(3) The assessment under sub. (2) does not apply if the small employer insurer discontinued coverage under the health benefit plan subject to ch. 635 for any of the following reasons:
(a) The small employer failed to pay premiums or contributions in accordance with the terms of the health benefit plan or in a timely manner.
(b) The small employer performed an act or engaged in a practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.
(c) The small employer failed to meet participation or contribution requirements under the health benefit plan.
16,2850e
Section 2850e. 149.14 (3) (nm) of the statutes is created to read:
149.14 (3) (nm) Hospice care provided by a hospice licensed under subch. IV of ch. 50.
16,2850f
Section 2850f. 149.14 (5) (title) of the statutes is amended to read:
149.14 (5) (title) Deductibles, copayments
and, coinsurance, and out-of-pocket limits.
16,2850g
Section 2850g. 149.14 (5) (b) of the statutes is amended to read:
149.14 (5) (b) Except as provided in par. pars. (c) and (e), 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.
16,2850h
Section 2850h. 149.14 (5) (c) of the statutes is amended to read:
149.14 (5) (c) If Except as provided in par. (e), if the aggregate of the covered costs not paid by the plan under par. (b) and the deductible exceeds $500 for an eligible person receiving medicare, $2,000 for any other eligible person during a calendar year or $4,000 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 paragraph are exceeded.
16,2850i
Section 2850i. 149.14 (5) (e) of the statutes is amended 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) copayment amounts, coinsurance rates, and copayment and coinsurance out-of-pocket limits over which the plan will pay 100% of covered costs under sub. (3) (d). Any copayment amounts or rates amount, coinsurance rate, or out-of-pocket limit established are under this paragraph is subject to the approval of the board. Copayments and coinsurance paid by an eligible person under this paragraph shall are separate from and do not count toward the deductible and covered costs not paid by the plan under pars. (a) to (c).
16,2850j
Section 2850j. 149.14 (6) (b) 1. of the statutes is repealed.
16,2850k
Section 2850k. 149.14 (6) (b) 2. of the statutes is renumbered 149.14 (6) (b) and amended to read:
149.14 (6) (b) An eligible individual who obtains coverage under the plan on or after June 17, 1998, may not be subject to any preexisting condition exclusion under the plan. An eligible individual who is covered under the plan on June 17, 1998, may not be subject to any preexisting condition exclusion on or after June 17, 1998.
16,2850Lc
Section 2850Lc. 149.142 (1) (b) of the statutes is amended to read:
149.142 (1) (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. Notwithstanding s. 149.17 (4), the department may not reduce the payment rate for prescription drugs below the rate specified in this paragraph, and the rate may not be adjusted under s. 149.143 or 149.144.
16,2850Ld
Section 2850Ld. 149.142 (2) of the statutes is amended to read:
149.142 (2) The Except as provided in sub. (1) (b), the rates established under this section are subject to adjustment under ss. 149.143 and 149.144.
16,2850Ldc
Section 2850Ldc. 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 under s. 149.13, 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:
16,2850Ldm
Section 2850Ldm. 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 (2) (a) 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 and from eligible persons with coverage under s. 149.14 (2) (b) set in accordance with s. 149.14 (5m), including amounts received for premium and deductible subsidies under s. 149.144 and under the transfer to the fund from the appropriation account under s. 20.435 (4) (ah), and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), and from 50% of small employer insurer assessments under s. 149.135.
16,2850Le
Section 2850Le. 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
under s. 149.13 , excluding assessments under s. 149.144, and adjusting provider payment rates, subject to s. 149.142 (1) (b) and excluding adjustments to those rates under s. 149.144, in equal proportions and to the extent that the amounts under subd. 1. a. to c. are insufficient to pay 60% of plan costs.
16,2850Lem
Section 2850Lem. 149.143 (1) (b) 2. a. of the statutes is amended to read:
149.143 (1) (b) 2. a. Fifty percent from insurer assessments under s. 149.13, excluding assessments under s. 149.144, and from 50% of small employer insurer assessments under s. 149.135.
16,2850Lf
Section 2850Lf. 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, subject to s. 149.142 (1) (b) and excluding adjustments to those rates under s. 149.144.
16,2850Lg
Section 2850Lg. 149.143 (2) (a) 4. of the statutes is amended to read:
149.143 (2) (a) 4. By the same rule as under subd. 3. adjust the provider payment rate for the new plan year, subject to s. 149.142 (1) (b), by estimating and setting the rate at the level necessary to equal the amounts specified in sub. (1) (b) 1. d. and 2. b. and as provided in s. 149.145.
16,2850Lgj
Section 2850Lgj. 149.143 (2m) (b) 3. of the statutes is created to read:
149.143 (2m) (b) 3. For distribution to eligible persons, notwithstanding any requirements in this chapter related to setting premium amounts. The department, with the approval of the board and the concurrence of the plan actuary, shall determine the policies, eligibility criteria, methodology, and other factors to be used in making any distribution under this subdivision.
16,2850Lh
Section 2850Lh. 149.143 (3) (a) of the statutes is amended to read:
149.143 (3) (a) If, during a plan year, the department determines that the amounts estimated to be received as a result of the rates and amount set under sub. (2) (a) 2. to 4. and any adjustments in insurer assessments and the provider payment rate under s. 149.144 will not be sufficient to cover plan costs, the department may by rule increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year, subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (b) 2. a., and by the same rule under which assessments are increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder of the plan year, subject to sub. (1) (b) 2. b. and s. 149.142 (1) (b).
16,2850Li
Section 2850Li. 149.143 (3) (b) of the statutes is amended to read:
149.143 (3) (b) If the department increases premium rates and insurer assessments and adjusts the provider payment rate under par. (a) 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 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. but subject to s. 149.142 (1) (b).
16,2850Lj
Section 2850Lj. 149.143 (5) (a) of the statutes is amended 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
under s. 149.13, or provider payment rates, subject to s. 149.142 (1) (b), for the fiscal year beginning on the first July 1 after the reconciliation, as provided in sub. (2) (b).
16,2850Lk
Section 2850Lk. 149.143 (5) (b) of the statutes is amended to read:
149.143 (5) (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, subject to s. 149.142 (1) (b). 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, subject to s. 149.142 (1) (b).
16,2850Lm
Section 2850Lm. 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 (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 (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 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. ss. 149.142 (1) (b) and 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). 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.
16,2850Ln
Section 2850Ln. 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. 149.142 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
under s. 149.13, and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b) and subject to s. 149.142 (1) (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.
16,2850m
Section 2850m. 149.146 (1) (b) 1. of the statutes is repealed.
16,2850p
Section 2850p. 149.146 (1) (b) 2. of the statutes is renumbered 149.146 (1) (b).
16,2850q
Section 2850q. 149.146 (2) (am) 2. of the statutes is amended to read:
149.146 (2) (am) 2. Except as provided in subd. subds. 3. and 5., 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.
16,2850r
Section 2850r. 149.146 (2) (am) 3. of the statutes is amended to read:
149.146 (2) (am) 3. If Except as provided in subd. 5., 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.
16,2850s
Section 2850s. 149.146 (2) (am) 5. of the statutes is created to read:
149.146 (2) (am) 5. Subject to s. 149.14 (8) (b), the department may, by rule under s. 149.17 (4), establish for prescription drug coverage under this section copayment amounts, coinsurance rates, and copayment and coinsurance out-of-pocket limits over which the plan will pay 100% of covered costs for prescription drugs. Any copayment amount, coinsurance rate, or out-of-pocket limit established under this subdivision is subject to the approval of the board. Copayments and coinsurance paid by an eligible person under this subdivision are separate from and do not count toward the deductible and covered costs not paid by the plan under subds. 1. to 3.
16,2850w
Section 2850w. 149.15 (1) of the statutes is amended to read:
149.15 (1) The plan shall have a board of governors consisting of representatives of 2 participating insurers which that 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 4 public members, including one representative of small businesses in the state, appointed by the 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 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
one of the public members shall be individuals reasonably expected to qualify for an individual who has coverage under the plan or the parent or spouse of such an individual. The secretary or the 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.
