149.14 (3) Covered expenses. (intro.) Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the board under s. 149.15 (3) (e) or by the department under s. ss. 149.143
or and 149.144, covered expenses for the coverage under this section shall be the usual and customary charges payment rates established by the department under s. 149.142 for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the board under s. 149.15 (3) (e) or by the department under s.
ss. 149.143 or and 149.144, covered expenses for the coverage under this section shall also be the usual and customary charges payment rates established by the department under s. 149.142 for the following services and articles if the service or article is prescribed by a physician who is licensed under ch. 448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45 (2) (a) 11.:
9,2259f
Section 2259f. 149.14 (3) (d) of the statutes is amended to read:
149.14 (3) (d) Drugs requiring a physician's prescription, subject to sub. (4c).
9,2259r
Section 2259r. 149.14 (4) (d) of the statutes is amended to read:
149.14 (4) (d) That part of any charge for services or articles rendered or prescribed by a physician, dentist or other health care personnel which that exceeds the prevailing charge in the locality where the service is provided payment rate established by the department under s. 149.142 and reduced under ss. 149.143 and 149.144 or any charge not medically necessary.
9,2260
Section
2260. 149.14 (4) (g) of the statutes is amended to read:
149.14 (4) (g) Dental care except as provided in sub. (3) (m) and (q).
9,2260c
Section 2260c. 149.14 (4) (n) of the statutes is created to read:
149.14 (4) (n) Services or drugs for the treatment of infertility, impotence or sterility.
9,2260d
Section 2260d. 149.14 (4c) of the statutes is created to read:
149.14 (4c) Coverage of prescription drugs. (a) The department may require a pharmacist or pharmacy that provides a prescription drug to an eligible person to submit a payment claim directly to the plan administrator.
(b) The department may limit coverage of prescription drugs under sub. (3) (d) to those prescription drugs for which payment claims are submitted by pharmacists or pharmacies directly to the plan administrator.
9,2260h
Section 2260h. 149.14 (4m) of the statutes is amended to read:
149.14 (4m) Payment is payment in full. Except for copayments, coinsurance or deductibles required or authorized under the plan, a provider of a covered service or article shall accept as payment in full for the covered service or article the payment rate determined under ss. 149.142, 149.143, and 149.144 and 149.15 (3) (e) and may not bill an eligible person who receives the service or article for any amount by which the charge for the service or article is reduced under s. 149.142, 149.143
, or 149.144 or 149.15 (3) (e).
9,2260m
Section 2260m. 149.14 (5) (title) of the statutes is amended to read:
149.14 (5) (title) Deductibles, copayments and coinsurance.
9,2260p
Section 2260p. 149.14 (5) (e) of the statutes is created to read:
149.14 (5) (e) Subject to sub. (8) (b), the department may, by rule under s. 149.17 (4), establish copayments for prescription drug coverage under sub. (3) (d). Any copayment amounts or rates established are subject to the approval of the board. Copayments paid by an eligible person under this paragraph shall count toward the deductible and covered costs not paid by the plan under pars. (a) to (c).
9,2261
Section
2261. 149.14 (6) (title) of the statutes is created to read:
149.14 (6) (title) Preexisting conditions.
9,2261f
Section 2261f. 149.14 (8) of the statutes is created to read:
149.14 (8) Applicability of medical assistance provisions. (a) Except as provided in par. (b), the department may, by rule under s. 149.17 (4), apply to the plan the same utilization and cost control procedures that apply under rules promulgated by the department to medical assistance under subch. IV of ch. 49.
(b) The department may not apply to eligible persons for covered services or articles the same copayments that apply to recipients of medical assistance under subch. IV of ch. 49 for services or articles covered under that program.
9,2261j
Section 2261j. 149.142 of the statutes is created to read:
149.142 Provider payment rates. (1) (a) Except as provided in par. (b), the department shall establish payment rates for covered expenses that consist of the allowable charges paid under s. 49.46 (2) for the services and articles provided plus an enhancement determined by the department. The rates shall be based on the allowable charges paid under s. 49.46 (2), projected plan costs and trend factors. Using the same methodology that applies to medical assistance under subch. IV of ch. 49, the department shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons.
(b) The payment rate for a prescription drug shall be the allowable charge paid under s. 49.46 (2) (b) 6. h. for the prescription drug.
(2) The rates established under this section are subject to adjustment under ss. 149.143 and 149.144.
9,2261m
Section 2261m. 149.143 (1) (intro.) of the statutes is amended to read:
149.143 (1) (intro.) The department shall pay or recover the operating costs of the plan from the appropriation under s. 20.435 (4) (v) and administrative costs of the plan from the appropriation under s. 20.435 (4) (u). For purposes of determining premiums, insurer assessments and provider payment rate adjustments, the department shall apportion and prioritize responsibility for payment or recovery of plan costs from among the moneys constituting the fund as follows:
9,2262b
Section 2262b. 149.143 (1) (a) of the statutes is amended to read:
149.143 (1) (a) First from the moneys transferred to the fund from the appropriation account under s. 20.435 (5) (4) (af).
9,2263b
Section 2263b. 149.143 (1) (b) 1. a. of the statutes is amended to read:
149.143 (1) (b) 1. a. First, from premiums from eligible persons with coverage under s. 149.14 set at 150% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan, including amounts received for premium and deductible subsidies under s. 149.144 and under the transfer to the fund from the appropriation account under ss.
s. 20.435 (5) (4) (ah) and 149.144, and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b).
9,2263bm
Section 2263bm. 149.143 (1) (b) 1. b. of the statutes is amended to read:
149.143 (1) (b) 1. b. Second, from the appropriation under s. 20.435 (5) (gh) moneys specified under sub. (2m), to the extent that the amounts under subd. 1. a. are insufficient to pay 60% of plan costs.
9,2263bn
Section 2263bn. 149.143 (1) (b) 1. c. of the statutes is amended to read:
149.143 (1) (b) 1. c. Third, by increasing premiums from eligible persons with coverage under s. 149.14 to more than 150% but not more than 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan, including amounts received for premium and deductible subsidies under s. 149.144 and under the transfer to the fund from the appropriation account under ss. s. 20.435 (5) (4) (ah) and 149.144, and by increasing premiums from eligible persons with coverage under s. 149.146 in accordance with s. 149.146 (2) (b), to the extent that the amounts under subd. 1. a. and b. are insufficient to pay 60% of plan costs.
9,2263bp
Section 2263bp. 149.143 (1) (b) 1. d. of the statutes is amended to read:
149.143 (1) (b) 1. d. Fourth, notwithstanding subd. 2., by increasing insurer assessments, excluding assessments under s. 149.144, and adjusting provider payment rates, excluding adjustments to those rates under ss.
s. 149.144 and 149.15 (3) (e), in equal proportions and to the extent that the amounts under subd. 1. a. to c. are insufficient to pay 60% of plan costs.
9,2264e
Section 2264e. 149.143 (1) (b) 2. b. of the statutes is amended to read:
149.143 (1) (b) 2. b. Fifty percent from adjustments to provider payment rates, excluding adjustments to those rates under ss. s. 149.144
and 149.15 (3) (e).
9,2265b
Section 2265b. 149.143 (2) (a) 1. a. of the statutes is amended to read:
149.143 (2) (a) 1. a. Estimate the amount of enrollee premiums that would be received in the new plan year if the enrollee premiums were set at a level sufficient, when including amounts received for premium and deductible subsidies under s. 149.144 and under the transfer to the fund from the appropriation account under ss.
s. 20.435 (5) (4) (ah) and 149.144 and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to cover 60% of the estimated plan costs for the new plan year, after deducting from the estimated plan costs the amount available in for transfer to the fund from the appropriation account under s. 20.435 (5) (4) (af) for that plan year.
9,2265bm
Section 2265bm. 149.143 (2) (a) 1. c. of the statutes is repealed.
9,2266g
Section 2266g. 149.143 (2m) of the statutes is created to read:
149.143 (2m) (a) The department shall keep a separate accounting of the difference between the following:
1. The amount of premiums received in a plan year from all eligible persons, including amounts received for premium and deductible subsidies.
2. The amount of premiums, including amounts received for premium and deductible subsidies, necessary to cover 60% of the plan costs for the plan year, after deducting the amount transferred to the fund from the appropriation account under s. 20.435 (4) (af).
(b) Any amount by which the amount under par. (a) 1. exceeds the amount under par. (a) 2. may be used only as follows:
1. To reduce premiums in succeeding plan years as provided in sub. (1) (b) 1. b. For eligible persons with coverage under s. 149.14, premiums may not be reduced below 150% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan.
2. For other needs of eligible persons, with the approval of the board.
9,2267j
Section 2267j. 149.143 (3) (b) of the statutes is amended to read:
149.143 (3) (b) If, after increasing
the department increases premium rates and insurer assessments and adjusting adjusts the provider payment rate under par. (a), the department and determines that there will still be a deficit and that premium rates have been increased to the maximum extent allowable under par. (a), the department shall may further adjust, in equal proportions, assessments set under sub. (2) (a) 3. and the provider payment rate set under sub. (2) (a) 4., without regard to sub. (1) (b) 2.
9,2267m
Section 2267m. 149.143 (5) of the statutes is created to read:
149.143 (5) (a) Annually, no later than April 30, the department shall perform a reconciliation with respect to plan costs, premiums, insurer assessments and provider payment rate adjustments based on data from the previous calendar year. On the basis of the reconciliation, the department shall make any necessary adjustments in premiums, insurer assessments or provider payment rates for the fiscal year beginning on the first July 1 after the reconciliation, as provided in sub. (2) (b).
(b) Except as provided in sub. (3) and s. 149.144, the department shall adjust the provider payment rates to meet the providers' specified portion of the plan costs no more than once annually. The department may not determine the adjustment on an individual provider basis or on the basis of provider type, but shall determine the adjustment for all providers in the aggregate.
9,2267r
Section 2267r. 149.144 of the statutes is amended to read:
149.144 Adjustments to insurer assessments and provider payment rates for premium and deductible reductions. If the moneys transferred to the fund under the appropriation under s. 20.435 (5) (4) (ah) are insufficient to reimburse the plan for premium reductions under s. 149.165 and deductible reductions under s. 149.14 (5) (a), or the department determines that the moneys transferred or to be transferred to the fund under the appropriation under s. 20.435 (5) (4) (ah) will be insufficient to reimburse the plan for premium reductions under s. 149.165 and deductible reductions under s. 149.14 (5) (a), the department shall may, by rule, adjust in equal proportions the amount of the assessment set under s. 149.143 (2) (a) 3. and the provider payment rate set under s. 149.143 (2) (a) 4., subject to s. 149.143 (1) (b) 1., sufficient to reimburse the plan for premium reductions under s. 149.165 and deductible reductions under s. 149.14 (5) (a). The If the department makes the adjustment under this section, the department shall notify the commissioner so that the commissioner may levy any increase in insurer assessments.
9,2268m
Section 2268m. 149.145 of the statutes is amended to read:
149.145 Program budget. The department, in consultation with the board, shall establish a program budget for each plan year. The program budget shall be based on the provider payment rates specified in s. 149.15 (3) (e) 149.142 and in the most recent provider contracts that are in effect and on the funding sources specified in s. 149.143 (1), including the methodologies specified in ss. 149.143, 149.144 and 149.146 for determining premium rates, insurer assessments and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b), from the program budget the department shall derive the actual provider payment rate for a plan year that reflects the providers' proportional share of the plan costs, consistent with ss. 149.143 and 149.144. The department may not implement a program budget established under this section unless it is approved by the board.
9,2269
Section
2269. 149.146 (1) (a) of the statutes is amended to read:
149.146
(1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 149.14, the plan shall offer to all eligible persons
who are not eligible for medicare 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.
9,2270
Section
2270. 149.146 (1) (b) 2. of the statutes is amended to read:
149.146 (1) (b) 2. An eligible person under par. (a) may elect once each year, at the time and according to procedures established by the department, among the coverages offered under this section and s. 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 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 chapter and the person remained continuously covered under this chapter up to the time of electing the new coverage.
9,2271
Section
2271. 149.146 (2) (am) of the statutes is created to read:
149.146 (2) (am) 1. For all eligible persons with coverage under this section, the deductible shall be $2,500. 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.
2. Except as provided in subd. 3., if the covered costs incurred by the eligible person exceed the deductible for major medical expense coverage in a calendar year, the plan shall pay at least 80% of any additional covered costs incurred by the person during the calendar year.
3. If the aggregate of the covered costs not paid by the plan under subd. 2. and the deductible exceeds $3,500 for any eligible person during a calendar year or $7,000 for all eligible persons in a family, the plan shall pay 100% of all covered costs incurred by the eligible person during the calendar year after the payment ceilings under this subdivision are exceeded.
4. Notwithstanding subds. 1. to 3., the department may establish different deductible amounts, a different coinsurance percentage and different covered costs and deductible aggregate amounts from those specified in subds. 1. to 3. in accordance with cost containment provisions established by the department under s. 149.17 (4).
9,2276m
Section 2276m. 149.15 (3) (e) of the statutes is repealed.
9,2277c
Section 2277c. 149.15 (3) (g) of the statutes is created to read:
149.15 (3) (g) Establish oversight committees to address various administrative issues, such as financial management of the plan and plan administrator performance standards. A representative of the department may not be the chairperson of any committee established under this paragraph.
9,2277d
Section 2277d. 149.16 (4) of the statutes is created to read:
149.16 (4) The plan administrator shall account for costs related to the plan separately from costs related to medical assistance under subch. IV of ch. 49.
9,2277f
Section 2277f. 149.16 (5) of the statutes is created to read:
149.16 (5) The department shall obtain the approval of the board before implementing any contract with the plan administrator.
9,2277m
Section 2277m. 149.165 (2) (intro.) of the statutes is amended to read:
149.165 (2) (intro.) If Subject to sub. (3m), if the household income, as defined in s. 71.52 (5) and as determined under 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 department shall reduce the premium for the eligible person to the rate shown after the amounts:
9,2277p
Section 2277p. 149.165 (2) (e) of the statutes is created to read:
149.165 (2) (e) If equal to or greater than $20,000 and less than $25,000, to 130% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under the plan.
9,2277t
Section 2277t. 149.165 (3m) of the statutes is created to read:
149.165 (3m)
Upon request of the board, the joint committee on finance may approve or disapprove adjustment
, by the board or the department, of the household income dollar amounts listed in sub. (2) (a) to (e), except for the first dollar amount listed in sub. (2) (a), to reflect changes in the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.
With any request for approval of adjustment under this subsection, the board shall submit to the joint committee on finance the proposed adjusted amounts.
9,2278b
Section 2278b. 149.165 (4) of the statutes is amended to read:
149.165 (4) The department shall reimburse the plan for premium reductions under sub. (2) and deductible reductions under s. 149.14 (5) (a) with moneys transferred to the fund from the appropriation account under s. 20.435 (5) (4) (ah).
9,2278c
Section 2278c. 149.17 (2) of the statutes is amended to read:
149.17 (2) A schedule of premiums, deductibles, copayments and coinsurance payments which that complies with all requirements of this chapter.
9,2278g
Section 2278g. 149.17 (4) of the statutes is amended to read:
149.17 (4) Cost containment provisions established by the department by rule, including managed care requirements. The department shall obtain the approval
of the board before promulgating a rule that establishes a cost containment provision that would have an effect on an eligible person's access to health care services, such as the creation of new prior authorization requirements.
9,2278r
Section 2278r. 150.46 (3) of the statutes is created to read:
