SB707: Bill Text

SB707, s. 46 Section 46. Subchapter I (title) of chapter 635 [precedes 635.01] of the statutes is created to read:

SB707,22,5 CHAPTER 635

SB707,22,7 Subchapter i General Provisions

SB707, s. 47 Section 47. 635.02 (1) of the statutes is renumbered 635.02 (1g).

SB707, s. 48 Section 48. 635.02 (1c) of the statutes is created to read:

SB707,22,11 635.02 (1c) "Authority" means the Small Business Health Options Program Authority.

SB707, s. 49 Section 49. 635.02 (1o) of the statutes is created to read:

SB707,22,13 635.02 (1o) "Board" means the board of directors of the authority.

SB707, s. 50 Section 50. 635.18 (1) of the statutes is amended to read:

SB707,22,16 635.18 (1) Every Any small employer insurer shall may actively market health benefit plan coverage to small employers in the state.

SB707, s. 51 Section 51. Subchapter II of chapter 635 [precedes 635.30] of the statutes is created to read:

SB707,22,19 CHAPTER 635

SB707,22,21 Subchapter II HEALTH BENEFIT PLAN exchange

SB707,22,25 635.30 Establishment of exchange; plans. (1) Subject to s. 635.45 (4), the authority shall establish and, by January 1, 2011, begin operating a health benefit plan exchange under which the authority shall enroll eligible groups and individuals in health benefit plans offered through the exchange.

SB707,23,6 (2) (a) The commissioner shall determine the initial plan designs, including minimum benefit levels, for the health benefit plans that may be offered through the exchange. Thereafter, the authority may modify the plan designs as it determines necessary or appropriate. Both the commissioner and the authority, in specifying plan designs under this subsection, shall attempt to limit the degree of variation among plans and the number of different plan choices for exchange participants.

SB707,23,11 (b) Only health benefit plans that satisfy the requirements under par. (a) and that are approved by the authority may be offered by insurers through the exchange. Each plan offered through the exchange shall contain a detailed description of the benefits provided, including any maximum or minimum amounts, limitations, or exclusions.

SB707,23,14 (3) The authority shall rank the health benefit plans that are offered through the exchange according to the benefits provided and place each one into one of the following 3 tiers:

SB707,23,15 (a) A plan with full benefits shall be designated as a "gold" plan.

SB707,23,17 (b) A plan providing 75 percent of the actuarial value of a "gold" plan shall be designated as a "silver" plan.

SB707,23,19 (c) A plan providing 60 percent of the actuarial value of a "gold" plan shall be designated as a "bronze" plan.

SB707,23,21 (4) The authority may eliminate a plan from the exchange only after notice to the insurer offering the plan.

SB707,23,23 635.35 Participation in exchange. (1) All of the following shall be eligible to purchase coverage under a health benefit plan offered through the exchange:

SB707,23,24 (a) A small employer.

SB707,24,2 (b) A state employee who is a limited term employee and who is not eligible for coverage under a health care coverage plan under subch. IV of ch. 40.

SB707,24,5 (c) An individual who contracts with this state for the performance of services for the state and who is not eligible for coverage under a health care coverage plan under subch. IV of ch. 40.

SB707,24,12 (2) The authority shall accept for enrollment through the exchange any small employer under sub. (1) (a) and any individual under sub. (1) (b) or (c) who applies for enrollment. An individual under sub. (1) (b) or (c) and an employee of a small employer under sub. (1) (a) may select coverage under any health benefit plan offered through the exchange, except that all employees of a single small employer must select coverage under health benefit plans that have been placed in the same tier under s. 635.30 (3) (a), (b), or (c).

SB707,24,16 (3) The authority shall collect initial premiums for coverage under each health benefit plan from enrollees in the plan and disburse the initial premium collected to the insurer offering the plan, along with enrollment information about each individual or employee enrolled in the plan.

SB707,24,25 635.37 Insurer requirements. (1) (a) Any insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, may offer coverage through the exchange. No insurer may offer or issue a health benefit plan to a small employer except through the exchange. An insurer that offers coverage through the exchange may offer only health benefit plans that satisfy the requirements under s. 635.30 (2) (a) and that are approved for the exchange by the authority. An insurer that offers coverage through the exchange must offer at least one health benefit plan in each tier under s. 635.30 (3) (a), (b), and (c).

SB707,25,3 (b) Notwithstanding ss. 631.36 (4) and 632.749 (1) and (2), a health benefit plan issued to a small employer that is in effect on the day that the exchange begins operating may remain in effect until the end of its term but may not be renewed.

SB707,25,8 (2) Premiums for coverage through the exchange may be based only on age, sex, geographic location, whether coverage is single or family, and plan design. For the purpose of determining premiums, an insurer shall pool together all individuals and employees who have coverage under all of the plans issued by the insurer through the exchange.

SB707,25,16 (3) An insurer may not impose any annual or lifetime limits or any preexisting condition exclusions under any plan offered through the exchange. An insurer offering coverage through the exchange shall accept for enrollment any individual under s. 635.35 (1) (b) or (c) and any employee of a small employer under s. 635.35 (1) (a) who applies for enrollment in a health benefit plan offered by the insurer through the exchange. Section 632.7495 applies to the renewability of an individual's or employee's coverage under a health benefit plan offered through the exchange.

SB707,25,20 (4) An insurer that offers health benefit plans through the exchange shall establish a toll-free hotline for providing information to enrollees and other individuals and shall furnish such reasonable reports as the authority determines necessary for the administration of the exchange.

SB707,25,24 (5) The authority may audit any insurer that provides coverage under a health benefit plan through the exchange for the purpose of ensuring that the insurer is providing covered individuals with the benefits provided for under this subchapter in a manner that does all of the following:

SB707,25,25 (a) Complies with the provisions of this chapter.

SB707,26,1 (b) Promotes positive health outcomes.

SB707,26,2 (c) Advances value-based and evidence-based medical practices.

SB707,26,5 (d) Avoids unnecessary operating and capital costs arising from inappropriate utilization or inefficient delivery of health care services, unwarranted duplication of services and infrastructure, or creation of excess care delivery capacity.

SB707,26,6 (e) Holds down the growth of health care costs.

SB707,26,15 635.40 Intermediaries. An insurance intermediary that enrolls an individual under s. 635.35 (1) (b) or (c) in a health benefit plan through the exchange shall be paid a commission by the insurer offering the health benefit plan. An insurance intermediary that enrolls the employees of a small employer under s. 635.35 (1) (a) in one or more health benefit plans through the exchange shall be paid a commission by each insurer offering a health benefit plan selected by an employee of the small employer. The authority shall determine the commission amounts that must be paid to intermediaries under this section after considering information provided to the commissioner under s. 628.81 with respect to health insurance.

SB707,26,19 635.45 Administration; rules. (1) For payment of administrative expenses, the authority may impose a surcharge on each insurer offering health benefit plans through the exchange. The surcharge shall be based on an insurer's total premium collected through the exchange.

SB707,26,20 (2) For administering the exchange the authority shall do all of the following:

SB707,26,24 (a) In consultation with the commissioner, establish procedures for approving plans that may be offered through the exchange, for ranking plans into the tiers under s. 635.30 (3), and for determining whether a plan should continue to be offered or should be eliminated from the exchange.

SB707,27,2 (b) Establish quality improvement standards for plans offered through the exchange.

SB707,27,4 (c) Establish a system for enrolling eligible groups and individuals, using a standard application form developed by the commissioner under sub. (5) (a).

SB707,27,6 (d) Establish procedures for collecting premiums and remitting premium payments and providing enrollment information to insurers.

SB707,27,9 (e) Establish, in consultation with the commissioner, the method for determining the amount of the surcharge under sub. (1) and establish the procedure for imposing and collecting the surcharge.

SB707,27,11 (f) Establish a plan for publicizing the exchange and the eligibility requirements and enrollment procedures.

SB707,27,13 (g) Establish and operate a service center to provide information to small employers, individuals, enrollees, and insurance intermediaries about the exchange.

SB707,27,15 (h) Establish a mechanism for regular communication and cooperation with insurance intermediaries.

SB707,27,17 (i) Establish an independent and binding appeals process for resolving disputes over eligibility and other determinations made by the authority.

SB707,27,18 (3) The authority may do all of the following:

SB707,27,20 (a) Contract with a 3rd-party administrator for the provision of services on behalf of the exchange.

SB707,27,21 (b) Establish risk adjustment mechanisms for the exchange.

SB707,27,22 (c) Enter into agreements with or establish sub-exchanges.

SB707,28,2 (4) The authority shall seek grants or other funding from the federal or state government for which it may be eligible and from private foundations. The authority may begin operating the exchange only if it receives federal grant moneys or other funds for that purpose.

SB707,28,4 (5) (a) The commissioner shall develop a standard application form for use in the exchange.

SB707,28,6 (b) The commissioner may promulgate rules, with the approval of the authority, for the administration of this subchapter.

