2005 Wisconsin Act 74

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74,125 Section 125. 149.142 (1) (b) of the statutes is repealed.

74,126 Section 126. 149.142 (2) of the statutes is repealed.

74,127 Section 127. 149.143 of the statutes is repealed and recreated to read: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74,128 Section 128. 149.144 of the statutes is repealed.

74,129 Section 129. 149.145 of the statutes is repealed.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.

149.47 Contracting for professional services. (1) Whenever contracting for professional services, the authority shall solicit competitive sealed bids or competitive sealed proposals, whichever is appropriate. Each request for competitive sealed proposals shall state the relative importance of price and other evaluation factors.

(2) (a) When the estimated cost exceeds $25,000, the authority may invite competitive sealed bids or proposals by publishing a class 2 notice under ch. 985 or by posting notice on the Internet at a site determined or approved by the authority. The notice shall describe the contractual services to be purchased, the intent to make the procurement by solicitation of bids or proposals, any requirement for surety, and the date the bids or proposals will be opened, which shall be at least 7 days after the date of the last insertion of the notice or at least 7 days after the date of posting on the Internet.

(b) When the estimated cost is $25,000 or less, the authority may award the contract in accordance with simplified procedures established by the authority for such transactions.

(c) For purposes of clarification, the authority may discuss the requirements of the proposed contract with any person who submits a bid or proposal and shall permit any offerer to revise his or her bid or proposal to ensure its responsiveness to those requirements.

(3) (a) The authority shall determine which bids or proposals are reasonably likely to be awarded the contract and shall provide each offerer of such a bid or proposal a fair and equal opportunity to discuss the bid or proposal. The authority may negotiate with each offerer in order to obtain terms that are advantageous to the authority. Prior to the award of the contract, any offerer may revise his or her bid or proposal. The authority shall keep a written record of all meetings, conferences, oral presentations, discussions, negotiations, and evaluations of bids or proposals under this section.

(b) In opening, discussing, and negotiating bids or proposals, the authority may not disclose any information that would reveal the terms of a competing bid or proposal.

(4) (a) After receiving each offerer's best and final offer, the authority shall determine which proposal is most advantageous and shall award the contract to the person who offered it. The authority's determination shall be based only on price and the other evaluation factors specified in the request for bids or proposals. The authority shall state in writing the reason for the award and shall place the statement in the contract file.

(b) Following the award of the contract, the authority shall prepare a register of all bids or proposals.