2005 Wisconsin Act 74

b. Care and services for the treatment of an emergency medical condition under 42 USC 1396b (v), as provided in s. 49.45 (27).

c. Medical assistance under s. 49.46 (1) (a) 15.

d. Ambulatory prenatal care under s. 49.465.

e. Medicare premium, coinsurance, and deductible payments under s. 49.46 (2) (c) 2. or 3., 49.468 (1) (b) or (c), or 49.47 (6) (a) 6. b. or c.

f. Medicare premium payments under s. 49.46 (2) (cm), 49.468 (1m) or (2), or 49.47 (6) (a) 6m.

74,84 Section 84. 149.12 (2) (g) of the statutes is created to read:

149.12 (2) (g) A person is not eligible for coverage under the plan if the person is eligible for any of the following:

1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.

2. Medical assistance provided as part of a family care benefit, as defined in s. 46.2805 (4).

3. Services provided under a waiver requested under 2001 Wisconsin Act 16, section 9123 (16rs), or 2003 Wisconsin Act 33, section 9124 (8c).

4. Services provided under the program of all-inclusive care for persons aged 55 or older authorized under 42 USC 1396u-4.

5. Services provided under the demonstration program under a federal waiver authorized under 42 USC 1315.

6. Health care coverage under the Badger Care health care program under s. 49.665.

74,85 Section 85. 149.12 (3) (a) of the statutes is amended to read:

149.12 (3) (a) Except as provided in pars. (b) to (c) and (bm), no person is eligible for coverage under the plan for whom a premium, deductible, or coinsurance amount is paid or reimbursed by a federal, state, county, or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.

74,86 Section 86. 149.12 (3) (c) of the statutes is repealed.

74,87 Section 87. 149.12 (4) and (5) of the statutes are created to read:

149.12 (4) Subject to subs. (1m), (2), and (3), the authority may establish criteria that would enable additional persons to be eligible for coverage under the plan. The authority shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.

(5) The authority shall establish policies for determining and verifying the continued eligibility of an eligible person.

74,88 Section 88. 149.13 (1) of the statutes is amended to read:

149.13 (1) Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department authority of the insurers participating in the cost of administering the plan.

74,89 Section 89. 149.13 (3) (a) of the statutes is amended to read:

149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the department under s. 149.143 (2) (a) 3. authority.

74,90 Section 90. 149.13 (3) (b) of the statutes is amended to read:

149.13 (3) (b) If the department authority or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600 to 646 and 655 is not adequate to permit the department, the commissioner or the board authority to carry out the department's, commissioner's or board's authority's responsibilities under this chapter subchapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and board authority to make the determinations required under this chapter subchapter.

74,91 Section 91 . 149.13 (4) of the statutes is amended to read:

149.13 (4) Notwithstanding subs. (1) to (3), the department, with the agreement of the commissioner, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan. Neither the commissioner nor the department may assess any type of insurance that was not being assessed as of December 1, 2005, or any type of insurer that was not being assessed as December 1, 2005.

74,92 Section 92 . 149.13 (4) of the statutes, as affected by 2005 Wisconsin Act .... (this act), is amended to read:

149.13 (4) Notwithstanding subs. (1) to (3), the department authority, with the agreement of the commissioner, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan. Neither the commissioner nor the department authority may assess any type of insurance that was not being assessed as of December 1, 2005, or any type of insurer that was not being assessed as December 1, 2005.

74,93 Section 93. 149.14 (1) (a) of the statutes is amended to read:

149.14 (1) (a) The plan shall offer coverage for each eligible person in an annually renewable policy the coverage specified in this section for each eligible person. If an eligible person is also eligible for medicare Medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by medicare Medicare. If an eligible person is eligible for a type of medical assistance specified in s. 149.12 (2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by Medical Assistance.

74,94 Section 94. 149.14 (2) (a) of the statutes is amended to read:

149.14 (2) (a) The plan shall provide every eligible person who is not eligible for medicare Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to sub. (3) and deductible, copayment, and coinsurance payments authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.

74,95 Section 95. 149.14 (3) (intro.) of the statutes is amended to read:

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 department under ss. 149.143 and 149.144, covered Covered expenses for the coverage under this section the plan shall be the payment rates established by the department under s. 149.142 authority 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 department under ss. 149.143 and 149.144, covered Covered expenses for the coverage under this section the plan shall also be the payment rates established by the department under s. 149.142 authority for, at a minimum, 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.:

74,96 Section 96. 149.14 (3) (b) of the statutes is repealed and recreated to read:

149.14 (3) (b) Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental.

74,97 Section 97. 149.14 (3) (c) 1. of the statutes is repealed and recreated to read:

149.14 (3) (c) 1. Inpatient hospital services, as defined in s. 632.89 (1) (d), outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment arrangements, as defined in s. 632.89 (1) (f), at least to the extent required under s. 632.89.

74,98 Section 98. 149.14 (3) (c) 2. of the statutes is repealed.

74,99 Section 99 . 149.14 (3) (c) 3. of the statutes is amended to read:

149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats., services for the chronically mentally ill in community support programs operated under s. 51.421.

74,100 Section 100 . 149.14 (3) (c) 3. of the statutes, as affected by 2005 Wisconsin Act .... (this act), is amended to read:

149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats. 1., services for the chronically mentally ill in community support programs operated under s. 51.421.

74,101 Section 101. 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).

74,102 Section 102. 149.14 (3) (e) of the statutes is amended to read:

149.14 (3) (e) Services For persons eligible for Medicare, services of a licensed skilled nursing facility for eligible persons eligible for medicare, to the extent required by s. 632.895 (3) and for not more than an aggregate 120 days during a calendar year, if the services are of the type which that would qualify as reimbursable services under medicare Medicare. Coverage under this paragraph which that is not required by s. 632.895 (3) is subject to the any deductible and coinsurance requirements under sub. (5) provided by the authority.

74,103 Section 103. 149.14 (3) (f) of the statutes is created to read:

149.14 (3) (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only to the extent required under s. 632.895 (2).

74,104 Section 104. 149.14 (3) (m) of the statutes is amended to read:

149.14 (3) (m) Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth.

74,105 Section 105. 149.14 (3) (o) of the statutes is amended to read:

149.14 (3) (o) Transportation Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat the a covered condition.

74,106 Section 106. 149.14 (3) (p) of the statutes is renumbered 149.14 (3) (em).

74,107 Section 107. 149.14 (4) of the statutes, as affected by 2005 Wisconsin Act .... (this act), is repealed and recreated to read:

149.14 (4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority shall establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state. The authority may develop additional benefit designs that are responsive to market conditions.

74,108 Section 108. 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 that exceeds the payment rate established by the department authority under s. 149.142 and reduced under ss. 149.143 and 149.144 or any charge not medically necessary.

74,109 Section 109. 149.14 (4) (m) of the statutes is amended to read:

149.14 (4) (m) Experimental treatment, as determined by the department authority.

74,110 Section 110. 149.14 (4c) of the statutes is repealed.

74,111 Section 111. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and amended to read:

149.142 (2m) 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 sub. (1) 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 sub. (1).

74,112 Section 112. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act .... (this act), is repealed and recreated to read:

149.14 (5) Deductible and copayment subsidies. (a) The authority shall establish and provide subsidies for deductibles paid by eligible persons with coverage under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.

(b) The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in par. (a).

74,113 Section 113. 149.14 (5) (b) of the statutes is amended to read:

149.14 (5) (b) Except as provided in pars. (c) and (e) par. (c), 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.

74,114 Section 114. 149.14 (5) (c) of the statutes is amended to read:

149.14 (5) (c) Except as provided in par. (e), if 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.

74,115 Section 115. 149.14 (5) (d) of the statutes is repealed.

74,116 Section 116. 149.14 (5) (e) of the statutes is repealed.

74,117 Section 117. 149.14 (5m) of the statutes is repealed.

74,118 Section 118. 149.14 (6) (a) of the statutes is repealed.

74,119 Section 119. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).

74,120 Section 120. 149.14 (7) (b) of the statutes is amended to read:

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: