A person is not eligible for coverage under the plan if the person is eligible for any of the following:
Except as provided in pars. (b)
, no person is eligible for coverage under the plan for whom a premium, deductible, or coinsurance amount is paid or reimbursed by a federal, state, county, or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.
Persons for whom deductible or coinsurance amounts are paid or reimbursed under ch. 47
for vocational rehabilitation, under s. 49.68
for renal disease, under s. 49.685 (8)
for hemophilia, under s. 49.683
for cystic fibrosis, under s. 253.05
for maternal and child health services or under s. 49.686
for the cost of drugs for the treatment of HIV infection or AIDS are not ineligible for coverage under the plan by reason of such payments or reimbursements.
Persons for whom premium costs for health insurance coverage are subsidized under s. 252.16
are not ineligible for coverage under the plan by reason of such payments.
Persons for whom premium costs for health insurance coverage and copayments for certain prescription drugs are paid under the pilot program under s. 49.686 (6)
are not ineligible for coverage under the plan by reason of such payments.
Subject to subs. (1m)
, and (3)
, the authority may establish criteria that would enable additional persons to be eligible for coverage under the plan. The authority shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.
The authority shall establish policies for determining and verifying the continued eligibility of an eligible person.
History: 1979 c. 313
; 1983 a. 27
; 1985 a. 29
; 1987 a. 27
; 1989 a. 201
; 1989 a. 332
; 1991 a. 39
; 1993 a. 27
; 1995 a. 27
; 1997 a. 27
; Stats. 1997 s. 149.12; 1999 a. 9
; 2005 a. 74
; 2007 a. 20
; 2009 a. 28
Participation of insurers. 149.13(1)
Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under sub. (2)
would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the authority of the insurers participating in the cost of administering the plan.
Every participating insurer shall share in the operating, administrative and subsidy expenses of the plan in proportion to the ratio of the insurer's total health care coverage revenue for residents of this state during the preceding calendar year to the aggregate health care coverage revenue of all participating insurers for residents of this state during the preceding calendar year, as determined by the commissioner.
Each insurer's proportion of participation under sub. (2)
shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the authority. An insurer shall pay the amount of the assessment directly to the authority.
If the authority or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600
is not adequate to permit the commissioner or the authority to carry out the commissioner's or authority's responsibilities under this subchapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the commissioner and authority to make the determinations required under this subchapter.
Notwithstanding subs. (1)
, the authority, with the agreement of the commissioner, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan. Neither the commissioner nor the authority may assess any type of insurance that was not being assessed as of December 1, 2005, or any type of insurer that was not being assessed as December 1, 2005.
The plan shall offer coverage for each eligible person in an annually renewable policy. If an eligible person is also eligible for Medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by Medicare. If an eligible person is eligible for a type of medical assistance specified in s. 149.12 (2) (f) 2.
, the plan shall not pay or reimburse the person for expenses paid for by Medical Assistance.
If an individual terminates medical assistance coverage and applies for coverage under the plan within 45 days after the termination and is subsequently found to be eligible under s. 149.12
, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.
(2) Major medical expense coverage. 149.14(2)(a)(a)
The plan shall provide every eligible person who is not eligible for Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to deductible, copayment, and coinsurance payments, up to a lifetime limit per covered individual of $1,000,000 or a higher amount, as determined by the authority.
The plan shall provide an alternative policy for those persons eligible for medicare which reduces the benefits payable under par. (a)
by the amounts paid under medicare.
In addition to the coverage under pars. (a)
, the plan shall offer to all eligible persons who are not eligible for Medicare a choice of coverage, as described in section 2744 (a) (1) (C), P.L. 104-191
. Any such choice of coverage shall be major medical expense coverage. An eligible person who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the authority, among the coverages offered under this paragraph and par. (a)
. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under the plan. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under the plan and the person remained continuously covered under the plan up to the time of electing the new coverage.
(3) Covered expenses.
Covered expenses for coverage under the plan shall be the payment rates established by the authority for services provided by persons licensed under ch. 446
and certified under s. 49.45 (2) (a) 11.
