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17(3) "Health care network" means a provider-driven, coordinated group of
18health care providers comprised of primary care physicians, medical specialists,
19physician assistants, nurses, clinics, one or more hospitals, and other health care
20providers and facilities, including providers and facilities that specialize in mental
21health services and alcohol or other drug abuse treatment.
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22(4) "Medical inflation" means changes in the consumer price index for all
23consumers, U.S. city average, for the medical care group, including medical care
24commodities and medical care services, as determined by the U.S. department of
25labor.
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1(5) "Plan" means the Healthy Wisconsin Plan.
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2(6) "Primary care provider" means a health care provider who is identified as
3the key professional responsible for coordinating all medical care for a given
4participant, including referral to a specialist. "Primary care provider" includes
5general practice physicians, family practitioners, internists, pediatricians,
6obstetricians and gynecologists, advanced practice nurses, certified nurse midwives,
7and physician assistants. "Primary care provider" may also include a specialist who
8is treating a person with a chronic medical condition or special health care needs for
9which regular treatment by a specialist is medically necessary or a specialist who is
10treating a disabled person.
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11260.05 Creation and organization of authority. (1) Creation and
12membership of board. There is created a public body corporate and politic to be
13known as the "Healthy Wisconsin Authority." The nonvoting members of the board
14shall consist of the secretary of employee trust funds and 4 representatives from the
15advisory committee under s. 260.49 who are health care personnel and
16administrators, selected by the advisory committee. The secretary of employee trust
17funds shall serve as the initial chairperson of the board until such time as the board
18elects a chairperson from its voting membership. The board shall also consist of the
19following voting members, nominated by the governor and with the advice and
20consent of the senate appointed, for staggered 6-year terms:
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(a) Four members selected from a list of names submitted by statewide labor
22or union coalitions. One of these members shall be a public employee.
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(b) Four members selected from a list of names submitted by statewide
24business and employer organizations. One of these members shall be a public
25employer.
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1(c) One member selected from a list of names submitted by statewide public
2school teacher labor organizations.
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(d) One member selected from a list of names submitted by statewide small
4business organizations.
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(e) Two members who are farmers, selected from a list of names submitted by
6statewide general farm organizations.
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(f) One member who is a self-employed person.
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(g) Three members selected from a list of names submitted by statewide health
9care consumer organizations.
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10(2) Terms of office; vacancies; quorum; business. (a) The terms of all members
11of the board shall expire on July 1.
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(b) Each member of the board shall hold office until a successor is appointed
13and qualified unless the member vacates or is removed from his or her office. A
14member who serves as a result of holding another office or position vacates his or her
15office as a member when he or she vacates the other office or position. A member who
16ceases to qualify for office vacates his or her office. A vacancy on the board shall be
17filled in the same manner as the original appointment to the board for the remainder
18of the unexpired term, if any.
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(c) A majority of the members of the board constitutes a quorum for the purpose
20of conducting its business and exercising its powers and for all other purposes,
21notwithstanding the existence of any vacancies. Action may be taken by the board
22upon a vote of a majority of the members present. Meetings of the members of the
23board may be held anywhere within or without the state.
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24(3) Board member responsibility as trustee. Each member of the board shall
25be responsible for taking care that the highest level of independence and judgment
1is exercised at all times in administering the plan and overseeing the individuals and
2organizations selected to implement the plan.
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3(4) Duties. The board shall:
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(a) Establish and administer a health care system in this state that ensures
5that all eligible persons have access to high quality, timely, and affordable health
6care. In establishing and administering the health care system, except as otherwise
7provided by law, the board shall seek to attain all of the following goals:
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1. Every resident of this state shall have access to affordable, comprehensive
9health care services.
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2. Health care reform shall maintain and improve choice of health care
11providers and high quality health care services in this state.
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3. Health care reform shall implement cost containment strategies that retain
13and assure affordable coverage for all residents of this state.
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(b) Establish, fund, and manage the plan as provided in this chapter.
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(c) Appoint an executive director, who shall serve at the pleasure of the board.
16The board may delegate to one or more of its members or its executive director any
17powers and duties the board considers proper. The executive director shall receive
18such compensation as may be determined by the board.
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(d) Provide for mechanisms to enroll every eligible resident in this state under
20the plan. Contracts entered into by the board with providers shall include provisions
21to enroll all eligible persons at the point of service, and outreach programs to assure
22every eligible person becomes enrolled in the plan.
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(e) Create a program for consumer protection and a process to resolve disputes
24with providers.
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1(f) Establish an independent and binding appeals process for resolving
2disputes over eligibility and other determinations made by the board. Any person
3who is adversely affected by a board eligibility determination or any other
4determination is entitled to judicial review of the determination.
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(g) Submit an annual report on its activities to the governor and chief clerk of
6each house of the legislature, for distribution under s. 13.172 (2).
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(h) Contract for annual, independent, program evaluations and financial
8audits that measure the extent to which the plan is achieving the goals under par.
9(a) 1. to 3. The board may not enter into a contract with the same auditor for more
10than 6 years.
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(i) Accept bids from health care networks in accordance with the criteria set out
12in s. 260.30, or make payments to fee-for-service providers in accordance with s.
13260.30. The board shall consult with the department of employee trust funds in
14determining the most effective and efficient way of purchasing health care benefits.
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(j) Audit health care networks and providers to determine if their services meet
16the plan objectives and criteria under this chapter.
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17(5) Powers. The board shall have all the powers necessary or convenient to
18carry out the purposes and provisions of this chapter. In addition to all other powers
19granted the board under this chapter, the board may:
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(a) Adopt, amend, and repeal bylaws and policies and procedures for the
21regulation of its affairs and the conduct of its business.
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(b) Have a seal and alter the seal at pleasure.
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(c) Maintain an office.
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(d) Sue and be sued.
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1(e) Accept gifts, grants, loans, or other contributions from private or public
2sources.
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(f) Establish the authority's annual budget and monitor the fiscal management
4of the authority.
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(g) Execute contracts and other instruments, including contracts for any
6professional services required for the authority.
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(h) Employ any officers, agents, and employees that it may require and
8determine their qualifications and compensation.
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(i) Procure liability insurance.
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(j) Contract for studies on issues, as identified by the board or by the advisory
11committee under s. 260.49, that relate to the plan.
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(k) Borrow money, as necessary on a short-term basis, to address cash flow
13issues.
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(L) Compel witnesses to attend meetings and to testify upon any necessary
15matter concerning the plan.
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16260.10 Eligibility. (1) Covered persons. Except as provided in subs. (2) to
17(5) and subject to sub. (6), a person is eligible to participate in the plan if the person
18satisfies all of the following criteria:
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(a) The person has maintained his or her place of permanent abode, as defined
20by the board, in this state for at least 12 months.
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(b) The person maintains a substantial presence in this state, as defined by the
22board.
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(c) The person is under 65 years of age.
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(d) The person is not eligible for health care coverage from the federal
25government or a foreign government, is not an inmate of a penal facility, as defined
1in s. 19.32 (1e), and is not placed or confined in, or committed to, an institution for
2the mentally ill or developmentally disabled.
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(e) Subject to s. 49.45 (54), unless a waiver requested under sub. (6) (b) has been
4granted and is in effect, the person is not eligible for Medical Assistance under subch.
5IV of ch. 49, including for health care coverage under BadgerCare Plus.
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6(2) Gainfully employed. If a person and the members of the person's
7immediate family do not meet the criteria under sub. (1) (a) and (b), but do meet the
8criteria under sub. (1) (c) to (e) and the person is gainfully employed in this state, as
9defined by the board, the person and the members of the person's immediate family
10are eligible to participate in the plan.
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11(3) Dependent children. If a child under age 18 resides with his or her parent
12in this state but the parent does not yet meet the residency requirement under sub.
13(1) (a), the child is eligible to participate in the plan regardless of the length of time
14the child has resided in this state, if the child meets the criteria under sub. (1) (b) to
15(e).
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16(4) Pregnant women. A pregnant woman who resides in this state who does
17not yet meet the residency requirement under sub. (1) (a) is eligible to participate in
18the plan regardless of the length of time the pregnant woman has resided in this
19state, if she meets the criteria under sub. (1) (b) to (e).
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20(5) Collective bargaining agreement. A person who is eligible to participate
21in the plan under sub. (1), (2), (3), or (4) and who receives health care coverage under
22a collective bargaining agreement that is in effect on January 1, 2010, is not eligible
23to participate in the plan until the day on which the collective bargaining agreement
24expires or the day on which the collective bargaining agreement is extended,
25modified, or renewed.
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1(6) Waiver request. (a) In this subsection, "department" means the
2department of health and family services.
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(b) 1. The department shall develop a request for a waiver from the secretary
4of the federal department of health and human services to provide coverage under
5the plan to individuals who are eligible for Medical Assistance under subch. IV of ch.
649 in the low-income families category, as determined by the department, including
7individuals who are eligible for health care coverage under BadgerCare Plus. The
8waiver request shall be written so as to allow the use of federal financial
9participation to fund, to the maximum extent possible, health care coverage under
10the plan for the individuals specified in this subdivision.
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2. The department shall, not later than July 1, 2009, submit the waiver request
12developed under subd. 1. to a special legislative committee that shall be comprised
13of the members of the joint committee on finance and the members of the standing
14committees of the senate and the assembly with subject matter jurisdiction over
15health issues. The special legislative committee shall have 60 days to review and
16comment to the department on the waiver request.
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(c) Except as required under par. (b), the department may develop waiver
18requests to the appropriate federal agencies to permit funds from federal health care
19services programs to be used for health care coverage for persons under the plan.
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20(7) Definitions of terms. For purposes of this chapter, the board shall define
21all of the following terms:
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(a) Place of permanent abode.
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(b) Substantial presence this state. In defining "substantial presence in this
24state," the board shall consider such factors as the amount of time per year that an
25individual is actually present in the state and the amount of taxes that an individual
1pays in this state, except that, if the individual attends school outside of this state
2and is under 23 years of age, the factors shall include the amount of time that the
3individual's parent or guardian is actually present in the state and the amount of
4taxes that the individual's parent or guardian pays in this state, and if the individual
5is in active service with the U.S. armed forces outside of this state, the factors shall
6include the amount of time that the individual's parent, guardian, or spouse is
7actually present in the state and the amount of taxes that the individual's parent,
8guardian, or spouse pays in this state.
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(c) Immediate family.
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(d) Gainfully employed. The definition shall include employment by persons
11who are self-employed and persons who work on farms.
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12260.12 Office of outreach, enrollment, and advocacy. (1) Establishment. 13The board shall establish an office of outreach, enrollment, and advocacy. The office
14shall contract with nonprofit organizations to perform the outreach, enrollment, and
15advocacy functions specified in this section, and to review the health care payment
16and services records of persons who are participating, or who are eligible to
17participate, in the plan and who have provided the office with informed consent for
18the review. The office may not contract with any organization under this subsection
19that provides services under the plan or that has any other conflict of interest, as
20described in sub. (3).
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21(2) Duties. The office of outreach, enrollment, and advocacy shall do all of the
22following:
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(a) Engage in aggressive outreach to enroll eligible persons and participants
24in their choice of health care coverage under the plan.
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1(b) Assist eligible persons in choosing health care coverage by examining cost,
2quality, and geographic coverage information regarding their choice of available
3networks or providers.
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(c) Inform plan participants of the role they can play in holding down health
5care costs by taking advantage of preventive care, enrolling in chronic disease
6management programs if appropriate, responsibly utilizing medical services, and
7engaging in healthy lifestyles. The office shall inform participants of networks or
8workplaces where healthy lifestyle incentives are in place.
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(d) At the direction of the board, establish a process for resolving disputes with
10providers.
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(e) Act as an advocate for plan participants having questions, difficulties, or
12complaints about their health care services or coverage, including investigating and
13attempting to resolve the complaint. Investigation should include, when
14appropriate, consulting with the health care advisory committee under s. 260.49
15regarding best practice guidelines.
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(f) If a participant's complaint cannot be successfully resolved, inform the
17participant of any legal or other means of recourse for his or her complaint. If the
18complaint involves a dispute over eligibility or other determinations made by the
19board, the participant shall be directed to the appeals process for board decisions.
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(g) Provide information to the public, agencies, legislators, and others
21regarding problems and concerns of plan participants and, in consultation with the
22health care advisory committee under s. 260.49, make recommendations for
23resolving those problems and concerns.
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(h) Ensure that plan participants have timely access to the services provided
25by the office.
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1(3) Conflict of interest limitation. The office and its employees and
2contractors shall not have any conflict of interest relating to the performance of their
3duties. There is a conflict of interest if, with respect to the office's director, employees,
4or contractors, or a person affiliated with the office's director, employees, or
5contractors, any of the following exists:
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(a) Direct involvement in the licensing, certification, or accreditation of a
7health care facility, health insurer, or health care provider.
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(b) Direct ownership interest or investment interest in a health care facility,
9health insurer, or health care provider.
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(c) Employment by, or participation in, the management of a health care
11facility, health insurer, or health care provider.
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(d) Receipt of, or having the right to receive, directly or indirectly, remuneration
13under a compensation arrangement with a health care facility, health insurer, or
14health care provider.
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15260.15 Benefits. (1) Generally. The board shall establish a health care plan
16that will take effect on January 1, 2010. The plan shall provide the same benefits
17as those that were in effect as of January 1, 2008, under the state employee health
18plan under s. 40.51 (6), 2005 stats. The board may adjust the plan benefits to provide
19additional cost-effective treatment options if there is evidence-based research that
20the options are likely to reduce health care costs, avoid health risks, or result in
21better health outcomes.
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22(2) Additional benefits. In addition to the benefit requirements under sub.
23(1), the plan shall provide coverage for mental health services and alcohol and other
24drug abuse treatment to the same extent as the plan covers treatment for physical
25conditions and coverage for preventive dental care for children up to 18 years of age.
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1260.20 Cost sharing. (1) No cost sharing. The plan shall cover the following
2preventive services without any cost-sharing requirement:
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(a) Prenatal care for pregnant women.
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(b) Well-baby care.
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(c) Medically appropriate examinations and immunizations for children up to
618 years of age.
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(d) Medically appropriate gynecological exams, Papanicolaou tests, and
8mammograms.
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(e) Medically appropriate regular medical examinations for adults, as
10determined by best practices.
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(f) Medically appropriate colonoscopies.
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(g) Preventive dental care for children up to 18 years of age.
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(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.
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(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.