(e) Take into account any federal funding available for the plan.
(f) Take into account the total amount available to fund the plan.
(a) The commissioner shall set the payment parameters as 13
described under sub. (2) by no later than March 30 of the calendar year before the 14
applicable benefit year or, if the commissioner specifies a different date by rule, the 15
date specified by the commissioner by rule.
(b) If the amount available for expenditure for the healthcare stability plan is 17
not anticipated to be adequate to fully fund the payment parameters set under par. 18
(a) as of July 1 of the calendar year before the applicable benefit year, the 19
commissioner shall adjust the payment parameters in accordance within the moneys 20
available to expend for the healthcare stability plan. The commissioner shall allow 21
an eligible health carrier to revise its rate filing based on the final payment 22
parameters for the applicable benefit year.
(c) If funding is not available to make all reinsurance payments to eligible 24
health carriers in a benefit year, the commissioner shall make reinsurance payments 25
in proportion to the eligible health carrier's share of aggregate health benefit plan
premiums from residents of this state for all health benefit plans during the given 2
benefit year, as determined by the commissioner. The commissioner shall notify 3
eligible health carriers if there are insufficient funds available to make reinsurance 4
payments in full and the estimated amount of payment as soon as practicable after 5
the commissioner becomes aware of the insufficiency.
6(4) Reinsurance payment calculation.
(a) The commissioner shall calculate 7
a reinsurance payment with respect to each eligible health carrier's incurred claims 8
costs for an enrolled individual's covered benefits in the applicable benefit year. If 9
the claims costs for an enrolled individual do not exceed the attachment point set 10
under sub. (2), the commissioner may not make a reinsurance payment with respect 11
to that enrollee. If the claims costs for an enrolled individual exceed the attachment 12
point, subject to par. (b), the commissioner shall make a reinsurance payment that 13
is calculated as the product of the coinsurance rate and whichever of the following 14
1. The claims costs minus the attachment point.
2. The reinsurance cap minus the attachment point.
(b) The commissioner shall ensure that any reinsurance payment made to an 18
eligible health carrier does not exceed the total amount paid by the eligible health 19
carrier for any claim. For purposes of this paragraph, the total amount paid of a 20
claim is the amount paid by the eligible health carrier based upon the allowed 21
amount less any deductible, coinsurance, or copayment paid by another person as of 22
the time the data are submitted or made accessible under sub. (5) (c).
23(5) Reinsurance payment requests.
(a) An eligible health carrier may request 24
reinsurance payments from the commissioner when the eligible health carrier meets 25
the requirements of this subsection and sub. (4).
(b) An eligible health carrier shall make any requests for a reinsurance 2
payment in accordance with any requirements established by the commissioner.
(c) Each eligible health carrier shall provide the commissioner with access to 4
the data within the dedicated data environment established by the eligible health 5
carrier under the federal risk adjustment program under 42 USC 18063
. Each 6
eligible health carrier shall submit to the commissioner attesting to compliance with 7
the dedicated data environments, data requirements, establishment and usage of 8
masked enrollee identification numbers, and data submission deadlines.
(d) Each eligible health carrier shall provide the access under par. (c) for each 10
applicable benefit year by April 30 of the calendar year following the end of the 11
applicable benefit year.
(e) Each eligible health carrier shall maintain for at least 6 years documents 13
and records, by paper, electronic, or other media, sufficient to substantiate a request 14
for a reinsurance payment made under this section. An eligible health carrier shall 15
make the documents and records available to the commissioner, upon request, for 16
purposes of verification, investigation, audit, or other review of a reinsurance 17
(f) The commissioner may have an eligible health carrier audited to assess the 19
health carrier's compliance with the requirements of this section. The eligible health 20
carrier shall ensure that its contractors, subcontractors, or agents cooperate with 21
any audit under this paragraph. Within 30 days of receiving notice that an audit 22
results in a proposed finding of material weakness or significant deficiency with 23
respect to compliance with any requirement of this section, the eligible health carrier 24
may provide a response to the proposed finding. Within 60 days of the issuance of
a final audit report that includes a finding of material weakness or significant 2
deficiency, the eligible health carrier shall do all of the following:
1. Provide a written corrective action plan to the commissioner for approval.
2. Implement the corrective action plan under subd. 1. as approved by the 5
3. Provide the commissioner with written documentation of the corrective 7
action after implementation.
(g) The commissioner may recover from an eligible health carrier any 9
overpayment of reinsurance payments as determined under the audit under par. (f).
(h) A health carrier is not eligible to receive a reinsurance payment unless the 11
health carrier agrees not to bring a lawsuit over any delay in reinsurance payments 12
or any reduction in reinsurance payments in accordance with sub. (3) (c).
13(6) Access to information.
Information submitted by an eligible health carrier 14
or obtained by the commissioner for purposes of the healthcare stability plan is 15
proprietary and confidential under s. 601.465.
601.85 of the statutes is created to read:
17601.85 Accounting, reports, and audits. (1) Accounting.
commissioner shall keep an accounting for each benefit year of all of the following:
(a) Funds appropriated for reinsurance payments and administrative and 20
(b) Requests for reinsurance payments received from eligible health carriers.
(c) Reinsurance payments made to eligible health carriers.
(d) Administrative and operational expenses incurred for the healthcare 24
By November 1 of the calendar year following the applicable 2
benefit year or by 60 days following the final disbursement of reinsurance payments 3
for the applicable benefit year, whichever is later, the commissioner shall make 4
available to the public a report summarizing the healthcare stability plan's 5
operations for each benefit year by posting the summary on the office's Internet site.
6(3) Legislative auditor.
The healthcare stability plan is subject to audit by the 7
legislative audit bureau. The commissioner shall ensure that its contractors, 8
subcontractors, or agents cooperate with any audit of the healthcare stability plan 9
performed by the legislative audit bureau.
10(4) Required recommendation report.
By December 31, 2018, the 11
commissioner shall submit to the governor recommendations on implementing a 12
waiver under s. 601.83 (1) (b), any possible additional waivers to be requested, and 13
any other options to stabilize the individual health care market in this state.
Subchapter VIII (title) of chapter 601 [precedes 601.93] of the 15
statutes is created to read:
FIRE DEPARTMENT DUES
Subchapter VI (title) of chapter 601 [precedes 601.93] of the 20
statutes is repealed.
(1) Payment parameters.
For the 2019 benefit year, the commissioner of 23
insurance shall set as payment parameters for the healthcare stability plan under 24
subchapter VII of chapter 601 an attachment point of $50,000, a coinsurance rate of 25
between 50 and 80 percent, and a reinsurance cap of $250,000. The commissioner
of insurance may adjust the payment parameters to the extent necessary to secure 2
federal approval of the waiver request under section 601.83 (1) (b) of the statutes. For 3
subsequent benefit years, the commissioner of insurance may adjust the payment 4
parameters in accordance with section 601.83 (2) of the statutes.
(1) Lapse from Medical Assistance general purpose revenue appropriation.
The secretary of health services shall ensure that there is lapsed to the general fund 8
from the appropriation under section 20.435 (4) (b) of the statutes an amount up to 9
$80,000,000, as determined by the secretary of administration.