Covered expenses for coverage under the plan shall also be the payment rates established by the authority for, at a minimum, the following services and articles if the service or article is prescribed by a physician who is licensed under ch. 448
or in another state and who is certified under s. 49.45 (2) (a) 11.
and if the service or article, except for prescription drugs that are provided by a network of pharmacies approved by the board, is provided by a provider certified under s. 49.45 (2) (a) 11.
Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental.
Subject to the limits under subd. 1.
, services for the chronically mentally ill in community support programs operated under s. 51.421
Drugs requiring a physician's prescription.
For persons eligible for Medicare, services of a licensed skilled nursing facility, to the extent required by s. 632.895 (3)
and for not more than an aggregate 120 days during a calendar year, if the services are of the type that would qualify as reimbursable services under Medicare. Coverage under this paragraph that is not required by s. 632.895 (3)
is subject to any deductible and coinsurance requirements provided by the authority.
For persons not eligible for medicare, services of a licensed skilled nursing facility, only to the extent required by s. 632.895 (3)
Use of radium or other radioactive materials.
Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids.
Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth.
Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat a covered condition.
Processing charges for blood including, but not limited to, the cost of collecting, testing, fractionating and distributing blood.
(3c) Temporary provider certification.
Notwithstanding the provider licensing and certification requirements under sub. (3) (intro.)
, for coverage of services or articles provided to an eligible person the authority may certify on a temporary basis a provider that is not licensed under ch. 446
but that is licensed in another state to provide the service or article, or a provider that is not certified under s. 49.45 (2) (a) 11.
The certification under this subsection may be retroactive.
(4) Plan design.
Subject to subs. (1)
, and (6)
, the authority shall establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate. Subject to subs. (1)
, and (6)
, the authority shall provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state. The authority may develop additional benefit designs that are responsive to market conditions.
(5) Deductible and copayment subsidies. 149.14(5)(a)(a)
The authority shall establish and provide subsidies for deductibles paid by eligible persons with household incomes specified in s. 149.165 (2) (a)
The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in par. (a)
(6) Preexisting conditions.
An eligible individual who obtains coverage under the plan may not be subject to any preexisting condition exclusion under the plan.
Covered expenses under the plan shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care insurance, medicare, medical assistance or any other governmental program, except as otherwise provided by law.
The authority has a cause of action against an eligible participant for the recovery of the amount of benefits paid that are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.
The authority is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan.
Percentage of costs.
Except as provided in sub. (2)
, the authority shall set premium rates for coverage under the plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1)
In no event may plan premium rates exceed 200 percent of rates applicable to individual standard risks.
History: 2005 a. 74
Provider payment rates. 149.142(1)
Establishment of rates.
The authority shall establish provider payment rates for covered expenses that consist of the usual and customary payment rates, as determined by the authority, for the services and articles provided plus an adjustment determined by the authority. The adjustments to the usual and customary rates shall be sufficient to cover the portion of plan costs specified in s. 149.143 (1) (c)
and (2) (b)
(2m) Payment is payment in full.
Except for copayments, coinsurance, or deductibles 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 sub. (1)
and may not bill an eligible person who receives the service or article for any amount by which the charge for the service or article is reduced under sub. (1)
Payment of plan costs. 149.143(1)
Costs excluding subsidies.
The authority shall pay plan costs, excluding any premium, deductible, and copayment subsidies, first from any federal funds under s. 149.11 (2) (a) 3.
that exceed premium, deductible, and copayment subsidy costs in a policy year. The remainder of the plan costs, excluding premium, deductible, and copayment subsidy costs, shall be paid as follows:
Sixty percent from premiums paid by eligible persons.
(2) Subsidy costs.
The authority shall pay for premium, deductible, and copayment subsidies in a policy year first from any federal funds under s. 149.11 (2) (a) 3.
received in that year. The remainder of the subsidy costs shall be paid as follows:
Reductions in premiums for low-income eligible persons. 149.165(1)(1)
The authority shall reduce the premiums established under s. 149.141
for the eligible persons and in the manner set forth in subs. (2)