16,2850x
Section 2850x. 149.25 of the statutes is created to read:
149.25 Case management pilot program.
(1) Definitions. In this section:
(a) "Chronic disease" means any disease, illness, impairment, or other physical condition that requires health care and treatment over a prolonged period and, although amenable to treatment, is irreversible and frequently progresses to increasing disability or death.
(b) "Health professional shortage area" means an area that is designated by the federal department of health and human services under
42 CFR part 5, appendix A, as having a shortage of medical care professionals.
(2) Program and eligibility requirements. (a) The department shall conduct a 3-year pilot program, beginning on July 1, 2002, under which eligible persons who qualify under par. (b) are provided community-based case management services.
(b) To be eligible to participate in the pilot program, an eligible person must satisfy any of the following criteria:
1. Be diagnosed as having a chronic disease.
2. Be taking 2 or more prescribed medications on a regular basis.
3. Within 6 months of applying for the pilot program, have been treated 2 or more times at a hospital emergency room or have been admitted 2 or more times to a hospital as an inpatient.
(c) 1. Participation in the pilot program shall be voluntary and limited to no more than 300 eligible persons. The department shall ensure that all eligible persons are advised in a timely manner of the opportunity to participate in the pilot program and of how to apply for participation.
2. If more than 300 eligible persons apply to participate, the department shall select pilot program participants from among those who qualify under par. (b) according to standards determined by the department, except that the department shall give preference to eligible persons who reside in medically underserved areas or health professional shortage areas.
(3) Provider organization and services requirements. (a) The department shall select and contract with an organization to provide the community-based case management services under the pilot program. To be eligible to provide the services, an organization must satisfy all of the following criteria:
1. Be a private, nonprofit, integrated health care system that provides access to health care in a medically underserved area of the state or in a health professional shortage area.
2. Operate an existing community-based case management program with demonstrated successful client and program outcomes.
3. Demonstrate an ability to assemble and coordinate an interdisciplinary team of health care professionals, including physicians, nurses, and pharmacists, for assessment of a program participant's treatment plan.
(b) The community-based case management services under the pilot program shall be provided by a team, consisting of a nurse case manager, a pharmacist, and a social worker, working in collaboration with the eligible person's primary care physician or other provider. Services to be provided include all of the following:
1. An initial intake assessment.
2. Development of a treatment plan based on best practices.
3. Coordination of health care services.
4. Patient education.
5. Family support.
6. Monitoring and reporting of patient outcomes and costs.
(c) The department shall pay contract costs from the appropriation under s. 20.435 (4) (u).
(4) Evaluation study. The department shall conduct a study that evaluates the pilot program in terms of health care outcomes and cost avoidance. In the study, the department shall measure and compare, for pilot program participants and similarly situated eligible persons not participating in the pilot program, plan costs and utilization of services, including inpatient hospital days, rates of hospital readmission within 30 days for the same diagnosis, and prescription drug utilization. The department shall submit a report on the results of the study, including the department's conclusions and recommendations, to the legislature under s. 13.172 (2) and to the governor.
16,2850y
Section 2850y. 150.345 of the statutes is created to read:
150.345 Nursing home bed transfers.
(1) Notwithstanding ss. 150.33 and 150.34, a nursing home may transfer a licensed bed to another nursing home, if all of the following apply:
(a) The receiving nursing home is within the same area for allocation of nursing home beds, as determined by the department, as is the transferring nursing home, or is in a county adjoining that area.
(b) The transferring nursing home and the receiving nursing home are owned by corporations that are owned by the same person.
(c) The transferring and receiving nursing homes notify the department of the proposed transfer within 30 days before the transfer occurs.
(d) The department reviews and approves the transfer.
(2) Upon receiving the notification specified in sub. (1) (c), the department shall adjust the allocation of licensed beds under s. 150.31 for each nursing home in accordance with the transfer that was made.
16,2852bb
Section 2852bb. 157.061 (1) of the statutes is renumbered 157.061 (1c) and amended to read:
