20,1133
Section
1133. 49.471 (8) (d) 2. dg. of the statutes is created to read:
49.471 (8) (d) 2. dg. The insurance is owned by someone not residing with the family and continuation of the coverage is beyond the family's control.
20,1134
Section
1134. 49.471 (8) (d) 2. dr. of the statutes is created to read:
49.471 (8) (d) 2. dr. The insurance only covers services provided in a service area that is beyond a reasonable driving distance.
20,1137
Section
1137. 49.471 (8) (fm) of the statutes is created to read:
49.471 (8) (fm) If an individual who is one of the following individuals had the health insurance coverage specified in par. (cg) 1. or (ct) but no longer has the coverage, the individual is not eligible for BadgerCare Plus for the 3 calendar months following the month in which the insurance coverage ended without a good cause reason specified in par. (g):
1. An individual who is not disabled and not pregnant, who is over 18 years of age, and whose family income exceeds 133 percent of the poverty line.
2. If the federal department of health and human services approves of the department's request to make such an individual ineligible, an individual who is not disabled and who is a child of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.
3. If the federal department of health and human services approves of the department's request to make such an individual ineligible, a parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
4. If the federal department of health and human services approves of the department's request to make such an individual ineligible, an adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
20,1138
Section
1138. 49.471 (8) (g) (intro.), 1., 2., 3., 4. and 5. of the statutes are amended to read:
49.471 (8) (g) (intro.) Any of the following is a good cause reason for purposes of par. pars. (f) and (fm):
1. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employment ended for a reason other than voluntary termination, unless the voluntary termination was a result of the incapacitation of the subscriber or because of an immediate family member's health condition.
2. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, the subscriber changed employers, and the new employer does not offer health insurance coverage.
3. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employer discontinued health plan coverage for all employees.
4. The
pregnant woman's individual's coverage was continuation coverage and the continuation coverage was exhausted in accordance with
29 CFR 2590.701-
2 (4).
5. The individual's or pregnant woman's coverage terminated due to the death or change in marital status of the subscriber.
20,1139
Section
1139. 49.471 (8) (g) 5g. of the statutes is created to read:
49.471 (8) (g) 5g. The insurance coverage is owned by someone not residing with the family and continuation of the coverage is beyond the family's control.
20,1140
Section
1140. 49.471 (8) (g) 5r. of the statutes is created to read:
49.471 (8) (g) 5r. The insurance coverage only covers services provided in a service area that is beyond a reasonable driving distance.
20,1141
Section
1141. 49.471 (9) (a) 2. b. of the statutes is amended to read:
49.471 (9) (a) 2. b. A child described in sub. (4) (a) 2. or (b) 2. 2m.
20,1142
Section
1142. 49.471 (10) (b) 1. of the statutes is amended to read:
49.471 (10) (b) 1. Except as provided in subd. subds. 1m. and 4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income. If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted.
20,1143
Section
1143
. 49.471 (10) (b) 1. of the statutes, as affected by 2013 Wisconsin Act .... (this act), is amended to read:
49.471 (10) (b) 1. Except as provided in subds. 1m. and 4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income. If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted.
20,1144
Section
1144. 49.471 (10) (b) 1m. of the statutes is created to read:
49.471 (10) (b) 1m. Except as provided in subd. 4., a recipient who is an adult parent or adult caretaker relative; who is not disabled, pregnant, or American Indian; and whose family income exceeds 133 percent of the federal poverty line shall pay a premium for coverage under BadgerCare Plus in an amount determined by the department that is based on a formula in which costs decrease for those with lower family incomes and that is no less than 3 percent of family income but no greater than 9.5 percent of family income. If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted. If the department intends to impose a premium under this subdivision after December 31, 2013, the department shall request from the federal department of health and human services any necessary approval to continue imposing premiums under this subdivision.
20,1146
Section
1146. 49.471 (10) (b) 2. of the statutes is amended to read:
49.471 (10) (b) 2. Except as provided in subds. 3. 3m. and 4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line.
20,1147
Section
1147. 49.471 (10) (b) 3. of the statutes is repealed.
20,1148
Section
1148. 49.471 (10) (b) 3m. of the statutes is created to read:
49.471 (10) (b) 3m. A recipient who is a child, who is not disabled, and whose family income is at a level determined by the department that is at least 150 percent of the poverty line shall pay a premium in an amount determined by the department. The department may apply this subdivision only to the extent the federal department of health and human services approves applying a premium to those individuals, if approval is required.
20,1149
Section
1149. 49.471 (10) (b) 4. (intro.) of the statutes is amended to read:
49.471 (10) (b) 4. (intro.) None of the following shall pay a premium, except as provided in subd. 3m.:
20,1150
Section
1150. 49.471 (10) (b) 4. b. of the statutes is amended to read:
49.471 (10) (b) 4. b. A child who is eligible under sub. (4) (a) 2. or (b) 2. 2m.
20,1151
Section
1151. 49.471 (10) (b) 5. of the statutes is amended to read:
49.471 (10) (b) 5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) or (4) (c) either does not pay a premium when due or requests that his or her coverage under this section be terminated, the recipient's coverage terminates and. If the recipient is an adult, the recipient is not eligible for BadgerCare Plus for 6 12 consecutive calendar months following the date on which the recipient's coverage terminated, except for any month during that 6-month 12-month period when the recipient's family income does not exceed 150 133 percent of the poverty line. If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 3 consecutive calendar months, or up to 12 consecutive calendar months if the federal department of health and human services approves, following the date on which the recipient's coverage terminated, except for any month during that period when the recipient's family income does not exceed 150 percent of the poverty line. This period of ineligibility for a child does not apply to any child who has paid the outstanding premiums.
20,1152
Section
1152
. 49.471 (10) (b) 5. of the statutes, as affected by 2013 Wisconsin Act .... (this act), is amended to read:
49.471 (10) (b) 5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) or (4) (c) either does not pay a premium when due or requests that his or her coverage under this section be terminated, the recipient's coverage terminates. If the recipient is an adult, the recipient is not eligible for BadgerCare Plus for 12 consecutive calendar months following the date on which the recipient's coverage terminated, except for any month during that 12-month period when the recipient's family income does not exceed 133 percent of the poverty line. If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 3 consecutive calendar months, or up to 12 consecutive calendar months if the federal department of health and human services approves, following the date on which the recipient's coverage terminated, except for any month during that period when the recipient's family income does not exceed 150 percent of the poverty line. This period of ineligibility for a child does not apply to any child who has paid the outstanding premiums.
20,1153
Section
1153. 49.471 (11) (intro.) of the statutes is amended to read:
49.471 (11) Benchmark plan benefits and copayments. (intro.) Recipients Except as provided in sub. (11r) and s. 49.45 (24j), recipients who are not eligible for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following benefits and pay the following copayments:
20,1154
Section
1154. 49.471 (11) (a) of the statutes is amended to read:
49.471 (11) (a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and subject to the Badger Rx Gold program discounts.
20,1155
Section
1155. 49.471 (11r) of the statutes is created to read:
49.471 (11r) Alternate Benchmark plan benefits and copayments. (a) If the department chooses to provide the alternate benchmark plan under this subsection, the department shall provide to the recipients described under sub. (4) (e) coverage for benefits similar to those in a commercial, major medical insurance policy.
(b) The department may charge copayments to recipients receiving coverage under the alternate benchmark plan under this subsection that are higher than copayments charged to recipients receiving coverage under the standard plan under s. 49.46 (2). The department may not charge to a recipient of coverage under the alternate benchmark plan under this subsection whose family income is at or below 150 percent of the poverty line a copayment that exceeds 5 percent of the individual's family income for all members of the family.
(c) 1. The department may only provide coverage under the alternate benchmark plan under this subsection to the extent the alternate benchmark plan is approved by the federal department of health and human services.
2. If the department is providing coverage under the alternate benchmark plan under this subsection the department may discontinue coverage under the benchmark plan under sub. (11) for those individuals eligible for the alternate benchmark plan under this subsection.
3. The department may provide services to individuals enrolled in the alternate benchmark plan under this subsection through a medical home initiative similar to an initiative described under s. 49.45 (24j).
20,1170
Section
1170. 49.475 (title) of the statutes is amended to read:
49.475 (title) Information about assistance program beneficiaries; electronic submission of claims.
20,1171
Section
1171. 49.475 (2) (except 49.475 (2) (title)) of the statutes is renumbered 49.475 (2) (ac), and 49.475 (2) (ac) 1. b. and 4. (intro.), as renumbered, are amended to read:
49.475 (2) (ac) 1. b. If subd. 1. a. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.
4. (intro.) If all of the following apply, agree not to deny a claim submitted by the department under par. (b) subd. 2. solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:
20,1172
Section
1172. 49.475 (2) (bc) of the statutes is created to read:
49.475 (2) (bc) A 3rd party shall accept the submission of claims from the department under par. (ac) 2. in electronic form and shall timely pay the claims in the manner provided in s. 628.46 (1) and (2). For purposes of timely payment of claims under this paragraph, "written notice" under s. 628.46 (1) includes receipt of a claim in electronic form.
20,1173
Section
1173. 49.475 (2m) (a) of the statutes is amended to read:
49.475 (2m) (a) The information that the department may request under this section is limited to the information specified in sub. (2) (a) (ac) 1. and does not include an employer's name unless that information is necessary for the department or a provider to obtain 3rd-party payment for an item or service.
20,1174
Section
1174. 49.475 (2m) (b) of the statutes is amended to read:
49.475 (2m) (b) If information under sub. (2) (a) (ac) 1. may be available from more than one source that includes an employer operating a self-insured plan, the department shall seek the information first from a 3rd-party administrator or other entity identified in sub. (1) (f) 7. or pharmacy benefits manager before seeking the information from the employer.
20,1175
Section
1175. 49.475 (3) (intro.) of the statutes is amended to read:
49.475 (3) Written agreement. (intro.) Upon requesting a 3rd party to provide the information under sub. (2) (a) (ac) 1., the department and the 3rd party shall enter into a written agreement that satisfies all of the following:
20,1176
Section
1176. 49.475 (4) (a) of the statutes is amended to read:
49.475 (4) (a) A 3rd party shall provide the information requested under sub. (2) (a) (ac) 1. within 180 days after receiving the department's request if it is the first time that the department has requested the 3rd party to disclose information under this section.
20,1177
Section
1177. 49.475 (4) (b) of the statutes is amended to read:
49.475 (4) (b) A 3rd party shall provide the information requested under sub. (2) (a) (ac) 1. within 30 days after receiving the department's request if the department has previously requested the 3rd party to disclose information under this section.
20,1178
Section
1178. 49.475 (5) of the statutes is amended to read:
49.475 (5) Reimbursement of costs. From the appropriations under s. 20.435 (4) (bm) and (pa), the department shall reimburse a 3rd party that provides information under sub. (2) (a) (ac) 1. for the 3rd party's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of the information.
20,1179
Section
1179. 49.496 (1) (a) of the statutes is renumbered 49.496 (1) (ah).
20,1180
Section
1180. 49.496 (1) (af) of the statutes is created to read:
49.496 (1) (af) "Decedent" means a deceased recipient or a deceased nonrecipient surviving spouse, whichever is applicable.
20,1181
Section
1181. 49.496 (1) (bk) of the statutes is created to read:
49.496 (1) (bk) "Long-term care program" means any of the following:
1. The family care program providing the benefit under s. 46.286.
2. The self-directed services option that operates under a waiver from the secretary of the federal department of health and human services under
42 USC 1396n (c) in which an enrolled individual selects his or her own services and service providers.
3. The family care partnership program that is an integrated health and long-term care program operated under an amendment to the state medical assistance plan under
42 USC 1396u-2 and a waiver under
42 USC 1396n (c).
4. The program for all-inclusive care for the elderly under
42 USC 1396u-4.
5. Any program that provides long-term care services and is operated by the department under an amendment to the state medical assistance plan under
42 USC 1396n (i) or
42 USC 1396u-2; a waiver of medical assistance laws under
42 USC 1396n (c),
42 USC 1396n (b) and (c), or
42 USC 1396u; or a demonstration project under
42 USC 1315 or
42 USC 1396n (c).
20,1182
Section
1182. 49.496 (1) (bw) of the statutes is created to read:
49.496 (1) (bw) "Nonrecipient surviving spouse" means any person who was married to a recipient while the recipient was receiving services for which the cost may be recovered under sub. (3) (a) and who survived the recipient.
20,1183
Section
1183. 49.496 (1) (cm) of the statutes is created to read:
49.496 (1) (cm) 1. "Property of a decedent" means all real and personal property to which the recipient held any legal title or in which the recipient had any legal interest immediately before death, to the extent of that title or interest, including assets transferred to a survivor, heir, or assignee through joint tenancy, tenancy in common, survivorship, life estate, living trust, or any other arrangement.
2. Notwithstanding subd. 1., "property of a decedent" includes all real and personal property in which the nonrecipient surviving spouse had an ownership interest at the recipient's death and in which the recipient had a marital property interest with that nonrecipient surviving spouse at any time within 5 years before the recipient applied for medical assistance or during the time that the recipient was eligible for medical assistance.
20,1184
Section
1184. 49.496 (3) (a) (intro.) of the statutes is amended to read:
49.496 (3) (a) (intro.) Except as provided in par. (b), the department shall file a claim against the estate of a recipient, and against the estate of a nonrecipient surviving spouse, for all of the following, subject to the exclusion of any amounts under the Long-Term Care Partnership Program established under s. 49.45 (31), unless already recovered by the department under this section:
20,1185
Section
1185. 49.496 (3) (a) 2. a. of the statutes is amended to read:
