Amendment AA8-ASA1-AB64

AB64-ASA1-AA8,65,18 (c) Enter into agreements with or establish sub-exchanges.

AB64-ASA1-AA8,65,20 (d) Create any other exchange, or component of the exchange, that is provided for under federal law.

AB64-ASA1-AA8,65,24 (3) The authority shall seek grants to the fullest extent to which it is eligible, including amounts under section 1311 (a) (1) and (4) of the federal act, or other funding from the federal or state government for which it may be eligible and from private foundations for the purpose of the exchange.

AB64-ASA1-AA8,66,2 636.42 Health benefit plan certification. (1) The authority may certify a health benefit plan as a qualified health plan if all of the following are true:

AB64-ASA1-AA8,66,6 (a) The plan provides the essential health benefits package described in section 1302 (a) of the federal act, except that the plan is not required to provide essential benefits that duplicate the minimum benefits of qualified dental plans, as provided in sub. (5), if all of the following are satisfied:

AB64-ASA1-AA8,66,8 1. The authority has determined that at least one qualified dental plan is available to supplement the plan's coverage.

AB64-ASA1-AA8,66,12 2. The health carrier makes prominent disclosure at the time it offers the plan, in a form approved by the authority, that the plan does not provide the full range of essential pediatric benefits and that qualified dental plans providing those benefits and other dental benefits not covered by the plan are offered through the exchange.

AB64-ASA1-AA8,66,14 (b) The premium rates and contract language have been filed with and not disapproved by the commissioner.

AB64-ASA1-AA8,66,18 (c) The plan provides at least a bronze level of coverage, as determined under s. 636.30 (1) (e), unless the plan is certified as a qualified catastrophic plan, meets the requirements of the federal act for catastrophic plans, and will only be offered to individuals eligible for catastrophic coverage.

AB64-ASA1-AA8,66,22 (d) The plan's cost-sharing requirements do not exceed the limits established under section 1302 (c) (1) of the federal act and, if the plan is offered through the SHOP Exchange, the plan's deductible does not exceed the limits established under section 1302 (c) (2) of the federal act.

AB64-ASA1-AA8,66,23 (e) The health carrier offering the plan satisfies all of the following:

AB64-ASA1-AA8,66,25 1. Is licensed and in good standing to offer health insurance coverage in this state.

AB64-ASA1-AA8,67,4 2. Offers at least one qualified health plan in the silver level and at least one qualified health plan in the gold level through each component of the exchange in which the health carrier participates. In this subdivision, “component" refers to the SHOP Exchange and the exchange for individual coverage.

AB64-ASA1-AA8,67,7 3. Charges the same premium rate for each qualified health plan without regard to whether the plan is offered directly from the health carrier or through an insurance intermediary.

AB64-ASA1-AA8,67,9 4. Does not charge any cancellation fees or penalties in violation of s. 636.25 (3).

AB64-ASA1-AA8,67,11 5. Complies with the regulations developed by the secretary under section 1311 (d) of the federal act and such other requirements as the authority may establish.

AB64-ASA1-AA8,67,17 (f) The plan meets the requirements of certification as required by any rules promulgated under s. 636.46 (1) and by the secretary under section 1311 (c) of the federal act, including minimum standards in the areas of marketing practices, network adequacy, essential community providers in underserved areas, accreditation, quality improvement, uniform enrollment forms, and descriptions of coverage and information on quality measures for health benefit plan performance.

AB64-ASA1-AA8,67,20 (g) The authority determines that making the plan available through the exchange is in the interest of qualified individuals and qualified employers in this state.

AB64-ASA1-AA8,67,22 (2) The authority shall not exclude a health benefit plan for any of the following reasons or in any of the following ways:

AB64-ASA1-AA8,67,23 (a) On the basis that the plan is a fee-for-service plan.

AB64-ASA1-AA8,67,24 (b) Through the imposition of premium price controls by the authority.

AB64-ASA1-AA8,68,3 (c) On the basis that the plan provides treatments necessary to prevent patients' deaths in circumstances the authority determines are inappropriate or too costly.

AB64-ASA1-AA8,68,5 (3) The authority shall require each health carrier seeking certification of a health benefit plan as a qualified health plan to do all of the following:

AB64-ASA1-AA8,68,11 (a) Submit a justification for any premium increase before implementation of that increase. The health carrier shall prominently post the information on its Internet site. The authority shall take this information, along with the information and the recommendations provided to the authority by the commissioner under 42 USC 300gg-94 (b), into consideration when determining whether to allow the health carrier to make the plan available through the exchange.

AB64-ASA1-AA8,68,14 (b) 1. Make available to the public, in the format described in subd. 2., and submit to the authority, the secretary, and the commissioner, accurate and timely disclosure of all of the following:

AB64-ASA1-AA8,68,15 a. Claims payment policies and practices.

AB64-ASA1-AA8,68,16 b. Periodic financial disclosures.

AB64-ASA1-AA8,68,17 c. Data on enrollment.

AB64-ASA1-AA8,68,18 d. Data on disenrollment.

AB64-ASA1-AA8,68,19 e. Data on the number of claims that are denied.

AB64-ASA1-AA8,68,20 f. Data on rating practices.

AB64-ASA1-AA8,68,22 g. Information on cost sharing and payments with respect to any out-of-network coverage.

AB64-ASA1-AA8,68,23 h. Information on enrollee and participant rights under title I of the federal act.

AB64-ASA1-AA8,68,24 i. Other information as determined appropriate by the secretary.

AB64-ASA1-AA8,69,2 2. The information required in subd. 1. shall be provided in plain language, as that term is defined in section 1311 (e) (3) (B) of the federal act.

AB64-ASA1-AA8,69,9 (c) Permit individuals to learn, in a timely manner upon the request of the individual, the amount of cost sharing, including deductibles, copayments, and coinsurance, under the individual's plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider. At a minimum, this information shall be made available to the individual through an Internet site and through other means for individuals without access to the Internet.

AB64-ASA1-AA8,69,14 (4) The authority may not exempt any health carrier seeking certification of a health benefit plan as a qualified health plan, regardless of the type or size of the health carrier, from state licensure or solvency requirements and shall apply the criteria of this section in a manner that assures equitable treatment of all health carriers participating in the exchange.

AB64-ASA1-AA8,69,18 (5) (a) The provisions of this chapter that are applicable to qualified health plans shall also apply to the extent relevant to qualified dental plans, except as modified in accordance with pars. (b), (c), and (d) or by regulations adopted by the authority.

AB64-ASA1-AA8,69,20 (b) The health carrier shall be licensed to offer dental coverage, but need not be licensed to offer other health benefits.

AB64-ASA1-AA8,70,2 (c) The plan shall be limited to dental and oral health benefits, without substantially duplicating the benefits typically offered by health benefit plans without dental coverage, and shall include, at a minimum, the essential pediatric dental benefits prescribed by the secretary under section 1302 (b) (1) (J) of the federal act and such other dental benefits as the authority or the secretary may specify by regulation.

AB64-ASA1-AA8,70,7 (d) Health carriers may jointly offer a comprehensive plan through the exchange in which the dental benefits are provided by a health carrier through a qualified dental plan and the other benefits are provided by a health carrier through a qualified health plan, provided that the plans are priced separately and are also made available for purchase separately at the same price.

AB64-ASA1-AA8,70,12 636.43 Insurer requirements. (1) Any health carrier that is authorized to do business in this state in one or more lines of insurance that includes health insurance may offer health benefit plans through the exchange. After the exchange becomes operational, no health carrier may offer or issue a health benefit plan in this state to an individual or to a small employer except through the exchange.

AB64-ASA1-AA8,70,15 (2) For the purpose of determining premiums, a health carrier may pool together all individuals and employees who have coverage under all of the qualified health plans issued by the health carrier through the exchange.

AB64-ASA1-AA8,70,19 (3) A health carrier that offers qualified health 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.

AB64-ASA1-AA8,70,23 (4) The authority may audit any health carrier that provides coverage under a qualified health plan through the exchange for the purpose of ensuring that the health carrier is providing covered individuals with the benefits provided for under this subchapter in a manner that does all of the following:

AB64-ASA1-AA8,70,24 (a) Complies with the provisions of this chapter.

AB64-ASA1-AA8,70,25 (b) Promotes positive health outcomes.

AB64-ASA1-AA8,71,1 (c) Advances value-based and evidence-based medical practices.

AB64-ASA1-AA8,71,4 (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.

AB64-ASA1-AA8,71,5 (e) Holds down the growth of health care costs.

AB64-ASA1-AA8,71,13 636.44 Intermediaries. An insurance intermediary that enrolls a qualified individual in a qualified health plan through the exchange shall be paid a commission by the health carrier offering the qualified health plan. An insurance intermediary that enrolls the employees of a qualified employer in one or more qualified health plans through the exchange shall be paid a commission by each health carrier offering a qualified health plan selected by an employee of the qualified employer. The authority shall determine the commission amounts that must be paid to intermediaries under this section.

AB64-ASA1-AA8,71,18 636.45 Funding; publication of costs. (1) For payment of administrative expenses, the authority may impose a surcharge on each health carrier offering qualified health plans through the exchange. The surcharge shall be based on the health carrier's total premium or flat dollar amount per enrollee collected through the exchange.

AB64-ASA1-AA8,71,22 (2) The authority shall publish the average costs of licensing, regulatory fees, and any other payments required by the authority, and the administrative costs of the authority, on an Internet site to educate consumers on such costs. This information shall include information on moneys lost to waste, fraud, and abuse.

AB64-ASA1-AA8,72,2 636.46 Rules; application form. (1) The commissioner may promulgate rules to implement the provisions of this chapter. Rules promulgated under this section may not conflict with or prevent the application of regulations promulgated by the secretary under the federal act.

AB64-ASA1-AA8,72,4 (2) The commissioner shall develop a standard application form for use in the exchange.

AB64-ASA1-AA8,72,11 636.48 Relation to other laws. Nothing in this chapter, and no action taken by the authority under this chapter, shall be construed to preempt or supersede the authority of the commissioner to regulate the business of insurance within this state. Except as expressly provided to the contrary in this chapter, all health carriers offering qualified health plans in this state shall comply fully with all applicable health insurance laws of this state and rules promulgated and orders issued by the commissioner.

AB64-ASA1-AA8,72,13 Subchapter III badger Health benefit authority

AB64-ASA1-AA8,72,24 636.70 Creation and organization of authority. (1) There is created a public body corporate and politic to be known as the “Badger Health Benefit 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, or his or her designee, of the Wisconsin Collaborative for Healthcare Quality, if that organization exists; the executive director, or his or her designee, of the Wisconsin Health Information Organization, if that organization exists; 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 except as provided in sub. (2):

AB64-ASA1-AA8,72,25 (a) A member in good standing of the American Academy of Actuaries.

AB64-ASA1-AA8,73,1 (b) A health economist.

AB64-ASA1-AA8,73,2 (c) An employee benefits specialist.

AB64-ASA1-AA8,73,3 (d) A representative of small employers.

AB64-ASA1-AA8,73,4 (e) A representative of an organization that represents consumer interests.

AB64-ASA1-AA8,73,5 (f) A representative of organized labor.

AB64-ASA1-AA8,73,6 (g) An individual with experience in health care administration.

AB64-ASA1-AA8,73,10 (2) No member of the board appointed under sub. (1) (a) to (g) may be a health care provider, as defined in s. 146.81 (1) (a) to (hp); an employee of a health care provider, as defined in s. 146.81 (1) (i) to (p); an employee of an insurer that is authorized to do business in the state; or an insurance intermediary.

AB64-ASA1-AA8,73,12 (3) 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.

AB64-ASA1-AA8,73,15 (4) 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.

AB64-ASA1-AA8,73,20 (5) The commissioner or the commissioner's designee shall be the chairperson of the board. Seven 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.

AB64-ASA1-AA8,74,7 (6) The board 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:

AB64-ASA1-AA8,74,9 (a) Supervising the administrative affairs and the general management and operation of the authority.

AB64-ASA1-AA8,74,11 (b) Planning, directing, coordinating, and executing administrative functions in conformity with the policies and directives of the board.

AB64-ASA1-AA8,74,12 (c) Employing professional and clerical staff, as necessary.

AB64-ASA1-AA8,74,14 (d) Reporting to the board on all operations under his or her control and supervision.

AB64-ASA1-AA8,74,16 (e) Preparing an annual budget and managing the administrative expenses of the authority.

AB64-ASA1-AA8,74,18 (f) Undertaking any activities necessary to implement the powers and duties set forth in this chapter.

AB64-ASA1-AA8,74,20 636.72 Authority duties. In addition to all other duties imposed under this chapter, the authority shall do all of the following:

AB64-ASA1-AA8,74,21 (1) Establish its annual budget and monitor its fiscal management.

AB64-ASA1-AA8,74,25 (2) No later than 2 years after an 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 any exchange under subch. II, including a review of all of the following:

AB64-ASA1-AA8,75,1 (a) Progress toward the goals of the exchange.

AB64-ASA1-AA8,75,2 (b) The operations and administration of the exchange.

AB64-ASA1-AA8,75,4 (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.

AB64-ASA1-AA8,75,7 (d) Surveys and reports on the insurers' experiences with different plans, including aggregated data on enrollees, claims, statistics, complaint data, and enrollee satisfaction data.

AB64-ASA1-AA8,75,9 (e) Significant observations regarding utilization and adoption of the exchange.

AB64-ASA1-AA8,75,11 (3) Annually submit to the governor and the legislative audit bureau a statement of its activities and financial condition.

AB64-ASA1-AA8,75,13 (4) Approve the use of any trademarks, seals, or logos by participating insurers and small employers.

AB64-ASA1-AA8,75,15 (5) Comply with the requirements of s. 16.413 as if the authority is a state agency.

AB64-ASA1-AA8,75,19 636.74 Authority 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:

AB64-ASA1-AA8,75,21 (1) Adopt bylaws and policies and procedures for the regulation of its affairs and the conduct of its business.