AB445: Bill Text

AB445,20,17 chapter 636 health benefit plan exchange

AB445,20,19 subchapter I general provisions

AB445,20,20 636.01 Definitions. In this chapter:

AB445,20,21 (1) “Authority" means the Badger Health Benefit Authority.

AB445,20,24 (2) “Educated health care consumer" means an individual who is knowledgeable about the health care system and who has background or experience in making informed decisions regarding health, medical, and scientific matters.

AB445,21,4 (3) “Federal act" means the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, P.L. 111-152, and any amendments to, or regulations or guidance issued under, those acts.

AB445,21,7 (4) (a) Except as provided in pars. (b) to (e), “health benefit plan" means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

AB445,21,8 (b) “Health benefit plan" does not include any of the following:

AB445,21,10 1. Coverage only for accident, or disability income insurance, or any combination of those.

AB445,21,11 2. Coverage issued as a supplement to liability insurance.

AB445,21,13 3. Liability insurance, including general liability insurance and automobile liability insurance.

AB445,21,14 4. Worker's compensation or similar insurance.

AB445,21,15 5. Automobile medical payment insurance.

AB445,21,16 6. Credit-only insurance.

AB445,21,17 7. Coverage for on-site medical clinics.

AB445,21,20 8. Other similar insurance coverage, specified in federal regulations issued under P.L. 104-191, under which benefits for health care services are secondary or incidental to other insurance benefits.

AB445,21,23 (c) “Health benefit plan" does not include any of the following benefits if they are provided under a separate policy, certificate, or contract of insurance or otherwise not an integral part of the plan:

AB445,21,24 1. Limited scope dental or vision benefits.

AB445,22,2 2. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those.

AB445,22,4 3. Other similar, limited benefits specified in federal regulations issued under P.L. 104-191.

AB445,22,11 (d) “Health benefit plan" does not include any of the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:

AB445,22,12 1. Coverage only for a specified disease or illness.

AB445,22,13 2. Hospital indemnity or other fixed indemnity insurance.

AB445,22,15 (e) “Health benefit plan" does not include any of the following if offered as a separate policy, certificate, or contract of insurance:

AB445,22,17 1. Medicare supplemental health insurance as defined under section 1882 (g) (1) of the federal Social Security Act.

AB445,22,19 2. Coverage supplemental to the coverage provided under the Civilian Health and Medical Program of the Uniformed Services 10 USC ch. 55.

AB445,22,21 3. Similar coverage supplemental to coverage provided under a group health plan.

AB445,23,3 (5) “Health carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services.

AB445,23,5 (5m) “Minimum essential coverage" has the meaning given in 26 USC 5000A (f) (1).

AB445,23,7 (6) “Qualified dental plan" means a limited scope dental plan that has been certified in accordance with s. 636.42 (5).

AB445,23,11 (7) “Qualified employer" means a small employer that elects to make its full-time employees eligible for one or more qualified health plans offered through the SHOP Exchange and, at the option of the employer, some or all of its part-time employees, provided that the employer satisfies any of the following:

AB445,23,14 (a) The employer has its principal place of business in this state and elects to provide coverage through the SHOP Exchange to all of its eligible employees, wherever employed.

AB445,23,16 (b) The employer elects to provide coverage through the SHOP Exchange to all of its eligible employees who are principally employed in this state.

AB445,23,19 (8) “Qualified health plan" means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in section 1311 (c) of the federal act and s. 636.42.

AB445,23,21 (9) “Qualified individual" means an individual, including a minor, who satisfies all of the following:

AB445,23,23 (a) The individual is seeking to enroll in a qualified health plan offered to individuals through the exchange under subch. II.

AB445,23,24 (b) The individual resides in this state.

AB445,24,2 (c) At the time of enrollment, the individual is not incarcerated in a correctional facility, other than incarceration pending the disposition of charges.

AB445,24,5 (d) The individual is, and is reasonably expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States.

AB445,24,7 (10) “Secretary" means the secretary of the federal department of health and human services.

AB445,24,9 (11) “SHOP Exchange" means a small business health options program established under s. 636.30 (1) (q).

AB445,24,11 (12) (a) “Small employer" means an employer that employed an average of not more than 100 employees during the preceding calendar year.

AB445,24,12 (b) For purposes of this subsection, all of the following apply:

AB445,24,14 1. All persons treated as a single employer under section 414 (b), (c), (m), or (o) of the Internal Revenue Code shall be treated as a single employer.

AB445,24,16 2. An employer and any predecessor employer shall be treated as a single employer.

AB445,24,18 3. All employees shall be counted, including part-time employees and employees who are not eligible for coverage through the employer.

AB445,24,22 4. If an employer was not in existence during the entire preceding calendar year, the determination of whether that employer is a small employer shall be based on the average number of employees that it is reasonably expected that employer will employ on business days in the current calendar year.

AB445,25,2 5. An employer that makes enrollment in qualified health plans available to its employees through the SHOP Exchange and that would cease to be a small employer by reason of an increase in the number of its employees shall continue to be treated as a small employer for purposes of this chapter as long as it continuously makes enrollment through the SHOP Exchange available to its employees.

AB445,25,4 subchapter II operation of exchange

AB445,25,8 636.25 General matters. (1) The authority shall establish and operate a Wisconsin Health Benefit Exchange and shall make qualified health plans, with effective dates on or before January 1, 2018, available to qualified individuals and qualified employers.

AB445,25,10 (2) (a) The authority may not make available any health benefit plan that is not a qualified health plan.

AB445,25,15 (b) The authority shall allow a health carrier to offer a plan that provides limited scope dental benefits meeting the requirements of section 9832 (c) (2) (A) of the Internal Revenue Code through the exchange under sub. (1), either separately or in conjunction with a qualified health plan, if the plan provides pediatric dental benefits meeting the requirements of section 1302 (b) (1) (J) of the federal act.

AB445,25,22 (3) Neither the authority nor a health carrier offering health benefit plans through the exchange under sub. (1) may charge an individual a fee or penalty for termination of coverage if the individual enrolls in another type of minimum essential coverage because the individual has become newly eligible for that coverage or because the individual's employer-sponsored coverage has become affordable under the standards of section 36B (c) (2) (C) of the Internal Revenue Code.

AB445,26,2 (4) The authority may enter into information-sharing agreements with federal and state agencies and entities operating exchanges in other states to carry out its responsibilities under this chapter, provided that such agreements include adequate protections with respect to the confidentiality of the information to be shared and comply with all state and federal laws and rules and regulations.

AB445,26,5 636.30 Exchange duties and powers. (1) In addition to all other duties imposed under this chapter, the authority shall do all of the following relating to the exchange under s. 636.25 (1):

AB445,26,9 (a) Implement procedures for the certification, recertification, and decertification, consistent with guidelines developed by the secretary under section 1311 (c) of the federal act and s. 636.42, of health benefit plans as qualified health plans.

AB445,26,11 (b) Provide for the operation of a toll-free telephone hotline to respond to requests for assistance.

AB445,26,13 (c) Provide for enrollment periods, as provided under section 1311 (c) (6) of the federal act.

AB445,26,16 (d) Maintain an Internet site through which enrollees and prospective enrollees of qualified health plans may obtain standardized comparative information on such plans.

AB445,26,21 (e) Assign a rating to each qualified health plan offered through the exchange in accordance with the criteria developed by the secretary under section 1311 (c) (3) of the federal act, and determine each qualified health plan's level of coverage in accordance with regulations issued by the secretary under section 1302 (d) (2) (A) of the federal act.

AB445,26,24 (f) Use a standardized format for presenting health benefit options in the exchange, including the use of the uniform outline of coverage established under 42 USC 300gg-15.

AB445,27,2 (g) Establish quality improvement standards for health benefit plans offered through the exchange.

AB445,27,4 (h) Establish a system for enrolling eligible groups and individuals, using a standard application form developed by the commissioner under s. 636.46 (2).

AB445,27,6 (i) Establish procedures for collecting premiums and remitting premium payments and providing enrollment information to health carriers.

AB445,27,9 (j) Establish, in consultation with the commissioner, the method for determining the amount of the surcharge under s. 636.45 (1) and establish the procedure for imposing and collecting the surcharge.

AB445,27,11 (k) Establish a plan for publicizing the exchange and the eligibility requirements and enrollment procedures.

AB445,27,13 (L) Establish and operate a service center to provide information to small employers, individuals, enrollees, and insurance intermediaries about the exchange.

AB445,27,15 (m) Establish a mechanism for regular communication and cooperation with insurance intermediaries.

AB445,27,17 (n) Establish an independent and binding appeals process for resolving disputes over eligibility and other determinations made by the authority.

AB445,27,22 (o) In accordance with section 1413 of the federal act, inform individuals of eligibility requirements for Medical Assistance under subch. IV of ch. 49 or any other applicable state or local public program and if, through screening of the application by the authority, the authority determines that any individual is eligible for any such program, assist that individual to enroll in that program.

AB445,28,2 (p) Establish and make available by electronic means a calculator to determine the actual cost of coverage after application of any premium tax credit under section 36B of the Internal Revenue Code and any cost-sharing reduction under section 1402 of the federal act.

AB445,28,6 (q) Establish a SHOP Exchange through which qualified employers may access health care coverage for their employees and that shall enable any qualified employer to specify the level of coverage at which its employees may enroll in any qualified health plan offered through the SHOP Exchange.

AB445,28,9 (r) Perform duties required of the authority by the secretary or the federal secretary of the treasury related to determining eligibility for premium tax credits, reduced cost sharing, or individual responsibility requirement exemptions.

AB445,28,13 (s) Select entities, which may include insurance intermediaries, that are qualified to serve as navigators in accordance with section 1311 (i) of the federal act and standards developed by the secretary, and award grants to enable navigators to do all of the following:

AB445,28,15 1. Conduct public education activities to raise awareness of the availability of qualified health plans.

AB445,28,19 2. Distribute fair and impartial information concerning enrollment in qualified health plans and concerning the availability of premium tax credits under section 36B of the Internal Revenue Code and cost-sharing reductions under section 1402 of the federal act.

AB445,28,20 3. Facilitate enrollment in qualified health plans.

AB445,28,25 4. Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under 42 USC 300gg-93, or to any other appropriate state agency or agencies, for any enrollee with a grievance, complaint, or question regarding the enrollee's health benefit plan, coverage, or determination under that plan or coverage.

AB445,29,2 5. Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the exchange.

AB445,29,5 (t) Assist in the coordination of any necessary administrative operations between the department of corrections and the department of health services to ensure all of the following:

AB445,29,8 1. That an individual, upon placement in a correctional facility, is disenrolled for the duration of his or her incarceration from any health care coverage in which he or she is enrolled.

AB445,29,13 2. That an individual who is incarcerated in a correctional facility, but scheduled to be released from incarceration in the near future, is enrolled prior to release, through the exchange and effective upon the date of his or her release, in Medical Assistance, a qualified health plan, or some other form of minimum essential coverage on the date of his or her release from incarceration.

AB445,29,19 (u) For those persons whose alcohol or other drug abuse or mental health treatment is not covered by a federally administered program, coordinate the relationships among the Medical Assistance program, the exchange, and the county departments under s. 51.42 or 51.437 to provide outpatient and inpatient mental health and alcohol or other drug abuse treatment with all of the following goals for the coordination:

AB445,29,21 1. Maximizing coverage and improving access through the exchange for outpatient and inpatient treatment of mental illness and alcohol or other drug abuse.

AB445,29,23 2. Improving the quality of treatment for persons with alcohol or other drug dependence or a mental illness.

AB445,29,25 3. Fully integrating the treatment for physical conditions, alcohol or other drug abuse, and mental illness.

AB445,30,5 4. Reducing the cost of the county departments under ss. 51.42 and 51.437 to taxpayers by avoiding unnecessary overlap between the improved coverage of alcohol or other drug abuse treatment or mental illness treatment by health plans offered through the exchange and the services provided by county departments under s. 51.42 or 51.437.

AB445,30,8 (v) Review the rate of premium growth within the exchange and outside the exchange, and consider the information in developing recommendations on whether to continue limiting qualified employer status to small employers.

AB445,30,11 (w) Credit the amount of any free choice voucher to the monthly premium of the plan in which a qualified employee is enrolled, in accordance with section 10108 of the federal act, and collect the amount credited from the offering employer.