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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.
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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.
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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.
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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.
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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.
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(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.
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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.
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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.
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(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.
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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.
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(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.
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(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.
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(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.
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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.
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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.
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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.
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(e)
Adjustments by board. Notwithstanding pars. (a) to (d), the board may
5adjust the copayment and coinsurance amounts specified in pars. (a) to (d).
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6(4) Maximum amounts. Notwithstanding the deductible, coinsurance, and
7copayment amounts in subs. (2) and (3), all of the following apply:
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(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).
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(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).
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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.
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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.
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(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:
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(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.
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2. Investments that the health care network has reasonably determined will
6improve the overall quality or lower the overall cost of patient care.
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(c) Ensures all of the following:
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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.
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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.
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(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.
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(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.
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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.