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 c. of the statutes is repealed.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:
150.46 (3) This subchapter does not apply to the nursing care facility operated by the department of veterans affairs under s. 45.385.
9,2278rm
Section 2278rm. 150.84 (2) of the statutes is amended to read:
150.84 (2) "Health care facility" means a facility, as defined in s. 647.01 (4), or any hospital, nursing home, community-based residential facility, county home, county infirmary, county hospital, county mental health center, tuberculosis sanatorium or other place licensed or approved by the department under s. 49.70, 49.71, 49.72, 50.02, 50.03, 50.35, 51.08, or 51.09
, 58.06, 252.073 or 252.076 or a facility under s. 45.365, 51.05, 51.06, 233.40, 233.41, 233.42 or 252.10.
9,2280
Section
2280. 153.05 (6m) of the statutes is amended to read:
153.05 (6m) The department may contract with the group insurance board for the provision of data collection and analysis services related to health maintenance organizations and insurance companies that provide health insurance for state employes. The department shall establish contract fees for the provision of the services. All moneys collected under this subsection shall be credited to the appropriation under s. 20.435 (1) (4) (hg).
9,2280b
Section 2280b. 153.45 (1) (b) of the statutes is renumbered 153.45 (1) (b) 1. and amended to read:
153.45 (1) (b) 1. Public For information that is submitted by hospitals or ambulatory surgery centers, public use data files which that do not permit the identification of specific patients, employers or health care providers, as defined by rules promulgated by the department. The identification of these groups patients, employers or health care providers shall be protected by all necessary means, including the deletion of patient identifiers and the use of calculated variables and aggregated variables.
9,2280c
Section 2280c. 153.45 (1) (b) 2. of the statutes is created to read:
153.45 (1) (b) 2. For information that is submitted by health care providers other than hospitals or ambulatory surgery centers, public use data files that do not permit the identification of specific patients, employers or health care providers, as defined by rules promulgated by the department. The identification of patients, employers or health care providers shall be protected by all necessary means, including the deletion of patient identifiers; the use of calculated variables and aggregated variables; the specification of counties as to residence, rather than zip codes; the use of 5-year categories for age, rather than exact age; not releasing information concerning a patient's race or ethnicity or dates of admission, discharge, procedures or visits; and masking sensitive diagnoses and procedures by use of larger diagnostic and procedure categories. Public use data files under this subdivision may include only the following:
a. The patient's county of residence.
b. The payment source, by type.
c. The patient's age category, by 5-year intervals
up to age 80 and a category of 80 years or older.
d. The patient's procedure code.
e. The patient's diagnosis code.
f. Charges assessed with respect to the procedure code.
g. The name and address of the facility in which the patient's services were rendered.
h. The patient's sex.
i. Information that contains the name of a health care provider that is not a hospital or ambulatory surgery center, if the independent review board first reviews and approves the release or if the department promulgates rules that specify circumstances under which the independent review board need not review and approve the release.
j. Calendar quarters of service, except if the department specifies by rule that the number of data elements included in the public use data file is too small to enable protection of patient confidentiality.
k. Information other than patient-identifiable data, as defined in s. 153.50 (1) (b), as approved by the independent review board.
9,2280e
Section 2280e. 153.45 (1) (c) of the statutes is renumbered 153.45 (1) (c) (intro.) and amended to read:
153.45 (1) (c) (intro.) Custom-designed reports containing portions of the data under par. (b). Of information submitted by health care providers that are not hospitals or ambulatory surgery centers, requests under this paragraph for data elements other than those available for public use data files under par. (b) 2., including the patient's month and year of birth, require review and approval by the independent review board before the data elements may be released. Information that contains the name of a health care provider that is not a hospital or ambulatory surgery center may be released only if the independent review board first reviews and approves the release or if the department promulgates rules that specify circumstances under which the independent review board need not review and approve the release. Reports under this paragraph may include the patient's zip code only if at least one of the following applies:
9,2280f
Section 2280f. 153.45 (1) (c) 1. to 4. of the statutes are created to read:
153.45 (1) (c) 1. Other potentially identifying data elements are not released.
2. Population density is sufficient to mask patient identity.
3. Other potentially identifying data elements are grouped to provide population density sufficient to protect identity.
4. Multiple years of data elements are added to protect identity.
9,2280g
Section 2280g. 153.45 (6) of the statutes is created to read:
153.45 (6) The department may not sell or distribute data bases of information, from health care providers who are not hospitals or ambulatory surgery centers, that are able to be linked with public use data files, unless first approved by the independent review board.
9,2280ge
Section 2280ge. 153.50 (1) (a) of the statutes is renumbered 153.01 (2m).
9,2280gg
Section 2280gg. 153.50 (1) (b) of the statutes is renumbered 153.50 (1) (b) 1., and 153.50 (1) (b) 1. (intro.), as renumbered, is amended to read:
153.50 (1) (b) 1. (intro.) "Patient-identifiable data", for information submitted by hospitals and ambulatory surgery centers, means all of the following data elements:
9,2280gm
Section 2280gm. 153.50 (1) (b) 2. of the statutes is created to read:
153.50 (1) (b) 2. "Patient-identifiable data", for information submitted by health care providers who are not hospitals or ambulatory surgery centers, means all of the following data elements:
a. Data elements specified in subd. 1. a. to g., L. and m.
