(a) Any charge for treatment for cosmetic purposes other than surgery for the repair or treatment of an injury or a congenital bodily defect. Breast reconstruction of the affected tissue incident to a mastectomy shall not be considered treatment for cosmetic purposes.
(m) Experimental treatment, as determined by the board or its designee department.
27,4852c
Section 4852c. 619.14 (5) (title) of the statutes is renumbered 149.14 (5) (title) and amended to read:
149.14 (5) (title) Premiums, deductibles Deductibles and coinsurance.
27,4853
Section 4853
. 619.14 (5) (a) of the statutes is renumbered 149.14 (5) (a) and amended to read:
149.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter chapter for major medical expense coverage required under this section. For coverage offered to those persons eligible for medicare, the plan shall offer a deductible equal to the deductible charged by part A of title XVIII of the federal social security act, as amended. The deductible amounts for all other eligible persons shall be dependent upon household income as determined under s. 619.165 149.165. For eligible persons under s. 619.165 (1) (b) 1. 149.165 (2) (a), the deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2. 149.165 (2) (b), the deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3. 149.165 (2) (c), the deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4. 149.165 (2) (d), the deductible shall be $800. For all other eligible persons who are not eligible for medicare, the deductible shall be $1,000. With respect to all eligible persons, expenses used to satisfy the deductible during the last 90 days of a calendar year shall also be applied to satisfy the deductible for the following calendar year. The schedule of premiums shall be promulgated by rule by the commissioner. The commissioner shall set rates at 60% of the operating and administrative costs of the plan.
27,4854c
Section 4854c. 619.14 (5) (b) of the statutes is renumbered 149.14 (5) (b).
27,4855c
Section 4855c. 619.14 (5) (c) of the statutes is renumbered 149.14 (5) (c)
27,4856
Section 4856
. 619.14 (5) (d) of the statutes is renumbered 149.14 (5) (d) and amended to read:
149.14 (5) (d) Notwithstanding pars. (a) to (c), the board department may establish different deductible amounts, a different coinsurance percentage and different covered costs and deductible aggregate amounts from those specified in pars. (a) to (c) in accordance with cost containment provisions established by the commissioner department under s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under s. 619.145 149.17 (4).
27,4856v
Section 4856v. 619.14 (5) (e) of the statutes is amended to read:
619.14 (5) (e) Using the procedure under s. 227.24, the commissioner may promulgate rules under par. (a) or s. 619.146 (2) (b) for the schedule of premiums for the period before the effective date of any permanent rules promulgated under par. (a) or s. 619.146 (2) (b) for the schedule of premiums, but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the commissioner is not required to make a finding of emergency.
27,4857c
Section 4857c. 619.14 (5) (e) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is repealed.
27,4858b
Section 4858b. 619.14 (6) of the statutes is renumbered 619.14 (6) (a) and amended to read:
619.14 (6) (a) No Except as provided in par. (b), no person who obtains coverage under the plan may be covered for any preexisting condition during the first 6 months of coverage under the plan if the person was diagnosed or treated for that condition during the 6 months immediately preceding the filing of an application with the plan.
27,4858c
Section 4858c. 619.14 (6) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.14 (6).
27,4858d
Section 4858d. 619.14 (6) (b) of the statutes is created to read:
619.14 (6) (b) An eligible individual who obtains coverage under the plan on or after the effective date of this paragraph .... [revisor inserts date], may not be subject to any preexisting condition exclusion under the plan. An eligible individual who is covered under the plan on the effective date of this paragraph .... [revisor inserts date], may not be subject to any preexisting condition exclusion on or after the effective date of this paragraph .... [revisor inserts date].
27,4859
Section 4859
. 619.14 (7) of the statutes is renumbered 149.14 (7), and 149.14 (7) (b) and (c), as renumbered, are amended to read:
149.14 (7) (b) The board department has a cause of action against an eligible participant for the recovery of the amount of benefits paid which are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.
(c) The board department is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan. Section 814.03 (3) applies to the department under this paragraph.
27,4860
Section 4860
. 619.145 of the statutes is repealed.
27,4860c
Section 4860c. 619.146 of the statutes is created to read:
619.146 Choice of coverage. (1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 619.14, the plan shall offer to all eligible persons a choice of coverage, as described in section 2744 (a) (1) (C) of P.L. 104-191. Any such choice of coverage shall be major medical expense coverage.
(b) An eligible person may elect once each year, at the time and according to procedures established by the board, among the coverages offered under this section and s. 619.14. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under this subchapter. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under this subchapter and the person remained continuously covered under this subchapter up to the time of electing new coverage.
(2) (a) Except as specified by the board, the terms of coverage under s. 619.14, including deductible reductions under s. 619.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under s. 619.165 do not apply to the coverage offered under this section.
(b) The schedule of premiums for coverage under this section shall be promulgated by rule by the commissioner. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 619.14 by the same percentage as the percentage difference between the following:
1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under s. 619.14.
2. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as the coverage offered under this section.
27,4860d
Section 4860d. 619.146 of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.146, and 149.146 (1) (a) and (b) and (2) (a) and (b) (intro.) and 1., as renumbered, are amended to read:
149.146 (1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 619.14
149.14, the plan shall offer to all eligible persons a choice of coverage, as described in section 2744 (a) (1) (C), P.L. 104-191. Any such choice of coverage shall be major medical expense coverage.
(b) An eligible person may elect once each year, at the time and according to procedures established by the board department, among the coverages offered under this section and s. 619.14 149.14. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under this subchapter chapter. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under this subchapter chapter and the person remained continuously covered under this subchapter chapter up to the time of electing the new coverage.
(2) (a) Except as specified by the board department, the terms of coverage under s. 619.14 149.14, including deductible reductions under s. 619.14 149.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under s. 619.165 149.165 do not apply to the coverage offered under this section.
(b) (intro.) The schedule of premiums for coverage under this section shall be promulgated by rule by the commissioner department, as provided in s. 149.143. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 619.14 149.14 by the same percentage as the percentage difference between the following:
1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under s. 619.14 149.14.
27,4861
Section 4861
. 619.15 (title) of the statutes is renumbered 149.15 (title).
27,4862
Section 4862
. 619.15 (1) of the statutes is renumbered 149.15 (1) and amended to read:
149.15 (1) The plan shall operate subject to the supervision and approval of a have a board of governors consisting of representatives of 2 participating insurers which are nonprofit corporations, representatives of 2 other participating insurers, 3 health care provider representatives, including one representative of the State Medical Society of Wisconsin, one representative of the Wisconsin Health and Hospital Association and one representative of an integrated multidisciplinary health system, and 3 public members, including one representative of small businesses in the state, appointed by the commissioner secretary for staggered 3-year terms. In addition, the commissioner, or a designated representative from the office of the commissioner, and the secretary, or a designated representative from the department, shall be a member members of the board. The public members shall not be professionally affiliated with the practice of medicine, a hospital or an insurer. At least 2 of the public members shall be individuals reasonably expected to qualify for coverage under the plan or the parent or spouse of such an individual. The commissioner
secretary or the commissioner's secretary's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative and the secretary or the secretary's representative, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.
27,4863
Section 4863
. 619.15 (2) of the statutes is renumbered 149.15 (2) and amended to read:
149.15 (2) Annually, the board shall make a report to the members of the plan and to the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under s. 13.172 (3),
and to the members of the plan summarizing the activities of the plan in the preceding calendar year. The annual report shall define the cost burden imposed by the plan on all policyholders in this state.
27,4864
Section 4864
. 619.15 (3) (intro.) of the statutes is renumbered 149.15 (3) (intro.) and amended to read:
149.15 (3) (intro.) The board shall do all of the following:
27,4865
Section 4865
. 619.15 (3) (a) of the statutes is renumbered 149.15 (3) (a).
27,4866
Section 4866
. 619.15 (3) (b) of the statutes is repealed.
27,4867c
Section 4867c. 619.15 (3) (c) of the statutes is renumbered 149.15 (3) (c) and amended to read:
149.15 (3) (c) Collect assessments from all insurers to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board
as provided under s. 149.143. Assessment of the insurers shall occur at the end of each calendar year or other fiscal year end established by the board. Assessments are due and payable within 30 days of receipt by the insurer of the assessment notice.
27,4868
Section 4868
. 619.15 (3) (d) of the statutes is renumbered 149.15 (3) (d).
27,4869c
Section 4869c. 619.15 (3) (e) of the statutes is renumbered 149.15 (3) (e) and amended to read:
149.15 (3) (e) Establish for payment of covered expenses, a payment rate that is 10% less than the charges approved by the administering carrier plan administrator for reimbursement of covered expenses under s. 619.14 149.14 (3). A provider of a covered service or article may not bill an eligible person who receives the service or article for any amount by which the charge is reduced under this paragraph.
27,4869d
Section 4869d. 619.15 (3) (f) of the statutes is created to read:
619.15 (3) (f) In consultation with the office and the department of health and family services, establish a choice of coverage under s. 619.146.
27,4869m
Section 4869m. 619.15 (3) (f) of the statutes, as created by 1997 Wisconsin Act .... (this act), is repealed.
27,4870
Section 4870
. 619.15 (4) (intro.) of the statutes is renumbered 149.15 (4) (intro.) and amended to read:
149.15 (4) (intro.) The board may do any of the following:
27,4871
Section 4871
. 619.15 (4) (a) of the statutes is renumbered 149.15 (4) (a).
27,4872
Section 4872
. 619.15 (4) (b) of the statutes is renumbered 149.15 (4) (b).
27,4873c
Section 4873c. 619.15 (4) (c) of the statutes is repealed.
27,4874
Section 4874
. 619.15 (4) (d) of the statutes is repealed.
27,4875
Section 4875
. 619.15 (4) (e) of the statutes is repealed.
27,4876
Section 4876
. 619.15 (5) of the statutes is renumbered 149.15 (5) and amended to read:
149.15 (5) The commissioner
department may, by rule, establish additional powers and duties of the board.
27,4877
Section 4877
. 619.15 (6) of the statutes is renumbered 149.15 (6) and amended to read:
149.15 (6) If any provision of this subchapter chapter conflicts with s. 625.11 or 625.12, this subchapter
chapter prevails.
27,4878
Section 4878
. 619.15 (7) of the statutes is renumbered 149.15 (7).
27,4879
Section 4879
. 619.16 (title) of the statutes is repealed.
27,4880
Section 4880
. 619.16 (1) of the statutes is repealed.
27,4881
Section 4881
. 619.16 (2) of the statutes is repealed.
27,4882
Section 4882
. 619.16 (3) (a) of the statutes is renumbered 149.16 (3) (a) and amended to read:
149.16 (3) (a) The administering carrier plan administrator shall perform all eligibility and administrative claims payment functions relating to the plan.
27,4883
Section
4883. 619.16 (3) (b) of the statutes is renumbered 149.16 (3) (b) and amended to read:
149.16 (3) (b) The administering carrier plan administrator shall establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the board department.
27,4884c
Section 4884c. 619.16 (3) (c) of the statutes is renumbered 149.16 (3) (c), and 149.16 (3) (c) (intro.), as renumbered, is amended to read:
149.16 (3) (c) (intro.) The administering carrier plan administrator shall perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
27,4885
Section 4885
. 619.16 (3) (d) of the statutes is repealed.
27,4886
Section 4886
. 619.16 (3) (e) of the statutes is renumbered 149.16 (3) (e) and amended to read:
149.16 (3) (e) The administering carrier plan administrator, under the direction of the department, shall pay claims expenses from the premium payments received from or on behalf of covered persons under the plan. If the administering carrier's plan administrator's payments for claims expenses exceed the portion of premiums allocated by the board for payment of claims expenses premium payments, the board shall forward to the department, and the department shall provide to the carrier plan administrator, additional funds for payment of claims expenses.
27,4887
Section 4887
. 619.16 (3) (em) of the statutes is repealed.
27,4888
Section 4888
. 619.16 (3) (f) of the statutes is repealed.
27,4889
Section 4889
. 619.165 (title) of the statutes is renumbered 149.165 (title).
27,4890
Section 4890
. 619.165 (1) (a) of the statutes is renumbered 149.165 (1) and amended to read:
149.165 (1) The board Except as provided in s. 149.146 (2) (a), the department shall reduce the premiums established by the commissioner under s.
619.11 149.11 in conformity with ss. 619.14 (5) 149.143 and 619.17 149.17, for the eligible persons and in the manner set forth in pars. (b) to (d) subs. (2) and (3).
27,4891
Section 4891
. 619.165 (1) (b) of the statutes is renumbered 149.165 (2), and 149.165 (2) (intro.), as renumbered, is amended to read:
149.165 (2) (intro.) If the household income, as defined in s. 71.52 (5) and as determined under par. (d) sub. (3), of an eligible person is equal to or greater than the first amount and less than the 2nd amount listed in any of the following, the board department shall reduce the premium for the eligible person, as established by the commissioner, to the rate shown after the amounts:
27,4891c
Section 4891c. 619.165 (1) (d) of the statutes is renumbered 619.165 (1) (d) 1. and amended to read:
619.165 (1) (d) 1. The Subject to subd. 2., the board shall establish and implement the method for determining the household income of an eligible person under par. (b).
27,4891r
Section 4891r. 619.165 (1) (d) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.165 (3), and 149.165 (3) (a) and (b) (intro.), as renumbered, are amended to read:
149.165 (3) (a) Subject to subd. 2., the board par. (b), the department shall establish and implement the method for determining the household income of an eligible person under par. (b) sub. (2).
(b) (intro.) In determining household income under par. (b), the board sub. (2), the department shall consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:
27,4891t
Section 4891t. 619.165 (1) (d) 2. of the statutes is created to read:
