SB562: Bill Text

SB562,56,16 2. Except for deductibles, copayments, coinsurance, and any other cost sharing required or authorized under the plan, a provider of a covered service or article shall accept as payment in full for the covered service or article the payment rate determined under subd. 1. and may not bill a participant who receives the service or article for any amount by which the charge for the service or article is reduced under subd. 1.

SB562,56,20 3. The board, with the assistance of its actuarial consultants, shall establish the monthly risk-adjusted cost of the fee-for-service option offered to participants under sub. (2) (a). The board shall classify the fee-for-service option in the same manner as the board classifies certified health care networks under sub. (5) (c).

SB562,56,25 4. If the board has determined under sub. (5) (c) that there is at least one certified low-cost health care network in an area, which may be the lowest-cost health care network, and if the fee-for-service option offered in that area has been classified as a higher-cost choice under subd. 3., the cost to a participant enrolling in the fee-for-service option shall be determined as follows:

SB562,57,7 a. If there are available to the participant 3 or more certified health care networks classified under sub. (5) (c) as low-cost networks, or as the lowest-cost network and 2 or more low-cost networks, the participant shall pay the difference between the cost of the lowest-cost health care network and the monthly risk-adjusted cost established under subd. 3. for the fee-for-service option, except that the amount paid may not exceed $100 per month for an individual, or $200 per month for a family, as adjusted for medical inflation.

SB562,57,14 b. If there are available to the participant 2 certified health care networks classified under sub. (5) (c) as low-cost networks, or as the lowest-cost network and one low-cost network, the participant shall pay the difference between the cost of the lowest-cost health care network and the monthly risk-adjusted cost established under subd. 3. for the fee-for-service option, except that the amount paid may not exceed $65 per month for an individual, or $125 per month for a family, as adjusted for medical inflation.

SB562,57,20 c. If there is available to the participant only one certified health care network classified under sub. (5) (c) as a low-cost network, or as the lowest-cost network, the person shall pay the difference between the cost of the lowest-cost health care network and the monthly risk-adjusted cost established under subd. 3. for the fee-for-service option, except that the amount paid may not exceed $25 per month for an individual, and $50 per month for a family, as adjusted for medical inflation.

SB562,57,23 5. If the board has determined, under sub. (5) (c), that there is no certified lowest-cost health care network or low-cost health care network in the area, there shall be no extra cost to the participant enrolling in the fee-for-service option.

SB562,58,7 (8) Incentive payments to fee-for-service providers. Health care providers and facilities providing services under the fee-for-service option under sub. (2) (a) shall be encouraged to collaborate with each other through financial incentives established by the board. Providers shall work with facilities to pool infrastructure and resources; to implement the use of best practices and quality measures; and to establish organized processes that will result in high-quality, low-cost medical care. The board shall establish an incentive payment system to providers and facilities that comply with this subsection, in accordance with criteria established by the board.

SB562,58,19 (9) Pharmacy benefit. Except for prescription drugs to which a deductible applies, the board shall assume the risk for, and pay directly for, prescription drugs provided to participants. In implementing this requirement, the board shall replicate the prescription drug buying system developed by the group insurance board for prescription drug coverage under the state employee health plan under s. 40.51 (6), unless the board determines that another approach would be more cost-effective. The board may join the prescription drug purchasing arrangement under this chapter with similar arrangements or programs in other states to form a multistate purchasing group to negotiate with prescription drug manufacturers and distributors for reduced prescription drug prices, or to contract with a 3rd party, such as a private pharmacy benefits manager, to negotiate with prescription drug manufacturers and distributors for reduced prescription drug prices.

SB562,58,23 260.35 Subrogation. The board and authority are entitled to the right of subrogation for reimbursement to the extent that a participant may recover reimbursement for health care services and items in an action or claim against any 3rd party.

SB562,59,2 260.37 Employer-provided health care benefits. Nothing in this chapter prevents an employer, or a Taft-Hartley trust on behalf of an employer, from paying all or part of any cost sharing under s. 260.20 or 260.30, or from providing any health care benefits not provided under the plan, for any of the employer's employees.

SB562,59,4 260.40 Assessments, individuals and businesses. (1) Definitions. In this section:

SB562,59,5 (a) "Department" means the department of revenue.

SB562,59,9 (b) "Dependent" means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.

SB562,59,11 (c) "Eligible individual" means an individual who is eligible to participate in the plan, other than an employee or a self-employed individual.

SB562,59,12 (d) "Employee" means an individual who has an employer.

SB562,59,14 (e) "Employer" means a person who is required under the Internal Revenue Code to file form 941.

SB562,59,17 (em) "Household" means an individual who is either an eligible individual, an employee, or a self-employed individual, and the individual's immediate family, as that term is defined by the board under s. 260.10 (7) (c).

SB562,59,24 (f) "Medical inflation" means the percentage change between the U.S. consumer price index for all urban consumers, U.S. city average, for the medical care group only, including medical care commodities and medical care services, for the month of August of the previous year and the U.S. consumer price index for all urban consumers, U.S. city average, for the medical care group only, including medical care commodities and medical care services, for the month of August 2008, as determined by the U.S. department of labor.

SB562,60,2 (g) "Poverty line" means the federal poverty line, as defined under 42 USC 9902 (2), for a family the size of the individual's family.

SB562,60,4 (h) "Self-employed individual" means an individual who is required under the Internal Revenue Code to file schedule SE.

SB562,60,5 (i) "Small employer" means an employer who has no more than 10 employees.

SB562,60,6 (j) "Social security wages" means:

SB562,60,9 1. For purposes of sub. (2) (a), the amount of wages, as defined in section 3121 (a) of the Internal Revenue Code, paid to an employee by an employer in a taxable year, up to a maximum amount that is equal to the social security wage base.

SB562,60,13 2. For purposes of sub. (2) (b), the amount of net earnings from self-employment, as defined in section 1402 (a) of the Internal Revenue Code, received by an individual in a taxable year, up to a maximum amount that is equal to the social security wage base.

SB562,60,18 3. For purposes of sub. (3), the amount of wages, as defined in section 3121 (a) of the Internal Revenue Code, paid by an employer in a taxable year with respect to employment, as defined in section 3121 (b) of the Internal Revenue Code, up to a maximum amount that is equal to the social security wage base multiplied by the number of the employer's employees.

SB562,60,20 (2) Individuals. Subject to sub. (4), the board shall calculate the following assessments, based on its anticipated revenue needs:

SB562,60,22 (a) For an employee who is under the age of 65, a percent of social security wages that is at least 2 percent and not more than 4 percent, subject to the following:

SB562,60,24 1. If the employee has social security wages that are 150 percent or less of the poverty line, the employee may not be assessed.

SB562,61,5 2. If the employee has no dependents and his or her social security wages are more than 150 percent and 200 percent or less of the poverty line the assessment shall be in an amount, as determined by the board on a sliding scale based on the employee's social security wages, that is between zero percent and 4 percent of the employee's social security wages.

SB562,61,11 3. If the employee has one or more dependents, or is a single individual who is pregnant, and the employee's social security wages are more than 150 percent and 300 percent or less of the poverty line the assessment shall be in an amount, as determined by the board on a sliding scale based on the employee's social security wages, that is between zero percent and 4 percent of the employee's social security wages.

SB562,61,13 (b) For a self-employed individual who is under the age of 65, a percent of social security wages that is at least 9 percent and not more than 10 percent.

SB562,61,17 (c) For an eligible individual who has no social security wages under sub. (1) (j) 1. or 2. or, from an employer, under sub. (1) (j) 3., 10 percent of federal adjusted gross income, up to the maximum amount of income that is subject to social security tax.

SB562,61,21 (3) Employers. (a) Subject to pars. (b), (c), and (d) and sub. (4), the board shall calculate an assessment, based on its anticipated revenue needs, that is a percent of aggregate social security wages that is at least 9 percent and not more than 12 percent.

SB562,61,24 (b) Except as provided in par. (d), for taxable year beginning after December 31, 2009, and before January 1, 2011, the assessment imposed on a small employer shall be 33 percent of the amount calculated for that employer under par. (a).

SB562,62,3 (c) Except as provided in par. (d), for taxable year beginning after December 31, 2010, and before January 1, 2012, the assessment imposed on a small employer shall be 67 percent of the amount calculated for that employer under par. (a).

SB562,62,10 (d) If a small employer begins doing business in this state, as defined in s. 71.22 (1r), during the period beginning on January 1, 2010, and ending on December 31, 2012, for the small employer's first taxable year the assessment imposed on the small employer shall be 33 percent of the amount calculated for that employer under par. (a) and for the small employer's 2nd taxable year the assessment imposed on the small employer shall be 67 percent of the amount calculated for that employer under par. (a).

SB562,62,21 (4) Collection and calculation of assessments. (a) For taxable years beginning after December 31, 2009, the department shall impose on, and collect from, individuals the assessment amounts that the board calculates under sub. (2), either through an assessment that is collected as part of the income tax under subch. I of ch. 71, or through another method devised by the department. For taxable years beginning after December 31, 2009, the department shall impose on, and collect from, employers the assessment amounts that the board calculates under sub. (3), either through an assessment that is collected as part of the tax under subch. IV of ch. 71, or through another method devised by the department. Section 71.80 (1) (c), as it applies to ch. 71, applies to the department's imposition and collection of assessments under this section.

SB562,62,23 (b) The amounts that the department collects under par. (a) shall be deposited into the Healthy Wisconsin trust fund under s. 25.775.

SB562,63,2 (c) The board may annually increase or decrease the amounts that may be assessed under subs. (2) and (3). No annual increase under this paragraph may exceed the percentage increase for medical inflation unless a greater increase is provided for by law.

SB562,63,6 (d) The maximum amount of assessment that the department may impose on, and collect from, a household under par. (a) is 4 percent of the annual limit on the contribution and benefit base of the Old-Age, Survivors, and Disability Insurance program, as calculated annually by the U.S. social security administration.

SB562,63,8 260.49 Advisory committee. (1) Duties. The board shall establish a health care advisory committee to advise the board on all of the following:

SB562,63,9 (a) Matters related to promoting healthier lifestyles.

SB562,63,10 (b) Promoting health care quality.

SB562,63,11 (c) Increasing the transparency of health care cost and quality information.

SB562,63,12 (d) Preventive care.

SB562,63,13 (e) Early identification of health disorders.

SB562,63,14 (f) Disease management.

SB562,63,16 (g) The appropriate use of primary care, medical specialists, prescription drugs, and hospital emergency rooms.

SB562,63,17 (h) Confidentiality of medical information.

SB562,63,18 (i) The appropriate use of technology.

SB562,63,19 (j) Benefit design.

SB562,63,20 (k) The availability of physicians, hospitals, and other providers.

SB562,63,21 (L) Reducing health care costs.

SB562,63,22 (m) Any other subject assigned to it by the board.

SB562,63,23 (n) Any other subject determined appropriate by the committee.

SB562,63,25 (2) Membership. The board shall appoint as members of the committee all of the following individuals:

SB562,64,1 (a) At least one member designated by the Wisconsin Medical Society, Inc.

SB562,64,3 (b) At least one member designated by the Wisconsin Academy of Family Physicians.

SB562,64,4 (c) At least one member designated by the Wisconsin Hospital Association, Inc.

SB562,64,7 (d) One member designated by the president of the Board of Regents of the University of Wisconsin System who is knowledgeable in the field of medicine and public health.

SB562,64,9 (e) One member designated by the president of the Medical College of Wisconsin.

SB562,64,12 (f) Two members designated by the Wisconsin Nurses Association, the Wisconsin Federation of Nurses and Health Professionals, and the Service Employees International Union.

SB562,64,13 (g) One member designated by the Wisconsin Dental Association.

SB562,64,15 (h) One member designated by statewide organizations interested in mental health issues.

SB562,64,16 (i) One member representing health care administrators.

SB562,64,17 (j) Other members representing health care professionals.

SB562, s. 77 Section 77. 285.59 (1) (b) of the statutes is amended to read:

SB562,65,2 285.59 (1) (b) "State agency" means any office, department, agency, institution of higher education, association, society, or other body in state government created or authorized to be created by the constitution or any law which that is entitled to expend moneys appropriated by law, including the legislature and the courts, the Wisconsin Housing and Economic Development Authority, the Bradley Center Sports and Entertainment Corporation, the University of Wisconsin Hospitals and Clinics Authority, the Fox River Navigational System Authority, the Wisconsin Aerospace Authority, and the Wisconsin Health and Educational Facilities Authority, and the Healthy Wisconsin Authority.

SB562, s. 78 Section 78. 609.01 (7) of the statutes is repealed.

SB562, s. 79 Section 79. 609.10 of the statutes is repealed.

SB562, s. 80 Section 80. 609.20 (1m) (c) of the statutes is repealed.

SB562, s. 81 Section 81. 609.20 (1m) (d) of the statutes is repealed.

SB562, s. 82 Section 82. 628.36 (4) (a) (intro.) of the statutes is amended to read:

SB562,65,11 628.36 (4) (a) (intro.) The commissioner shall provide information and assistance to the department of employee trust funds, employers and their employees, providers of health care services, and members of the public, as provided in par. (b), for the following purposes:

SB562, s. 83 Section 83. 628.36 (4) (b) 1. of the statutes is repealed.

SB562, s. 84 Section 84. 628.36 (4) (b) 2. of the statutes is repealed.

SB562, s. 85 Section 85. 628.36 (4) (b) 3. of the statutes is repealed.

SB562, s. 86 Section 86. 632.87 (5) of the statutes is amended to read:

SB562,65,23 632.87 (5) No insurer or self-insured school district, city or village may, under a policy, plan, or contract covering gynecological services or procedures, exclude or refuse to provide coverage for Papanicolaou tests, pelvic examinations , or associated laboratory fees when the test or examination is performed by a licensed nurse practitioner, as defined in s. 632.895 (8) (a) 3., within the scope of the nurse practitioner's professional license, if the policy, plan, or contract includes coverage for Papanicolaou tests, pelvic examinations, or associated laboratory fees when the test or examination is performed by a physician.

SB562, s. 87 Section 87. 632.895 (8) (f) 4. of the statutes is created to read:

SB562,66,2 632.895 (8) (f) 4. A disability insurance policy providing only health care benefits not provided under the Healthy Wisconsin Plan under ch. 260.

SB562, s. 88 Section 88. 632.895 (9) (d) 4. of the statutes is created to read:

SB562,66,5 632.895 (9) (d) 4. A disability insurance policy providing only health care benefits not provided under the Healthy Wisconsin Plan under ch. 260.

SB562, s. 89 Section 89. 632.895 (10) (a) of the statutes is amended to read:

SB562,66,14 632.895 (10) (a) Except as provided in par. (b), every disability insurance policy and every health care benefits plan provided on a self-insured basis by a county board under s. 59.52 (11), by a city or village under s. 66.0137 (4), by a political subdivision under s. 66.0137 (4m), by a town under s. 60.23 (25), or by a school district under s. 120.13 (2) shall provide coverage for blood lead tests for children under 6 years of age, which shall be conducted in accordance with any recommended lead screening methods and intervals contained in any rules promulgated by the department of health and family services under s. 254.158.

SB562, s. 90 Section 90. 632.895 (10) (b) 6. of the statutes is created to read:

SB562,66,17 632.895 (10) (b) 6. A disability insurance policy providing only health care benefits not provided under the Healthy Wisconsin Plan under ch. 260.

SB562, s. 91 Section 91. 632.895 (11) (a) (intro.) of the statutes is amended to read: