Amendment ASA1-AB100

AB100-ASA1,1814,12 149.14 (2) (a) The plan shall provide every eligible person who is not eligible for 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 and coinsurance payments authorized under sub. (5), up to a lifetime limit of $500,000 $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.

AB100-ASA1, s. 3427 Section 3427. 619.14 (3) of the statutes is renumbered 149.14 (3), and 149.14 (3) (intro.) and (c) 3., as renumbered, are amended to read:

AB100-ASA1,1814,25 149.14 (3) Covered expenses. (intro.) Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 149.15 (3) (e) or by the department under s. 149.143 (2) (a) 3. or (3) or 149.144, covered expenses for the coverage under this section shall be the usual and customary charges for the services provided by persons licensed under ch. 446. Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 149.15 (3) (e) or by the department under s. 149.143 (2) (a) 3. or (3) or 149.144, covered expenses for the coverage under this section shall also be the usual and customary charges for the following services and articles when prescribed by a physician licensed under ch. 448 or in another state:

AB100-ASA1,1815,3 (c) 3. Subject to the limits under subd. 2. and to rules promulgated by the commissioner department, services for the chronically mentally ill in community support programs operated under s. 51.421.

AB100-ASA1, s. 3428 Section 3428. 619.14 (4) of the statutes is renumbered 149.14 (4), and 149.14 (4) (intro.) and (m), as renumbered, are amended to read:

AB100-ASA1,1815,7 149.14 (4) Exclusions. (intro.) Covered expenses for the coverage under this section shall not include the following:

AB100-ASA1,1815,9 (m) Experimental treatment, as determined by the board or its designee department.

AB100-ASA1, s. 4852c Section 4852c. 619.14 (5) (title) of the statutes is renumbered 149.14 (5) (title) and amended to read:

AB100-ASA1,1815,12 149.14 (5) (title) Premiums, deductibles Deductibles and coinsurance.

AB100-ASA1, s. 3429 Section 3429. 619.14 (5) (a) of the statutes is renumbered 149.14 (5) (a) and amended to read:

AB100-ASA1,1816,6 149.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter chapter for major medical expense coverage required under this section. For coverage offered to those persons eligible for medicare, the plan shall offer a deductible equal to the deductible charged by part A of title XVIII of the federal social security act, as amended. The deductible amounts for all other eligible persons shall be dependent upon household income as determined under s. 619.165 149.165. For eligible persons under s. 619.165 (1) (b) 1. 149.165 (2) (a), the deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2. 149.165 (2) (b), the deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3. 149.165 (2) (c), the deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4. 149.165 (2) (d), the deductible shall be $800. For all other eligible persons who are not eligible for medicare, the deductible shall be $1,000. With respect to all eligible persons, 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. The schedule of premiums shall be promulgated by rule by the commissioner. The commissioner shall set rates at 60% of the operating and administrative costs of the plan.

AB100-ASA1, s. 4854c Section 4854c. 619.14 (5) (b) of the statutes is renumbered 149.14 (5) (b).

AB100-ASA1, s. 4855c Section 4855c. 619.14 (5) (c) of the statutes is renumbered 149.14 (5) (c)

AB100-ASA1, s. 3430 Section 3430. 619.14 (5) (d) of the statutes is renumbered 149.14 (5) (d) and amended to read:

AB100-ASA1,1816,16 149.14 (5) (d) Notwithstanding pars. (a) to (c), the board department may establish different deductible amounts, a different coinsurance percentage and different covered costs and deductible aggregate amounts from those specified in pars. (a) to (c) in accordance with cost containment provisions established by the commissioner department under s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under s. 619.145 149.17 (4).

AB100-ASA1, s. 4856v Section 4856v. 619.14 (5) (e) of the statutes is amended to read:

AB100-ASA1,1816,23 619.14 (5) (e) Using the procedure under s. 227.24, the commissioner may promulgate rules under par. (a) or s. 619.146 (2) (b) for the schedule of premiums for the period before the effective date of any permanent rules promulgated under par. (a) or s. 619.146 (2) (b) for the schedule of premiums, but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the commissioner is not required to make a finding of emergency.

AB100-ASA1, s. 4857c Section 4857c. 619.14 (5) (e) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is repealed.

AB100-ASA1, s. 4858b Section 4858b. 619.14 (6) of the statutes is renumbered 619.14 (6) (a) and amended to read:

AB100-ASA1,1817,6 619.14 (6) (a) No Except as provided in par. (b), no person who obtains coverage under the plan may be covered for any preexisting condition during the first 6 months of coverage under the plan if the person was diagnosed or treated for that condition during the 6 months immediately preceding the filing of an application with the plan.

AB100-ASA1, s. 4858c Section 4858c. 619.14 (6) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.14 (6).

AB100-ASA1, s. 4858d Section 4858d. 619.14 (6) (b) of the statutes is created to read:

AB100-ASA1,1817,15 619.14 (6) (b) An eligible individual who obtains coverage under the plan on or after the effective date of this paragraph .... [revisor inserts date], may not be subject to any preexisting condition exclusion under the plan. An eligible individual who is covered under the plan on the effective date of this paragraph .... [revisor inserts date], may not be subject to any preexisting condition exclusion on or after the effective date of this paragraph .... [revisor inserts date].

AB100-ASA1, s. 3431 Section 3431. 619.14 (7) of the statutes is renumbered 149.14 (7), and 149.14 (7) (b) and (c), as renumbered, are amended to read:

AB100-ASA1,1817,21 149.14 (7) (b) The board department has a cause of action against an eligible participant for the recovery of the amount of benefits paid which 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.

AB100-ASA1,1817,25 (c) The board department 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.

AB100-ASA1, s. 3432 Section 3432. 619.145 of the statutes is repealed.

AB100-ASA1, s. 4860c Section 4860c. 619.146 of the statutes is created to read:

AB100-ASA1,1818,6 619.146 Choice of coverage. (1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 619.14, the plan shall offer to all eligible persons a choice of coverage, as described in section 2744 (a) (1) (C) of P.L. 104-191. Any such choice of coverage shall be major medical expense coverage.

AB100-ASA1,1818,15 (b) An eligible person may elect once each year, at the time and according to procedures established by the board, among the coverages offered under this section and s. 619.14. 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 subchapter. 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 subchapter and the person remained continuously covered under this subchapter up to the time of electing new coverage.

AB100-ASA1,1818,19 (2) (a) Except as specified by the board, the terms of coverage under s. 619.14, including deductible reductions under s. 619.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under s. 619.165 do not apply to the coverage offered under this section.

AB100-ASA1,1818,23 (b) The schedule of premiums for coverage under this section shall be promulgated by rule by the commissioner. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 619.14 by the same percentage as the percentage difference between the following:

AB100-ASA1,1819,3 1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under s. 619.14.

AB100-ASA1,1819,6 2. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as the coverage offered under this section.

AB100-ASA1, s. 4860d Section 4860d. 619.146 of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.146, and 149.146 (1) (a) and (b) and (2) (a) and (b) (intro.) and 1., as renumbered, are amended to read:

AB100-ASA1,1819,13 149.146 (1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 619.14 149.14, the plan shall offer to all eligible persons 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.

AB100-ASA1,1819,22 (b) An eligible person may elect once each year, at the time and according to procedures established by the board, among the coverages offered under this section and s. 619.14 149.14. 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 subchapter 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 subchapter chapter and the person remained continuously covered under this subchapter chapter up to the time of electing the new coverage.

AB100-ASA1,1820,2 (2) (a) Except as specified by the board, the terms of coverage under s. 619.14 149.14, including deductible reductions under s. 619.14 149.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under s. 619.165 149.165 do not apply to the coverage offered under this section.

AB100-ASA1,1820,7 (b) (intro.) The schedule of premiums for coverage under this section shall be promulgated by rule by the commissioner department, as provided in s. 149.143. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 619.14 149.14 by the same percentage as the percentage difference between the following:

AB100-ASA1,1820,10 1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under s. 619.14 149.14.

AB100-ASA1, s. 3433 Section 3433. 619.15 (title) of the statutes is renumbered 149.15 (title).

AB100-ASA1, s. 3434 Section 3434. 619.15 (1) of the statutes is renumbered 149.15 (1) and amended to read:

AB100-ASA1,1821,6 149.15 (1) The plan shall operate subject to the supervision and approval of a have a board of governors consisting of representatives of 2 participating insurers which 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 public members, including one representative of small businesses in the state, appointed by the commissioner 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 a member 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 of the public members shall be individuals reasonably expected to qualify for coverage under the plan or the parent or spouse of such an individual. The commissioner secretary or the commissioner's 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.

AB100-ASA1, s. 3435 Section 3435. 619.15 (2) of the statutes is renumbered 149.15 (2) and amended to read:

AB100-ASA1,1821,14 149.15 (2) Annually, the board shall make a report to the members of the plan and to the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under s. 13.172 (3), and to the members of the plan summarizing the activities of the plan in the preceding calendar year. The annual report shall define the cost burden imposed by the plan on all policyholders in this state.

AB100-ASA1, s. 3436 Section 3436. 619.15 (3) (intro.) of the statutes is renumbered 149.15 (3) (intro.) and amended to read:

AB100-ASA1,1821,17 149.15 (3) (intro.) The board shall do all of the following:

AB100-ASA1, s. 3437 Section 3437. 619.15 (3) (a) of the statutes is renumbered 149.15 (3) (a).

AB100-ASA1, s. 3438 Section 3438. 619.15 (3) (b) of the statutes is repealed.

AB100-ASA1, s. 4867c Section 4867c. 619.15 (3) (c) of the statutes is renumbered 149.15 (3) (c) and amended to read:

AB100-ASA1,1822,3 149.15 (3) (c) Collect assessments from all insurers to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board as provided under s. 149.143. Assessment of the insurers shall occur at the end of each calendar year or other fiscal year end established by the board. Assessments are due and payable within 30 days of receipt by the insurer of the assessment notice.

AB100-ASA1, s. 3439 Section 3439. 619.15 (3) (d) of the statutes is renumbered 149.15 (3) (d).

AB100-ASA1, s. 4869c Section 4869c. 619.15 (3) (e) of the statutes is renumbered 149.15 (3) (e) and amended to read:

AB100-ASA1,1822,12 149.15 (3) (e) Establish for payment of covered expenses, a payment rate that is 10% less than the charges approved by the administering carrier plan administrator for reimbursement of covered expenses under s. 619.14 149.14 (3). A provider of a covered service or article may not bill an eligible person who receives the service or article for any amount by which the charge is reduced under this paragraph.

AB100-ASA1, s. 4869d Section 4869d. 619.15 (3) (f) of the statutes is created to read:

AB100-ASA1,1822,15 619.15 (3) (f) In consultation with the office and the department of health and family services, establish a choice of coverage under s. 619.146.

AB100-ASA1, s. 4869f Section 4869f. 619.15 (3) (f) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.15 (3) (f) and amended to read:

AB100-ASA1,1822,20 149.15 (3) (f) In consultation with the office of the commissioner of insurance and the department of health and family services, establish a choice of coverage under s. 619.146 149.146.

AB100-ASA1, s. 3440 Section 3440. 619.15 (4) (intro.) of the statutes is renumbered 149.15 (4) (intro.) and amended to read:

AB100-ASA1,1822,23 149.15 (4) (intro.) The board may do any of the following:

AB100-ASA1, s. 3441 Section 3441. 619.15 (4) (a) of the statutes is renumbered 149.15 (4) (a).

AB100-ASA1, s. 3442 Section 3442. 619.15 (4) (b) of the statutes is renumbered 149.15 (4) (b).

AB100-ASA1, s. 4873c Section 4873c. 619.15 (4) (c) of the statutes is repealed.

AB100-ASA1, s. 3443 Section 3443. 619.15 (4) (d) of the statutes is repealed.

AB100-ASA1, s. 3444 Section 3444. 619.15 (4) (e) of the statutes is repealed.

AB100-ASA1, s. 3445 Section 3445. 619.15 (5) of the statutes is renumbered 149.15 (5) and amended to read:

AB100-ASA1,1823,7 149.15 (5) The commissioner department may, by rule, establish additional powers and duties of the board.

AB100-ASA1, s. 3446 Section 3446. 619.15 (6) of the statutes is renumbered 149.15 (6) and amended to read:

AB100-ASA1,1823,11 149.15 (6) If any provision of this subchapter chapter conflicts with s. 625.11 or 625.12, this subchapter chapter prevails.

AB100-ASA1, s. 3447 Section 3447. 619.15 (7) of the statutes is renumbered 149.15 (7).

AB100-ASA1, s. 3448 Section 3448. 619.16 (title) of the statutes is repealed.

AB100-ASA1, s. 3449 Section 3449. 619.16 (1) of the statutes is repealed.

AB100-ASA1, s. 3450 Section 3450. 619.16 (2) of the statutes is repealed.

AB100-ASA1, s. 3451 Section 3451. 619.16 (3) (a) of the statutes is renumbered 149.16 (3) (a) and amended to read:

AB100-ASA1,1823,19 149.16 (3) (a) The administering carrier plan administrator shall perform all eligibility and administrative claims payment functions relating to the plan.

AB100-ASA1, s. 3452 Section 3452. 619.16 (3) (b) of the statutes is renumbered 149.16 (3) (b) and amended to read:

AB100-ASA1,1823,24 149.16 (3) (b) The administering carrier plan administrator shall establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the board department.

AB100-ASA1, s. 4884c Section 4884c. 619.16 (3) (c) of the statutes is renumbered 149.16 (3) (c), and 149.16 (3) (c) (intro.), as renumbered, is amended to read:

AB100-ASA1,1824,5 149.16 (3) (c) (intro.) The administering carrier plan administrator shall perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:

AB100-ASA1, s. 3453 Section 3453. 619.16 (3) (d) of the statutes is repealed.

AB100-ASA1, s. 3454 Section 3454. 619.16 (3) (e) of the statutes is renumbered 149.16 (3) (e) and amended to read:

AB100-ASA1,1824,16 149.16 (3) (e) The administering carrier plan administrator, under the direction of the department, shall pay claims expenses from the premium payments received from or on behalf of covered persons under the plan. If the administering carrier's plan administrator's payments for claims expenses exceed the portion of premiums allocated by the board for payment of claims expenses premium payments, the board shall forward to the department, and the department shall provide to the carrier plan administrator, additional funds for payment of claims expenses.

AB100-ASA1, s. 3455 Section 3455. 619.16 (3) (em) of the statutes is repealed.

AB100-ASA1, s. 3456 Section 3456. 619.16 (3) (f) of the statutes is repealed.

AB100-ASA1, s. 3457 Section 3457. 619.165 (title) of the statutes is renumbered 149.165 (title).

AB100-ASA1, s. 3458 Section 3458. 619.165 (1) (a) of the statutes is renumbered 149.165 (1) and amended to read:

AB100-ASA1,1824,25 149.165 (1) The board Except as provided in s. 149.146 (2) (a), the department shall reduce the premiums established by the commissioner under s. 619.11 149.11 in conformity with ss. 619.14 (5) 149.143 and 619.17 149.17, for the eligible persons and in the manner set forth in pars. (b) to (d) subs. (2) and (3).

AB100-ASA1, s. 3459 Section 3459. 619.165 (1) (b) of the statutes is renumbered 149.165 (2), and 149.165 (2) (intro.), as renumbered, is amended to read:

AB100-ASA1,1825,7 149.165 (2) (intro.) If the household income, as defined in s. 71.52 (5) and as determined under par. (d) 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 board department shall reduce the premium for the eligible person, as established by the commissioner, to the rate shown after the amounts: