,33 6. Any other reason determined by the department to be a good cause reason.
SB1,743,8 4(9) Employer verification of insurance coverage. (a) 1. Except as provided
5in subd. 2., for an applicant or recipient with a family income that exceeds 150
6percent of the poverty line, the department shall verify insurance coverage and
7access information directly with the employer through which the applicant or
8recipient may have health insurance coverage or access to coverage.
SB1,743,99 2. Subdivision 1. does not apply to any of the following:
SB1,743,1010 a. A pregnant woman.
SB1,743,1111 b. A child described in sub. (4) (a) 2. or (b) 2.
SB1,743,1212 c. An individual described in sub. (4) (a) 5.
SB1,743,1613 (b) An employer that receives a request from the department for insurance
14coverage and access to coverage information shall supply the information requested
15by the department in the format specified by the department within 30 calendar days
16after receiving the request.
SB1,743,2417 (c) 1. Subject to subds. 2. and 3., an employer that does not comply with the
18requirements under par. (b) shall be required to pay, within 45 days after the
19requested information was due, a penalty equal to the full per member per month
20cost of coverage under BadgerCare Plus for the individual about whom the
21information is requested, and for each of the individual's family members with
22coverage under BadgerCare Plus, for each month in which the individual and the
23individual's family members are covered before the employer provides the
24information.
SB1,744,5
12. An employer with fewer than 250 employees may not be required to pay more
2than $1,000 in penalties under this paragraph that are attributable to any 6-month
3period. An employer with 250 or more employees may not be required to pay more
4than $15,000 in penalties under this paragraph that are attributable to any 6-month
5period.
SB1,744,106 3. Notwithstanding subd. 1., an employer shall not be subject to any penalties
7if the employer, at least once per year, timely provides to the department, in the
8manner and format specified by the department, information from which the
9department may determine whether the employer provides its employees with
10access to health insurance coverage.
SB1,744,1211 4. All penalty assessments collected under this paragraph shall be credited to
12the appropriation accounts under s. 20.435 (4) (jw) and (jz).
SB1,744,1613 (d) An employer may contest a penalty assessment under par. (c) by sending
14a written request for hearing to the division of hearings and appeals in the
15department of administration. Proceedings before the division are governed by ch.
16227.
SB1,744,20 17(10) Cost sharing. (a) Copayments. Except as provided in s. 49.45 (18) (am),
18all cost-sharing provisions under s. 49.45 (18) apply to a recipient with coverage of
19the benefits described in s. 49.46 (2) (a) and (b) to the same extent as they apply to
20a person eligible for medical assistance under s. 49.46, 49.468, or 49.47.
SB1,745,221 (b) Premiums. 1. Except as provided in subd. 4., a recipient who is an adult,
22who is not a pregnant woman, and whose family income is greater than 150 percent
23but not greater than 200 percent of the poverty line shall pay a premium for coverage
24under BadgerCare Plus that does not exceed 5 percent of his or her family income.
25If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the

1premium may not exceed 5 percent of family income calculated before depreciation
2was deducted.
SB1,745,73 2. Except as provided in subds. 3. and 4., a recipient who is a child whose family
4income is greater than 200 percent of the poverty line shall pay a premium for
5coverage of the benefits described in sub. (11) that does not exceed the full per
6member per month cost of coverage for a child with a family income of 300 percent
7of the poverty line.
SB1,745,128 3. Except as provided in subd. 4., a recipient who is an unborn child, or a
9pregnant woman eligible under sub. (4) (b) 1., whose family income is greater than
10200 percent of the poverty line shall pay a premium for coverage of the benefits
11described in sub. (11) that does not exceed the full per member per month cost of
12coverage for an adult with a family income of 300 percent of the poverty line.
SB1,745,1313 4. None of the following shall pay a premium:
SB1,745,1514 a. A child who is a Native American or an Alaskan Native with a family income
15that does not exceed 300 percent of the poverty line.
SB1,745,1616 b. A child who is eligible under sub. (4) (a) 2. or (b) 2.
SB1,745,1717 c. A child whose family income does not exceed 200 percent of the poverty line.
SB1,745,1918 d. A pregnant woman whose family income does not exceed 200 percent of the
19poverty line.
SB1,745,2020 e. A child who obtains eligibility under sub. (7) (b) 2.
SB1,745,2121 f. An individual who is eligible under sub. (4) (a) 5.
SB1,745,2522 5. If a recipient who is required to pay a premium under this paragraph or
23under sub. (2m) or (4) (c) does not pay a premium when due, the recipient's coverage
24terminates and the recipient is not eligible for BadgerCare Plus for 6 calendar
25months following the date on which the recipient's coverage terminated.
SB1,746,3
1(11) Benchmark plan benefits and copayments. Recipients who are not eligible
2for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following
3benefits and pay the following copayments:
SB1,746,64 (a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as
5defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and
6subject to the Badger Rx Gold program discounts.
SB1,746,87 (b) Physicians' services, including one annual routine physical examination,
8with a copayment of no more than $15 per visit.
SB1,746,129 (c) Inpatient hospital services as medically necessary, subject to coinsurance
10payment per inpatient stay of no more than 10 percent of the allowable payment
11rates under s. 49.46 (2) for the services provided and a copayment of no more than
12$50 per admission for psychiatric services.
SB1,746,1713 (d) Outpatient hospital services, subject to coinsurance payment of no more
14than 10 percent of the allowable payment rates under s. 49.46 (2) for the services
15provided, except that use of emergency room services for treatment of a condition
16that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall
17require a copayment of no more than $75.
SB1,746,1818 (e) Laboratory and X-ray services, including mammography.
SB1,746,1919 (f) Home health services, limited to 60 visits per year.
SB1,746,2220 (g) Skilled nursing home services, limited to 30 days per year, and subject to
21coinsurance payment of no more than 10 percent of the allowable payment rates
22under s. 49.46 (2) for the services provided.
SB1,746,2523 (h) Inpatient rehabilitation services, limited to 60 days per year, and subject
24to coinsurance payment of no more than 10 percent of the allowable payment rates
25under s. 49.46 (2) for the services provided.
SB1,747,3
1(i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits
2per year for each type of therapy, and subject to coinsurance payment of no more than
310 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
SB1,747,64 (j) Cardiac rehabilitation, limited to 36 visits per year and subject to
5coinsurance payment of no more than 10 percent of the allowable payment rates
6under s. 49.46 (2) for the services provided.
SB1,747,107 (k) Inpatient, outpatient, and transitional treatment for nervous or mental
8disorders and alcoholism and other drug abuse problems, with a copayment of no
9more than $15 per visit and coverage limits that are the same as those under the state
10employee health plan under s. 40.51 (6).
SB1,747,1311 (L) Durable medical equipment, limited to $2,500 per year, and subject to
12coinsurance payment of no more than 10 percent of the allowable payment rates
13under s. 49.46 (2) for the articles provided.
SB1,747,1614 (m) Transportation to obtain emergency medical care only, as medically
15necessary, and subject to coinsurance payment of no more than 10 percent of the
16allowable payment rates under s. 49.46 (2) for the services provided.
SB1,747,1817 (n) One refractive eye examination every 2 years, with a copayment of no more
18than $15 per visit.
SB1,747,2319 (o) Fifty percent of allowable charges for preventive and basic dental services,
20including services for accidental injury and for the diagnosis and treatment of
21temporomandibular disorders. The coverage under this paragraph is limited to $750
22per year, applies only to pregnant women and children under 19 years of age, and
23requires an annual deductible of $200 and a copayment of no more than $15 per visit.
SB1,747,2424 (p) Early childhood developmental services, for children under 6 years of age.
SB1,747,2525 (q) Smoking cessation treatment, for pregnant women only.
SB1,748,1
1(r) Prenatal care coordination, for pregnant women at high risk only.
SB1,748,11 2(11m) Provider payments and requirements. The provider of a service or
3equipment under sub. (11) shall collect the specified or allowable copayment or
4coinsurance, unless the provider determines that the cost of collecting the copayment
5or coinsurance exceeds the amount to be collected. The department shall reduce
6payments for services or equipment under sub. (11) by the amount of the specified
7or allowable copayment or coinsurance. A provider may deny care or services or
8equipment under sub. (11) if the recipient does not pay the specified or allowable
9copayment or coinsurance. If a provider provides care or services or equipment
10under sub. (11) to a recipient who is unable to share costs as specified in sub. (11),
11the recipient is not relieved of liability for those costs.
SB1,748,14 12(12) Rules; notice of effective date. (a) 1. The department may promulgate
13any rules necessary for and consistent with its administrative responsibilities under
14this section, including additional eligibility criteria.
SB1,748,2215 2. The department may promulgate emergency rules under s. 227.24 for the
16administration of this section for the period before the effective date of any
17permanent rules promulgated under subd. 1., but not to exceed the period authorized
18under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the
19department is not required to provide evidence that promulgating a rule under this
20subdivision as an emergency rule is necessary for the preservation of the public
21peace, health, safety, or welfare and is not required to provide a finding of emergency
22for a rule promulgated under this subdivision.
SB1,749,223 (b) If the amendments to the state plan submitted under sub. (2) are approved
24and a waiver that is consistent with all of the provisions of this section is granted and

1in effect, the department shall publish a notice in the Wisconsin Administrative
2Register that states the date on which BadgerCare Plus is implemented.
SB1, s. 1606 3Section 1606. 49.472 (6) (a) of the statutes is amended to read:
SB1,749,94 49.472 (6) (a) Notwithstanding sub. (4) (a) 3., from the appropriation account
5under s. 20.435 (4) (b), (gp), or (w), or (xd), the department shall, on the part of an
6individual who is eligible for medical assistance under sub. (3), pay premiums for or
7purchase individual coverage offered by the individual's employer if the department
8determines that paying the premiums for or purchasing the coverage will not be more
9costly than providing medical assistance.
SB1, s. 1607 10Section 1607. 49.472 (6) (b) of the statutes is amended to read:
SB1,749,1411 49.472 (6) (b) If federal financial participation is available, from the
12appropriation account under s. 20.435 (4) (b), (gp), or (w), or (xd), the department may
13pay medicare Part A and Part B premiums for individuals who are eligible for
14medicare and for medical assistance under sub. (3).
SB1, s. 1608 15Section 1608. 49.473 (2) (a) of the statutes is amended to read:
SB1,749,1816 49.473 (2) (a) The woman is not eligible for medical assistance under ss. 49.46
17(1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health
18care coverage under s. 49.665.
SB1, s. 1609 19Section 1609. 49.473 (5) of the statutes is amended to read:
SB1,749,2420 49.473 (5) The department shall audit and pay, from the appropriation
21accounts under s. 20.435 (4) (b), (gp), and (o), and (xd), allowable charges to a provider
22who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman
23who meets the requirements under sub. (2) for all benefits and services specified
24under s. 49.46 (2).
SB1, s. 1610 25Section 1610. 49.475 (1) (a) of the statutes is renumbered 49.475 (1) (ar).
SB1, s. 1611
1Section 1611. 49.475 (1) (ag) of the statutes is created to read:
SB1,750,32 49.475 (1) (ag) "Covered entity" means any of the following that is not an
3insurer:
SB1,750,44 1. A nonprofit hospital, as defined in s. 46.21 (2) (m).
SB1,750,85 2. An employer, as defined in s. 101.01 (4), labor union, or other group of persons
6organized in this state if the employer, labor union, or other group provides
7prescription drug coverage to covered individuals who reside or are employed in this
8state.
SB1,750,109 3. A comprehensive or limited health care benefits program administered by
10the state that provides prescription drug coverage.
SB1, s. 1612 11Section 1612. 49.475 (1) (am) of the statutes is created to read:
SB1,750,1512 49.475 (1) (am) "Covered individual" means an individual who is a member,
13participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary
14of a covered entity, or a dependent of the individual, and who receives prescription
15drug coverage from or through the covered entity.
SB1, s. 1613 16Section 1613. 49.475 (1) (c) of the statutes is created to read:
SB1,750,2117 49.475 (1) (c) "Pharmacy benefits management" means the procurement of
18prescription drugs at a negotiated rate for dispensation in this state to covered
19individuals; the administration or management of prescription drug benefits
20provided by a covered entity for the benefit of covered individuals; or any of the
21following services provided in the administration of pharmacy benefits:
SB1,750,2222 1. Dispensation of prescription drugs by mail.
SB1,750,2423 2. Claims processing, retail network management, and payment of claims to
24pharmacies for prescription drugs dispensed to covered individuals.
SB1,750,2525 3. Clinical formulary development and management services.
SB1,751,1
14. Rebate contracting and administration.
SB1,751,32 5. Conduct of patient compliance, therapeutic intervention, generic
3substitution, and disease management programs.
SB1, s. 1614 4Section 1614. 49.475 (1) (d) of the statutes is created to read:
SB1,751,65 49.475 (1) (d) "Pharmacy benefits manager" means a person that performs
6pharmacy benefits management functions.
SB1, s. 1615 7Section 1615. 49.475 (1) (e) of the statutes is created to read:
SB1,751,98 49.475 (1) (e) "Recipient" means an individual or his or her spouse or dependent
9who has been or is one of the following:
SB1,751,1110 1. A recipient of medical assistance or of a program administered under medical
11assistance under a waiver of federal Medicaid laws.
SB1,751,1212 2. An enrollee of family care.
SB1,751,1313 3. A recipient of the Badger Care health care program.
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