SB562,46,1111
(f) Medically appropriate colonoscopies.
SB562,46,1212
(g) Preventive dental care for children up to 18 years of age.
SB562,46,1513
(h) Other preventive services or procedures, as determined by the board, for
14which there is scientific evidence that exemption from cost sharing is likely to reduce
15health care costs or avoid health risks.
SB562,46,1816
(i) Chronic care services, provided that the participant receiving the services
17is participating in, and complying with, a chronic disease management program as
18defined by the board.
SB562,46,22
19(2) Deductibles. (a)
Maximum amounts and who must pay. 1. Subject to subd.
202., during any year, a participant who is 18 years of age or older on January 1 of that
21year shall pay a deductible of $300, which shall apply to all covered services and
22articles.
SB562,46,2523
2. During any year, a family consisting of 2 or more participants who are 18
24years of age or older on January 1 of that year shall pay a deductible of $600, which
25shall apply to all covered services and articles.
SB562,47,2
13. During any year, a participant who is under 18 years of age on January 1 of
2that year shall not be required to pay a deductible.
SB562,47,73
4. Except for copayments and coinsurance, the plan shall provide a participant
4with full coverage for all covered services and articles after the participant has
5received covered services and articles totaling the applicable deductible amount
6under this paragraph, regardless of whether the participant has paid the deductible
7amount.
SB562,47,188
(b)
Provider requirements. 1. A provider that provides to a participant a
9covered service or article to which a deductible applies shall charge for the service
10or article the payment rate established by the board under s. 260.30 (7) (b) 1. if the
11participant's coverage is under the fee-for-service option under s. 260.30 (2) (a) or
12the applicable network rate for the service or article, as determined by the board, if
13the participant's coverage is under the health care network option under s. 260.30
14(2) (b). Except as provided in subd. 3., a provider of a covered service or article to
15which a deductible applies shall accept as payment in full for the covered service or
16article the payment rate specified in this subdivision and may not bill a participant
17who receives the service or article for any amount by which the charge for the service
18or article is reduced under this subdivision.
SB562,47,2219
2. Except for prescription drugs, a provider may not refuse to provide to a
20participant a covered service or article to which a deductible applies on the basis that
21the participant does not pay, or has not paid, any applicable deductible amount
22before the service or article is provided.
SB562,48,423
3. A provider may not charge any interest, penalty, or late fee on any deductible
24amount owed by a participant unless the deductible amount owed is at least 6
25months past due and the provider has provided the participant with notice of the
1interest, penalty, or late fee at least 90 days before the interest, penalty, or late fee
2payment is due. Interest may not exceed 1 percent per month, and any penalty or
3late fee may not exceed the provider's reasonable cost of administering the unpaid
4bill.
SB562,48,75
(c)
Adjustments by board. Notwithstanding par. (a) 1. and 2., the board may
6adjust the deductible amounts specified in par. (a) 1. and 2., but only to reduce those
7amounts.
SB562,48,11
8(3) Copayments and coinsurance. (a)
General copayments. During any year,
9a participant who is 18 years of age or older on January 1 of that year shall pay a
10copayment of $20 for medical, hospital, and related health care services, as
11determined by the board.
SB562,48,1512
(b)
Specialist provider services without referral. A participant, regardless of
13age, who receives health care services from a specialist provider without a referral
14from his or her primary care provider under the plan shall be required to pay 25
15percent of the cost of the services provided.
SB562,48,1816
(c)
Inappropriate emergency room use. Notwithstanding par. (a), a participant
17who is 18 years of age or older shall pay a copayment of $60 for inappropriate
18emergency room use, as determined by the board.
SB562,48,2019
(d)
Prescription drugs. 1. All participants, regardless of age, shall pay $5 for
20each prescription of a generic drug that is on the formulary determined by the board.
SB562,48,2221
2. All participants, regardless of age, shall pay $15 for each prescription of a
22brand-name drug that is on the formulary determined by the board.
SB562,48,2423
3. All participants, regardless of age, shall pay $40 for each prescription of a
24brand-name drug that is not on the formulary determined by the board.
SB562,49,3
14. Notwithstanding subds. 1. to 3., no participant shall pay more for a
2prescription drug than the actual cost of the prescription drug plus the negotiated
3dispensing fee.
SB562,49,54
(e)
Adjustments by board. Notwithstanding pars. (a) to (d), the board may
5adjust the copayment and coinsurance amounts specified in pars. (a) to (d).
SB562,49,7
6(4) Maximum amounts. Notwithstanding the deductible, coinsurance, and
7copayment amounts in subs. (2) and (3), all of the following apply:
SB562,49,108
(a) Subject to par. (b), a participant who is 18 years of age or older on January
91 of a year may not be required to pay more than $2,000 during that year in total cost
10sharing under subs. (2) and (3).
SB562,49,1211
(b) A family consisting of 2 or more participants may not be required to pay
12more than $3,000 during a year in total cost sharing under subs. (2) and (3).
SB562,49,19
13260.30 Service areas; selection and payment of health care providers
14and health care networks. (1) Establishment of areas where services will be
15provided. The board may establish areas in the state, which may be counties,
16multicounty regions, or other areas, for the purpose of receiving bids from health care
17networks. These areas shall be established so as to maximize the level and quality
18of competition among health care networks or to increase the number of provider
19choices available to eligible persons and participants in the areas.
SB562,49,22
20(2) Options available in each area. In each area designated by the board under
21sub. (1), the board shall offer both of the following options for delivery of health care
22services under the plan:
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(a) An option, known as the "fee-for-service option," under which participants
24must choose a primary care provider, may be referred by the primary care provider
25to any medical specialist, and may be admitted by the primary care provider or
1specialist to any hospital or other facility, for the purpose of receiving the benefits
2provided under this chapter. Under this option, the board, with the assistance of one
3or more administrators chosen by a competitive bidding process and with whom the
4board has contracted, shall pay directly, at the provider payment rates established
5by the board under sub. (7) (b) 1., for all health care services and articles that are
6covered under the plan.
SB562,50,117
(b) An option under which one or more health care networks that meet the
8qualifying criteria in sub. (4) and are certified under sub. (5) provide health care
9services to participants. The board is required to offer this option in each area
10designated by the board to the extent that qualifying health care networks exist in
11the area.
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12(3) Solicitation of bids from health care networks. The board shall annually
13solicit sealed risk-adjusted premium bids from competing health care networks for
14the purpose of offering health care coverage to participants. The board shall request
15each bidder to submit information pertaining to whether the bidder is a qualifying
16health care network, as described in sub. (4).
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17(4) Qualifying health care networks. A health care network is qualifying if
18it does all of the following:
SB562,50,2419
(a) Demonstrates to the satisfaction of the board that the fixed monthly
20risk-adjusted amount that it bids to provide participants with the health care
21benefits specified in this chapter reasonably reflects its estimated actual costs for
22providing participants with such benefits in light of its underlying efficiency as a
23network, and has not been artificially underbid for the predatory purpose of gaining
24market share.
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1(b) Will spend at least 92 percent of the revenue it receives under this chapter
2on one of the following:
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1. Payments to health care providers in order to provide the health care benefits
4specified in this chapter to participants who choose the health care network.
SB562,51,65
2. Investments that the health care network has reasonably determined will
6improve the overall quality or lower the overall cost of patient care.
SB562,51,77
(c) Ensures all of the following:
SB562,51,118
1. That participants living in an area that the health care network serves shall
9not be required to drive more than 30 minutes, or, in a metropolitan area served by
10mass transit, spend more than 60 minutes using mass transit facilities, in order to
11reach the offices of at least 2 primary care providers, as defined by the board.
SB562,51,1612
2. That physicians, physician assistants, nurses, clinics, hospitals, and other
13health care providers and facilities, including providers and facilities that specialize
14in mental health services and alcohol and other drug abuse treatment, are
15conveniently available, as defined by the board, to participants living in every part
16of the area that the health care network serves.
SB562,51,2017
(d) Ensures that participants have access, 24 hours a day, 7 days a week, to a
18toll-free hotline and help desk that is staffed by persons who live in the area and who
19have been fully trained to communicate the benefits provided under this chapter and
20the choices of providers that participants have in using the health care network.
SB562,51,2221
(e) Ensures that each participant who chooses the health care network selects
22a primary care provider who is responsible for overseeing all of the participant's care.
SB562,51,2523
(f) Will provide each participant with medically appropriate and high-quality
24health care, including mental health services and alcohol or other drug abuse
25treatment, in a highly coordinated manner.
SB562,52,7
1(g) Emphasizes, in its policies and operations, the promotion of healthy
2lifestyles; preventive care, including early identification of and response to high-risk
3individuals and groups, early identification of and response to health disorders,
4disease management, including chronic care management, and best practices,
5including the appropriate use of primary care, medical specialists, medications, and
6hospital emergency rooms; and the utilization of continuous quality improvement
7standards and practices that are generally accepted in the medical field.
SB562,52,128
(h) Has developed and is implementing a program, including providing
9incentives to providers when appropriate, to promote health care quality, increase
10the transparency of health care cost and quality information, ensure the
11confidentiality of medical information, and advance the appropriate use of
12technology.
SB562,52,2013
(i) Has entered into shared service agreements with out-of-network medical
14specialists, hospitals, and other facilities, including medical centers of excellence in
15the state, through which participants can obtain, at no additional expense to
16participants beyond the normally required level of cost sharing, the services of
17out-of-network providers that the network's primary care physicians selected by
18participants have determined is necessary to ensure medically appropriate and
19high-quality health care, to facilitate the best outcome, or, without reducing the
20quality of care, to lower costs.
SB562,52,2221
(j) Has in place a comprehensive, shared, electronic patient records and
22treatment tracking system and an electronic provider payment system.
SB562,52,2423
(k) Has adopted and implemented a strong policy to safeguard against conflicts
24of interest.
SB562,53,6
1(L) Has been organized by physicians or other health care providers, a
2cooperative, or an entity whose mission includes improving the quality and lowering
3the cost of health care, including the avoidance of unnecessary operating and capital
4costs arising from inappropriate utilization or inefficient delivery of health care
5services, unwarranted duplication of services and infrastructure, or creation of
6excess capacity.
SB562,53,117
(m) Agrees to enroll and provide the benefits specified in this chapter to all
8participants who choose the health care network, regardless of the participant's age,
9sex, race, religion, national origin, sexual orientation, health status, marital status,
10disability status, or employment status, except that a health care network may do
11one of the following:
SB562,53,1712
1. Limit the number of new enrollees it accepts if the health care network
13certifies to the board that accepting more than a specified number of enrollees would
14make it impossible to provide all enrollees with the benefits specified in this chapter
15at the level of quality that the network is committed to maintaining, provided that
16the health care network uses a random method for deciding which new enrollees it
17accepts.
SB562,53,2318
2. Limit the participants that it serves to a specific affinity group, such as
19farmers or teachers, that the health care network has certified to the board, provided
20that the limitation does not involve discrimination based on any of the factors
21described in this paragraph and has neither been created for the purpose, nor will
22have the effect, of screening out higher-risk enrollees. This subdivision applies only
23to affinity groups that are in existence as of December 31, 2008.
SB562,54,3
24(5) Certification of health care networks and classification of bids. (a) The
25board shall review the bids submitted under sub. (3), the information submitted by
1bidders pertaining to whether the bidders are qualifying health care networks, and
2other evidence provided to the board as to whether a particular bidder is a qualifying
3health care network.
SB562,54,64
(b) Based on the information about bidder qualification submitted or otherwise
5provided under par. (a), the board shall certify which health care networks are
6qualifying health care networks.
SB562,54,147
(c) With respect to all health care networks that the board certifies under par.
8(b), the board shall open the submitted, sealed bids at a predetermined time. The
9board shall classify the certified health care networks according to price and quality
10measures after comparing their risk-adjusted per-month bids and assessing their
11quality. The board shall classify the network that bid the lowest price as the
12lowest-cost network, and shall classify as a low-cost network any network that has
13bid a price that is close to the price bid by the lowest-cost network. Any other
14network shall be classified as a higher-cost network.
SB562,55,2
15(6) Open enrollment. The board shall provide an annual open enrollment
16period during which each participant may select a certified health care network from
17among those offered, or a fee-for-service option. Coverage shall be effective on the
18following January 1. A participant who does not select a certified health care
19network or the fee-for-service option will be assigned randomly to one of the
20networks that have been classified under sub. (5) as having submitted the lowest or
21a low bid and as performing well on quality measures, or to the fee-for-service option
22if that is the lowest-cost option. A participant who selects the fee-for-service option
23or a certified health care network that has been classified as a higher-cost network,
24but who fails to pay the additional payment under sub. (7) (a) 2., shall be assigned
25randomly to one of the networks that has been classified under sub. (5) as the
1lowest-cost network or as a low-cost network and as performing well on quality
2measures, or to the fee-for-service option if that is the lowest-cost option.
SB562,55,12
3(7) Payments to networks and providers. (a)
Payments to health care
4networks. 1. On behalf of each participant who selects or has been assigned to a
5certified health care network that has been classified under sub. (5) (c) as the
6lowest-cost network or a low-cost network and as performing well on quality
7measures, the board shall pay monthly to the health care network the full
8risk-adjusted per-member per-month amount that was bid by the network. The
9dollar amount shall be actuarially adjusted for the participant based on age, sex, and
10other appropriate risk factors determined by the board. A participant who selects
11or is assigned to the lowest-cost network or a low-cost network shall not be required
12to pay any additional amount to the network.
SB562,55,2213
2. If a participant chooses instead to enroll in a certified health care network
14that has been classified under sub. (5) (c) as a higher-cost network, the board shall
15pay monthly to the chosen health care network an amount equal to the bid submitted
16by the network that the board classified under sub. (5) (c) as the lowest-cost network
17and as having performed well on quality measures. The dollar amount shall be
18actuarially adjusted for the participant based on age, sex, and other appropriate risk
19factors determined by the board. A participant who chooses to enroll in a higher-cost
20network shall be required to pay monthly, in addition to the amount paid by the
21board, an amount sufficient to ensure that the chosen network receives the full price
22bid by that network.
SB562,56,323
3. The board may retain a percentage of the dollar amounts established for each
24participant under subds. 1. and 2. to pay to certified health care networks that have
25incurred disproportionate risk not fully compensated for by the actuarial adjustment
1in the amount established for each eligible person. Any payment to a certified health
2care network under this subdivision shall reflect the disproportionate risk incurred
3by the health care network.
SB562,56,104
(b)
Payments to fee-for-service providers. 1. The board shall establish provider
5payment rates that will be paid to providers of covered services and articles that are
6provided to participants who choose the fee-for-service option under sub. (2) (a). The
7payment rates shall be fair and adequate to ensure that this state is able to retain
8the highest quality of medical practitioners. The board shall limit increases in the
9provider payment rate for each service or article such that any increase in per person
10spending under the plan does not exceed the national rate of medical inflation.
SB562,56,1611
2. Except for deductibles, copayments, coinsurance, and any other cost sharing
12required or authorized under the plan, a provider of a covered service or article shall
13accept as payment in full for the covered service or article the payment rate
14determined under subd. 1. and may not bill a participant who receives the service or
15article for any amount by which the charge for the service or article is reduced under
16subd. 1.
SB562,56,2017
3. The board, with the assistance of its actuarial consultants, shall establish
18the monthly risk-adjusted cost of the fee-for-service option offered to participants
19under sub. (2) (a). The board shall classify the fee-for-service option in the same
20manner as the board classifies certified health care networks under sub. (5) (c).
SB562,56,2521
4. If the board has determined under sub. (5) (c) that there is at least one
22certified low-cost health care network in an area, which may be the lowest-cost
23health care network, and if the fee-for-service option offered in that area has been
24classified as a higher-cost choice under subd. 3., the cost to a participant enrolling
25in the fee-for-service option shall be determined as follows:
SB562,57,7
1a. If there are available to the participant 3 or more certified health care
2networks classified under sub. (5) (c) as low-cost networks, or as the lowest-cost
3network and 2 or more low-cost networks, the participant shall pay the difference
4between the cost of the lowest-cost health care network and the monthly
5risk-adjusted cost established under subd. 3. for the fee-for-service option, except
6that the amount paid may not exceed $100 per month for an individual, or $200 per
7month for a family, as adjusted for medical inflation.
SB562,57,148
b. If there are available to the participant 2 certified health care networks
9classified under sub. (5) (c) as low-cost networks, or as the lowest-cost network and
10one low-cost network, the participant shall pay the difference between the cost of the
11lowest-cost health care network and the monthly risk-adjusted cost established
12under subd. 3. for the fee-for-service option, except that the amount paid may not
13exceed $65 per month for an individual, or $125 per month for a family, as adjusted
14for medical inflation.
SB562,57,2015
c. If there is available to the participant only one certified health care network
16classified under sub. (5) (c) as a low-cost network, or as the lowest-cost network, the
17person shall pay the difference between the cost of the lowest-cost health care
18network and the monthly risk-adjusted cost established under subd. 3. for the
19fee-for-service option, except that the amount paid may not exceed $25 per month
20for an individual, and $50 per month for a family, as adjusted for medical inflation.
SB562,57,2321
5. If the board has determined, under sub. (5) (c), that there is no certified
22lowest-cost health care network or low-cost health care network in the area, there
23shall be no extra cost to the participant enrolling in the fee-for-service option.
SB562,58,7
24(8) Incentive payments to fee-for-service providers. Health care providers
25and facilities providing services under the fee-for-service option under sub. (2) (a)
1shall be encouraged to collaborate with each other through financial incentives
2established by the board. Providers shall work with facilities to pool infrastructure
3and resources; to implement the use of best practices and quality measures; and to
4establish organized processes that will result in high-quality, low-cost medical care.
5The board shall establish an incentive payment system to providers and facilities
6that comply with this subsection, in accordance with criteria established by the
7board.
SB562,58,19
8(9) Pharmacy benefit. Except for prescription drugs to which a deductible
9applies, the board shall assume the risk for, and pay directly for, prescription drugs
10provided to participants. In implementing this requirement, the board shall
11replicate the prescription drug buying system developed by the group insurance
12board for prescription drug coverage under the state employee health plan under s.
1340.51 (6), unless the board determines that another approach would be more
14cost-effective. The board may join the prescription drug purchasing arrangement
15under this chapter with similar arrangements or programs in other states to form
16a multistate purchasing group to negotiate with prescription drug manufacturers
17and distributors for reduced prescription drug prices, or to contract with a 3rd party,
18such as a private pharmacy benefits manager, to negotiate with prescription drug
19manufacturers and distributors for reduced prescription drug prices.
SB562,58,23
20260.35 Subrogation. The board and authority are entitled to the right of
21subrogation for reimbursement to the extent that a participant may recover
22reimbursement for health care services and items in an action or claim against any
233rd party.
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24260.37 Employer-provided health care benefits. Nothing in this chapter
25prevents an employer, or a Taft-Hartley trust on behalf of an employer, from paying
1all or part of any cost sharing under s. 260.20 or 260.30, or from providing any health
2care benefits not provided under the plan, for any of the employer's employees.
SB562,59,4
3260.40 Assessments, individuals and businesses. (1) Definitions. In this
4section:
SB562,59,55
(a) "Department" means the department of revenue.
SB562,59,96
(b) "Dependent" means a spouse, an unmarried child under the age of 19 years,
7an unmarried child who is a full-time student under the age of 21 years and who is
8financially dependent upon the parent, or an unmarried child of any age who is
9medically certified as disabled and who is dependent upon the parent.
SB562,59,1110
(c) "Eligible individual" means an individual who is eligible to participate in
11the plan, other than an employee or a self-employed individual.
SB562,59,1212
(d) "Employee" means an individual who has an employer.
SB562,59,1413
(e) "Employer" means a person who is required under the Internal Revenue
14Code to file form 941.
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(em) "Household" means an individual who is either an eligible individual, an
16employee, or a self-employed individual, and the individual's immediate family, as
17that term is defined by the board under s. 260.10 (7) (c).
SB562,59,2418
(f) "Medical inflation" means the percentage change between the U.S.
19consumer price index for all urban consumers, U.S. city average, for the medical care
20group only, including medical care commodities and medical care services, for the
21month of August of the previous year and the U.S. consumer price index for all urban
22consumers, U.S. city average, for the medical care group only, including medical care
23commodities and medical care services, for the month of August 2008, as determined
24by the U.S. department of labor.
SB562,60,2
1(g) "Poverty line" means the federal poverty line, as defined under
42 USC 9902 2(2), for a family the size of the individual's family.
SB562,60,43
(h) "Self-employed individual" means an individual who is required under the
4Internal Revenue Code to file schedule SE.
SB562,60,55
(i) "Small employer" means an employer who has no more than 10 employees.
SB562,60,66
(j) "Social security wages" means:
SB562,60,971. For purposes of sub. (2) (a), the amount of wages, as defined in section
3121 8(a) of the Internal Revenue Code, paid to an employee by an employer in a taxable
9year, up to a maximum amount that is equal to the social security wage base.
SB562,60,1310
2. For purposes of sub. (2) (b), the amount of net earnings from
11self-employment, as defined in section
1402 (a) of the Internal Revenue Code,
12received by an individual in a taxable year, up to a maximum amount that is equal
13to the social security wage base.
SB562,60,18143. For purposes of sub. (3), the amount of wages, as defined in section
3121 (a)
15of the Internal Revenue Code, paid by an employer in a taxable year with respect to
16employment, as defined in section
3121 (b) of the Internal Revenue Code, up to a
17maximum amount that is equal to the social security wage base multiplied by the
18number of the employer's employees.
SB562,60,20
19(2) Individuals. Subject to sub. (4), the board shall calculate the following
20assessments, based on its anticipated revenue needs:
SB562,60,2221
(a) For an employee who is under the age of 65, a percent of social security
22wages that is at least 2 percent and not more than 4 percent, subject to the following:
SB562,60,2423
1. If the employee has social security wages that are 150 percent or less of the
24poverty line, the employee may not be assessed.
SB562,61,5
12. If the employee has no dependents and his or her social security wages are
2more than 150 percent and 200 percent or less of the poverty line the assessment
3shall be in an amount, as determined by the board on a sliding scale based on the
4employee's social security wages, that is between zero percent and 4 percent of the
5employee's social security wages.
SB562,61,116
3. If the employee has one or more dependents, or is a single individual who is
7pregnant, and the employee's social security wages are more than 150 percent and
8300 percent or less of the poverty line the assessment shall be in an amount, as
9determined by the board on a sliding scale based on the employee's social security
10wages, that is between zero percent and 4 percent of the employee's social security
11wages.
SB562,61,1312
(b) For a self-employed individual who is under the age of 65, a percent of social
13security wages that is at least 9 percent and not more than 10 percent.
SB562,61,1714
(c) For an eligible individual who has no social security wages under sub. (1)
15(j) 1. or 2. or, from an employer, under sub. (1) (j) 3., 10 percent of federal adjusted
16gross income, up to the maximum amount of income that is subject to social security
17tax.