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(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.
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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.
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(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.
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(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.
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(j) Has in place a comprehensive, shared, electronic patient records and
22treatment tracking system and an electronic provider payment system.
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(k) Has adopted and implemented a strong policy to safeguard against conflicts
24of interest.
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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.
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(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:
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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.
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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.
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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.
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(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.
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(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.
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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.
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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.
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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.
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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.
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(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.
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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.
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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).
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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.
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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.
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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.
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(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.
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(c) "Eligible individual" means an individual who is eligible to participate in
11the plan, other than an employee or a self-employed individual.
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(d) "Employee" means an individual who has an employer.
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(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).
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(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.
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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.
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(h) "Self-employed individual" means an individual who is required under the
4Internal Revenue Code to file schedule SE.
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(i) "Small employer" means an employer who has no more than 10 employees.
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(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.
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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.
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19(2) Individuals. Subject to sub. (4), the board shall calculate the following
20assessments, based on its anticipated revenue needs:
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(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:
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1. If the employee has social security wages that are 150 percent or less of the
24poverty line, the employee may not be assessed.
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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.
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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.
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(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.
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(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.
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18(3) Employers. (a) Subject to pars. (b), (c), and (d) and sub. (4), the board shall
19calculate an assessment, based on its anticipated revenue needs, that is a percent of
20aggregate social security wages that is at least 9 percent and not more than 12
21percent.
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(b) Except as provided in par. (d), for taxable year beginning after December
2331, 2009, and before January 1, 2011, the assessment imposed on a small employer
24shall be 33 percent of the amount calculated for that employer under par. (a).
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1(c) Except as provided in par. (d), for taxable year beginning after December 31,
22010, and before January 1, 2012, the assessment imposed on a small employer shall
3be 67 percent of the amount calculated for that employer under par. (a).
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(d) If a small employer begins doing business in this state, as defined in s. 71.22
5(1r), during the period beginning on January 1, 2010, and ending on December 31,
62012, for the small employer's first taxable year the assessment imposed on the small
7employer shall be 33 percent of the amount calculated for that employer under par.
8(a) and for the small employer's 2nd taxable year the assessment imposed on the
9small employer shall be 67 percent of the amount calculated for that employer under
10par. (a).
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11(4) Collection and calculation of assessments. (a) For taxable years
12beginning after December 31, 2009, the department shall impose on, and collect
13from, individuals the assessment amounts that the board calculates under sub. (2),
14either through an assessment that is collected as part of the income tax under subch.
15I of ch. 71, or through another method devised by the department. For taxable years
16beginning after December 31, 2009, the department shall impose on, and collect
17from, employers the assessment amounts that the board calculates under sub. (3),
18either through an assessment that is collected as part of the tax under subch. IV of
19ch. 71, or through another method devised by the department. Section 71.80 (1) (c),
20as it applies to ch. 71, applies to the department's imposition and collection of
21assessments under this section.
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(b) The amounts that the department collects under par. (a) shall be deposited
23into the Healthy Wisconsin trust fund under s. 25.775.
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(c) The board may annually increase or decrease the amounts that may be
25assessed under subs. (2) and (3). No annual increase under this paragraph may
1exceed the percentage increase for medical inflation unless a greater increase is
2provided for by law.
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(d) The maximum amount of assessment that the department may impose on,
4and collect from, a household under par. (a) is 4 percent of the annual limit on the
5contribution and benefit base of the Old-Age, Survivors, and Disability Insurance
6program, as calculated annually by the U.S. social security administration.
SB562,63,8
7260.49 Advisory committee. (1) Duties. The board shall establish a health
8care advisory committee to advise the board on all of the following:
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(a) Matters related to promoting healthier lifestyles.
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(b) Promoting health care quality.
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(c) Increasing the transparency of health care cost and quality information.
SB562,63,1212
(d) Preventive care.
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(e) Early identification of health disorders.
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(f) Disease management.
SB562,63,1615
(g) The appropriate use of primary care, medical specialists, prescription
16drugs, and hospital emergency rooms.
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(h) Confidentiality of medical information.
SB562,63,1818
(i) The appropriate use of technology.
SB562,63,1919
(j) Benefit design.
SB562,63,2020
(k) The availability of physicians, hospitals, and other providers.
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(L) Reducing health care costs.
SB562,63,2222
(m) Any other subject assigned to it by the board.
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(n) Any other subject determined appropriate by the committee.
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24(2) Membership. The board shall appoint as members of the committee all of
25the following individuals:
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1(a) At least one member designated by the Wisconsin Medical Society, Inc.
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(b) At least one member designated by the Wisconsin Academy of Family
3Physicians.
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(c) At least one member designated by the Wisconsin Hospital Association, Inc.
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(d) One member designated by the president of the Board of Regents of the
6University of Wisconsin System who is knowledgeable in the field of medicine and
7public health.
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(e) One member designated by the president of the Medical College of
9Wisconsin.
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(f) Two members designated by the Wisconsin Nurses Association, the
11Wisconsin Federation of Nurses and Health Professionals, and the Service
12Employees International Union.
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(g) One member designated by the Wisconsin Dental Association.
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(h) One member designated by statewide organizations interested in mental
15health issues.
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(i) One member representing health care administrators.
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(j) Other members representing health care professionals.
SB562, s. 77
18Section
77. 285.59 (1) (b) of the statutes is amended to read:
SB562,65,219
285.59
(1) (b) "State agency" means any office, department, agency, institution
20of higher education, association, society
, or other body in state government created
21or authorized to be created by the constitution or any law
which that is entitled to
22expend moneys appropriated by law, including the legislature and the courts, the
23Wisconsin Housing and Economic Development Authority, the Bradley Center
24Sports and Entertainment Corporation, the University of Wisconsin Hospitals and
25Clinics Authority, the Fox River Navigational System Authority, the Wisconsin
1Aerospace Authority,
and the Wisconsin Health and Educational Facilities
2Authority
, and the Healthy Wisconsin Authority.
SB562, s. 78
3Section
78. 609.01 (7) of the statutes is repealed.
SB562, s. 79
4Section
79. 609.10 of the statutes is repealed.