SB707, s. 52 Section 52. Subchapter III of chapter 635 [precedes 635.70] of the statutes is created to read:

SB707,28,9 CHAPTER 635

SB707,28,12 Subchapter III Small Business Health Options Program authority

SB707,28,22 635.70 Creation and organization of authority. (1) There is created a public body corporate and politic to be known as the "Small Business Health Options Program Authority." The board of directors of the authority shall consist of the commissioner, or his or her designee; the secretary of employee trust funds, or his or her designee; the person who is appointed by the secretary of health services to be the director of the Medical Assistance program, or his or her designee; the executive director of the Health Insurance Risk-Sharing Plan Authority, or his or her designee; and all of the following members, who shall be nominated by the governor, and with the advice and consent of the senate appointed for 3-year terms, and none of whom shall be an employee of an insurer that is authorized to do business in the state:

SB707,28,23 (a) A member in good standing of the American Academy of Actuaries.

SB707,28,24 (b) A health economist.

SB707,28,25 (c) An employee benefits specialist.

SB707,29,1 (d) A representative of small employers.

SB707,29,2 (e) A representative of an organization that represents consumer interests.

SB707,29,3 (f) A representative of organized labor.

SB707,29,5 (2) A vacancy on the board shall be filled in the same manner as the original appointment to the board for the remainder of the unexpired term, if any.

SB707,29,8 (3) A member of the board shall receive no compensation for services under this chapter but shall be reimbursed for actual and necessary expenses, including travel expenses, incurred in the discharge of the member's duties under this chapter.

SB707,29,13 (4) The commissioner or the commissioner's designee shall be the chairperson of the board. Five members of the board constitute a quorum for the purpose of conducting the business and exercising the powers of the authority, notwithstanding the existence of any vacancy. The board may take action upon a vote of a majority of the members present, unless the bylaws of the authority require a larger number.

SB707,29,25 (5) The chairperson shall appoint an executive director who shall not be a member of the board and who shall serve at the pleasure of the board. The executive director shall receive compensation commensurate with the duties of the office, as determined by the board. The executive director shall serve as secretary of the authority and shall keep a record of the proceedings of the authority and shall be custodian of all books, documents, and papers filed with the authority, the minute book or journal of the authority, and its official seal. The executive director or other person may cause copies to be made of all minutes and other records and documents of the authority and may give certificates under the official seal of the authority to the effect that such copies are true copies, and all persons dealing with the authority may rely upon such certificates. The executive director shall have all of the following duties:

SB707,30,2 (a) Supervising the administrative affairs and the general management and operation of the authority.

SB707,30,4 (b) Planning, directing, coordinating, and executing administrative functions in conformity with the policies and directives of the board.

SB707,30,5 (c) Employing professional and clerical staff, as necessary.

SB707,30,7 (d) Reporting to the board on all operations under his or her control and supervision.

SB707,30,9 (e) Preparing an annual budget and managing the administrative expenses of the authority.

SB707,30,11 (f) Undertaking any activities necessary to implement the powers and duties set forth in this chapter.

SB707,30,13 635.72 Duties. In addition to all other duties imposed under this chapter, the authority shall do all of the following:

SB707,30,14 (1) Establish its annual budget and monitor its fiscal management.

SB707,30,18 (2) No later than two years after the exchange under subch. II begins operation, and annually thereafter, submit a report to the legislature under s. 13.172 (2) and to the governor on the operation of the exchange under subch. II, including a review of all of the following:

SB707,30,19 (a) Progress toward the goals of the exchange.

SB707,30,20 (b) The operations and administration of the exchange.

SB707,30,22 (c) The types of health insurance plans available to eligible individuals and groups and the percentage of the total exchange enrollees served by each plan.

SB707,30,25 (d) Surveys and reports on the insurers' experiences with different plans, including aggregated data on enrollees, claims, statistics, complaint data, and enrollee satisfaction data.

SB707,31,2 (e) Significant observations regarding utilization and adoption of the exchange.

SB707,31,4 (3) Annually submit to the governor and the legislative audit bureau a statement of its activities and financial condition.

SB707,31,6 (4) Approve the use of any trademarks, seals, or logos by participating insurers and small employers.

SB707,31,9 635.74 Powers. The authority has all of the powers necessary or convenient to carry out its duties under this chapter, except that it may not acquire or hold title to real estate or issue bonds. In addition, the authority may do any of the following:

SB707,31,11 (1) Adopt bylaws and policies and procedures for the regulation of its affairs and the conduct of its business.