1997 Wisconsin Act 27

1. A group health plan.

2. Health insurance.

3. Part A or part B of title XVIII of the federal Social Security Act.

4. Title XIX of the federal Social Security Act, except for coverage consisting solely of benefits under section 1928 of that act.

5. Chapter 55 of title 10 of the United States Code.

6. A medical care program of the federal Indian health service or of an American Indian tribal organization.

7. A state health benefits risk pool.

8. A health plan offered under chapter 89 of title 5 of the United States Code.

9. A public health plan.

10. A health coverage plan under section 5 (e) of the federal Peace Corps Act, 22 USC 2504 (e).

(b) “Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in section 2791 (c) of P.L. 104-191.

27,4817cm Section 4817cm. 619.10 (2j) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (2j).

27,4817m Section 4817m. 619.10 (2t) of the statutes is created to read:

619.10 (2t) “Eligible individual" means an individual for whom all of the following apply:

(a) The aggregate of the individual's periods of creditable coverage is 18 months or more.

(b) The individual's most recent period of creditable coverage was under a group health plan, governmental plan, federal governmental plan or church plan, or under any health insurance offered in connection with any of those plans.

(c) The individual does not have creditable coverage and is not eligible for coverage under a group health plan, part A or part B of title XVIII of the federal Social Security Act or a state plan under title XIX of the federal Social Security Act or any successor program.

(d) The individual's most recent period of creditable coverage was not terminated for any reason related to fraud or intentional misrepresentation of material fact or a failure to pay premiums.

(e) If the individual was offered the option of continuation coverage under a federal continuation provision or similar state program, the individual elected the continuation coverage.

(f) The individual has exhausted any continuation coverage under par. (e).

27,4817mm Section 4817mm. 619.10 (2t) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (2t).

27,4818 Section 4818 . 619.10 (3) of the statutes is renumbered 149.10 (3) and amended to read:

149.10 (3) “Eligible person" means a resident of this state who qualifies under s. 619.12 149.12 whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.

27,4818c Section 4818c. 619.10 (3c) of the statutes is created to read:

619.10 (3c) “Federal continuation provision" means any of the following:

(a) Section 4980B of the Internal Revenue Code of 1986, except for section 4980B (f) (1) of that code insofar as it relates to pediatric vaccines.

(b) Part 6 of subtitle B of title I of the federal Employee Retirement Income Security Act of 1974, except for section 609 of that act.

(c) Title XXII of P.L. 104-191.

27,4818cm Section 4818cm. 619.10 (3c) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (3c).

27,4818d Section 4818d. 619.10 (3d) of the statutes is created to read:

619.10 (3d) “Federal governmental plan" means a benefit program established or maintained for its employes by the government of the United States or by any agency or instrumentality of the government of the United States.

27,4818dm Section 4818dm. 619.10 (3d) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (3d).

27,4818g Section 4818g. 619.10 (3g) of the statutes is created to read:

619.10 (3g) “Governmental plan" has the meaning given under section 3 (32) of the federal Employee Retirement Income Security Act of 1974.

27,4818gm Section 4818gm. 619.10 (3g) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (3g).

27,4818j Section 4818j. 619.10 (3j) of the statutes is created to read:

619.10 (3j) “Group health plan" means any of the following:

(a) An employe welfare plan, as defined in section 3 (1) of the federal Employee Retirement Security Act of 1974, to the extent that the employe welfare plan provides medical care, including items and services paid for as medical care, to employes or to their dependents, as defined under the terms of the employe welfare plan, directly or through insurance, reimbursement or otherwise.

(b) Any program that would not otherwise be an employe welfare benefit plan and that is established or maintained by a partnership, to the extent that the program provides medical care, including items and services paid for as medical care, to present or former partners of the partnership or to their dependents, as defined under the terms of the program, directly or through insurance, reimbursement or otherwise.

27,4818jm Section 4818jm. 619.10 (3j) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (3j).

27,4819 Section 4819 . 619.10 (3m) and (4) of the statutes are renumbered 149.10 (3m) and (4).

27,4820 Section 4820 . 619.10 (4m) of the statutes is renumbered 149.10 (4m).

27,4821 Section 4821 . 619.10 (5) of the statutes is renumbered 149.10 (5) and amended to read:

149.10 (5) “Insurer" means any person or association of persons, including a health maintenance organization, limited service health organization or preferred provider plan offering or insuring health services on a prepaid basis, including, but not limited to, policies of health insurance issued by a currently licensed insurer, as defined in s. 600.03 (27), nonprofit hospital or medical service plans under ch. 613, cooperative medical service plans under s. 185.981, or other entity whose primary function is to provide diagnostic, therapeutic or preventive services to a defined population in return for a premium paid on a periodic basis. “Insurer" includes any person providing health services coverage for individuals on a self-insurance basis without the intervention of other entities, as well as any person providing health insurance coverage under a medical reimbursement plan to persons. “Insurer" does not include a plan under ch. 613 which offers only dental care.

27,4822 Section 4822 . 619.10 (6) and (7) of the statutes are renumbered 149.10 (6) and (7).

27,4823 Section 4823 . 619.10 (8) of the statutes is renumbered 149.10 (8) and amended to read:

149.10 (8) “Plan" means the health care insurance plan established and administered under this subchapter chapter.

27,4824 Section 4824 . 619.10 (9) of the statutes is renumbered 149.10 (9) and amended to read:

149.10 (9) “Resident" means a person who has been legally domiciled in this state for a period of at least 30 days or, with respect to an eligible individual, an individual who resides in this state. For purposes of this subchapter chapter, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin or filing a Wisconsin income tax return. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state. A person with a developmental disability or another disability which prevents the person from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in this state by living in this state for 30 days.

27,4825 Section 4825 . 619.11 of the statutes is renumbered 149.11 and amended to read:

149.11 (title) Establishment Operation of plan. The commissioner department shall promulgate rules establishing for the operation of a plan of health insurance coverage for an eligible person which satisfies the requirements of this chapter.

27,4825c Section 4825c. 619.115 of the statutes is created to read:

619.115 Rules relating to creditable coverage. The commissioner shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 619.10 (2t) (a) and that determine the creditable coverage to which s. 619.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.

27,4825f Section 4825f. 619.115 of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.115 and amended to read:

149.115 Rules relating to creditable coverage. The commissioner, in consultation with the department, shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 619.10 149.10 (2t) (a) and that determine the creditable coverage to which s. 619.10 149.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.

27,4826 Section 4826 . 619.12 (title) of the statutes is renumbered 149.12 (title).

27,4827 Section 4827 . 619.12 (1) of the statutes is renumbered 149.12 (1), and 149.12 (1) (intro.), as renumbered, is amended to read:

149.12 (1) (intro.) Except as provided in subs. (1m) and (2), the board or administering carrier plan administrator shall certify as eligible a person who is covered by medicare because he or she is disabled under 42 USC 423, a person who submits evidence that he or she has tested positive for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV, a person who is an eligible individual, and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:

27,4828 Section 4828 . 619.12 (1m) (intro) and (a) of the statutes are consolidated, renumbered 149.12 (1m) and amended to read:

149.12 (1m) The board or administering carrier plan administrator may not certify a person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required notices were issued by one of the following: (a) An an insurance intermediary who is not acting as an administrator, as defined in s. 633.01.

27,4829 Section 4829 . 619.12 (1m) (b) of the statutes is repealed.

27,4830b Section 4830b. 619.12 (2) (b) of the statutes is renumbered 149.12 (2) (b) and amended to read:

149.12 (2) (b) 1. Except as provided in subd. 2., no person who is covered under the plan and who voluntarily terminates the coverage under the plan, is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan.

2. Subdivision 1. does not apply to any person who is an eligible individual or to any person who terminates coverage under the plan because he or she is receiving, or is eligible to receive, medical assistance benefits.

27,4830c Section 4830c. 619.12 (2) (c) of the statutes is renumbered 149.12 (2) (c) and amended to read:

149.12 (2) (c) No person on whose behalf the plan has paid out $500,000 $1,000,000 or more is eligible for coverage under the plan.

27,4830d Section 4830d. 619.12 (2) (d) of the statutes is renumbered 149.12 (2) (d) and amended to read:

149.12 (2) (d) No Except for a person who is an eligible individual, no person who is 65 years of age or older is eligible for coverage under the plan.

27,4830ec Section 4830ec. 619.12 (2) (e) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.12 (2) (e) and amended to read:

149.12 (2) (e) No person who is eligible for health care benefits creditable coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that are is provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.

27,4830em Section 4830em. 619.12 (2) (e) 1. of the statutes is renumbered 619.12 (2) (e) and amended to read:

619.12 (2) (e) Except as provided in subd. 2., no No person who is eligible for health care benefits, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that are provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.

27,4830f Section 4830f. 619.12 (2) (e) 2. of the statutes is repealed.

27,4830g Section 4830g. 619.12 (2) (e) 3. of the statutes is repealed.

27,4831 Section 4831 . 619.12 (3) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.12 (3), and 149.12 (3) (c), as renumbered, is amended to read:

149.12 (3) (c) The commissioner, in consultation with the board, department may promulgate rules specifying other deductible or coinsurance amounts that, if paid or reimbursed for persons, will not make the persons ineligible for coverage under the plan.

27,4831c Section 4831c. 619.12 (3) (a) of the statutes is amended to read:

619.12 (3) (a) Except as provided in pars. (b) and to (c), 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.

27,4831e Section 4831e. 619.12 (3) (bm) of the statutes is created to read:

619.12 (3) (bm) 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.

27,4832b Section 4832b. 619.123 of the statutes is repealed.

27,4833 Section 4833 . 619.125 of the statutes is renumbered 149.125 and amended to read:

149.125 Health insurance risk-sharing plan fund. There is created a health insurance risk-sharing plan fund, under the management of the board department, to fund administrative expenses.

27,4834 Section 4834 . 619.13 (title) of the statutes is renumbered 149.13 (title).

27,4835 Section 4835 . 619.13 (1) (a) of the statutes is renumbered 149.13 (1) and amended to read:

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 par. (b) sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department of the insurers participating in the cost of administering the plan.

27,4836 Section 4836 . 619.13 (1) (b) of the statutes is renumbered 149.13 (2) and amended to read:

149.13 (2) Except as provided by a rule promulgated under s. 619.145 (4), every 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.

27,4837 Section 4837 . 619.13 (1) (c) of the statutes is repealed.