149.14 (7) (b) The department authority has a cause of action against an eligible participant for the recovery of the amount of benefits paid which that 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.
74,121
Section
121. 149.14 (7) (c) of the statutes is amended to read:
149.14 (7) (c) The department authority 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.
74,122
Section
122. 149.14 (8) of the statutes is repealed.
74,123
Section
123. 149.141 of the statutes is created to read:
149.141 Premiums. (1)
Percentage of costs. Except as provided in sub. (2), the authority shall set premium rates for coverage under the plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).
(2) Limitation. In no event may plan premium rates exceed 200 percent of rates applicable to individual standard risks.
74,124
Section
124. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and amended to read:
149.142 (1) Establishment of rates.
Except as provided in par. (b), the department The authority shall establish provider 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 authority. 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 authority shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons. The adjustments to the usual and customary rates shall be sufficient to cover the portion of plan costs specified in s. 149.143 (1) (c) and (2) (b).
74,125
Section
125. 149.142 (1) (b) of the statutes is repealed.
74,126
Section
126. 149.142 (2) of the statutes is repealed.
74,127
Section
127. 149.143 of the statutes is repealed and recreated to read:
149.143 Payment of plan costs. (1) Costs excluding subsidies. The authority shall pay plan costs, excluding any premium, deductible, and copayment subsidies, first from federal funds, if any, that are transferred to the fund under s. 20.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in a policy year. The remainder of the plan costs, excluding premium, deductible, and copayment subsidy costs, shall be paid as follows:
(a) Sixty percent from premiums paid by eligible persons.
(b) Twenty percent from insurer assessments under s. 149.13.
(c) Twenty percent from adjustments to provider payment rates under s. 149.142.
(2) Subsidy costs. The authority shall pay for premium, deductible, and copayment subsidies in a policy year first from federal funds, if any, that are transferred to the fund under s. 20.145 (5) (m) in that year. The remainder of the subsidy costs shall be paid as follows:
(a) Fifty percent from insurer assessments under s. 149.13.
(b) Fifty percent from adjustments to provider payment rates under s. 149.142.
74,128
Section
128. 149.144 of the statutes is repealed.
74,129
Section
129. 149.145 of the statutes is repealed.
74,130
Section
130. 149.146 (1) (a) and (b) of the statutes are consolidated, renumbered 149.14 (2) (c) 1. and amended to read:
149.14
(2) (c) 1.
Beginning on January 1, 1998, in In addition to the coverage
required under
s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons who are not eligible for
medicare 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.
(b) An eligible person
under par. (a) who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the
department authority, among the coverages offered under this
section and s. 149.14 paragraph and par. (a). 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 the plan. 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 the plan and the person remained continuously covered under
this chapter
the plan up to the time of electing the new coverage.
74,131
Section
131. 149.146 (2) (a) of the statutes is renumbered 149.14 (2) (c) 2. and amended to read:
149.14 (2) (c) 2. Except as specified by the department, the terms of coverage under s. 149.14, including deductible reductions under s. 149.14 (5) (a) and prescription drug copayment reductions under s. 149.14 (5) (e), do not apply to the coverage offered under this section. Premium reductions under s. 149.165 and deductible subsidies and prescription drug copayment subsidies under s. 149.14 (5) do not apply to the coverage offered under this section paragraph.
74,132
Section
132. 149.146 (2) (am) of the statutes is repealed.
74,133
Section
133. 149.146 (2) (b) of the statutes is repealed.
74,134
Section
134. 149.15 of the statutes is repealed.
74,135
Section
135. 149.16 of the statutes is repealed.
74,136
Section
136. 149.165 (1) of the statutes is amended to read:
149.165 (1) Except as provided in s. 149.146 (2) (a), the department The authority shall reduce the premiums established under s. 149.11 in conformity with ss. 149.14 (5m), 149.143 and 149.17 s. 149.141 for the eligible persons and in the manner set forth in subs. (2) and (3).
74,137
Section
137. 149.165 (2) (a) (intro.) of the statutes is amended to read:
149.165 (2) (a) (intro.) 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 with coverage under s. 149.14 (2) (a) is equal to or greater than the first amount and less than the 2nd amount listed in any of the following, the department authority shall reduce the premium for the eligible person to the rate shown after the amounts:
74,138
Section
138. 149.165 (2) (bc) of the statutes is amended to read:
149.165 (2) (bc) 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 with coverage under s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd amount listed in par. (a) 1., 2., 3., 4., or 5., the department authority shall reduce the premium established for the eligible person by the same percentage as the department authority reduces, under par. (a), the premium established for an eligible person with coverage under s. 149.14 (2) (a) who has a household income specified in the same subdivision under par. (a) as the household income of the eligible person with coverage under s. 149.14 (2) (b).
74,139
Section
139. 149.165 (3) (a) of the statutes is amended to read:
149.165 (3) (a) Subject to par. (b), the department authority shall establish and implement the method for determining the household income of an eligible person under sub. (2).
74,140
Section
140. 149.165 (3) (b) (intro.) of the statutes is amended to read:
149.165 (3) (b) (intro.) In determining household income under sub. (2), the department authority 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:
74,141
Section
141. 149.165 (3m) of the statutes is amended to read:
149.165 (3m) The board authority may approve adjustment of the household income dollar amounts listed in sub. (2) (a) 1. to 5., except for the first dollar amount listed in sub. (2) (a) 1., 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.
74,142
Section
142. 149.165 (4) of the statutes is repealed.
74,143
Section
143. 149.17 (1) of the statutes is amended to read:
149.17 (1) Subject to ss. 149.14 (5m),
s. 149.143 and 149.146 (2) (b), a rating plan calculated in accordance with generally accepted actuarial principles.
74,144
Section
144. 149.17 (2) of the statutes is repealed.
74,145
Section
145. 149.17 (4) of the statutes is repealed.
74,146
Section
146. 149.175 of the statutes is repealed.
74,147
Section
147. 149.18 of the statutes is amended to read:
149.18 Chapters 600 to 645 applicable. Except as otherwise provided in this chapter subchapter, the plan shall comply and be administered in compliance with chs. 600 to 645.
74,148
Section
148. 149.20 of the statutes is repealed.
74,149
Section
149. 149.25 of the statutes is repealed.
74,150
Section
150. Subchapter III of chapter 149 [precedes 149.40] of the statutes is created to read:
CHapter 149
Subchapter III
Health Insurance Risk-Sharing
Plan Authority
149.40 Definitions. In this subchapter:
(1) "Authority" means the Health Insurance Risk-Sharing Plan Authority.
(2) "Board" means the board of directors of the authority.
149.41 Creation and organization of authority. (1) There is created a public body corporate and politic to be known as the "Health Insurance Risk-Sharing Plan Authority." The board of directors of the authority shall consist of the commissioner of insurance, or his or her designee, as a nonvoting member, and the following members, who shall be nominated by the governor, and with the advice and consent of the senate appointed, for 3-year terms:
(a) Four members who represent insurers participating in the plan.
(b) Four members who represent health care providers, including one representative of the Wisconsin Medical Society, one representative of the Wisconsin Hospital Association, Inc., one representative of the Pharmacy Society of Wisconsin, and one representative of health care providers that provide services to persons with coverage under the plan.
(c) Five other members, at least one of whom represents small businesses that purchase private health insurance, one of whom is a professional consumer advocate who is familiar with the plan, and at least 2 of whom are persons with coverage under the plan.
(2) A vacancy on the board shall be filled in the same manner as the original appointment to the board for the remainder of the unexpired term, if any.
(3) A member of the board may not be compensated for his or her services but shall be reimbursed for actual and necessary expenses, including travel expenses, incurred in the performance of his or her duties.
(4) Annually, the governor shall appoint one member other than the commissioner as chairperson, and the members of the board may elect other officers as they consider appropriate. Seven voting members of the board constitute a quorum for the purpose of conducting the business and exercising the powers of the authority, notwithstanding the existence of any vacancy. The board may take action upon a vote of a majority of the members present, unless the bylaws of the authority require a larger number.
(5) The board may appoint an executive director who shall not be a member of the board and who shall serve at the pleasure of the board. The authority may delegate by resolution to one or more of its members or its executive director any powers and duties that it considers proper. The executive director shall receive such compensation as may be determined by the board. The executive director or other person designated by resolution of the board shall keep a record of the proceedings of the authority and shall be custodian of all books, documents, and papers filed with the authority, the minute book or journal of the authority, and its official seal. The executive director or other person may cause copies to be made of all minutes and other records and documents of the authority and may give certificates under the official seal of the authority to the effect that such copies are true copies, and all persons dealing with the authority may rely upon such certificates.
149.43 Duties of authority. In addition to all other duties imposed under this chapter, the authority shall do all of the following:
(1) Adopt policies for the administration of this chapter.
(2) Contract with the plan administrator under s. 149.16, 2003 stats., in the manner required under 2005 Wisconsin Act .... (this act), section 165 (1) (b) until the end of the contract term.
(3) Establish the authority's annual budget and monitor the fiscal management of the authority.
(4) Beginning on July 1, 2006, do, or contract with another person to do, all of the following:
(a) Perform all eligibility and administrative claims payment functions relating to the plan.
(b) Establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the authority.
(c) Perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
1. Making available information relating to the proper manner of submitting a claim for benefits under the plan and distributing forms upon which submissions shall be made.
2. Evaluating the eligibility of each claim for payment under the plan.
3. Notifying each claimant within 30 days after receiving a properly completed and executed proof of loss whether the claim is accepted, rejected, or compromised.
(5) Seek to qualify or maintain the plan as a state pharmacy assistance program, as defined in
42 CFR 423.464.
(6) Annually submit a report to the legislature under s. 13.172 (2) and to the governor on the operation of the plan.
149.45 Powers of authority. (1) Except as restricted under sub. (2), the authority shall have all the powers necessary or convenient to carry out the purposes and provisions of this chapter. In addition to all other powers granted by this chapter, the authority may:
(a) Adopt bylaws and policies and procedures for the regulation of its affairs and the conduct of its business.
(b) Have a seal and alter the seal at pleasure; have perpetual existence; and maintain an office.
(c) Hire employees, define their duties, and fix their rate of compensation.
(d) Incur debt, except as restricted under sub. (2).
(e) Contract for any professional services required for the authority, subject to ss. 149.43 (2) and 149.47.
(f) Appoint any technical or professional advisory committee that the authority finds necessary to assist the authority in exercising its duties and powers. The authority shall define the duties of the committee, and provide reimbursement for the expenses of the committee.
(g) Execute contracts and other instruments.
(h) Accept gifts, grants, loans, or other contributions from private or public sources.
(i) Procure liability insurance.
(2) The authority may not issue bonds.
