Amendment ASA1-AB265

LRBs0084/1

PJK:kmg:jf

2001 - 2002 LEGISLATURE

ASSEMBLY SUBSTITUTE AMENDMENT 1, TO 2001 ASSEMBLY BILL 265

April 18, 2001 - Offered by Representative Wasserman.

AB265-ASA1,1,8 An Act to repeal 149.14 (5) (d) and 149.146 (2) (am) 4.; to renumber and amend 149.14 (5) (c) and 149.14 (5) (e); to amend 149.14 (5) (title), 149.14 (5) (a), 149.14 (5) (b), 149.146 (2) (am) 1., 149.146 (2) (am) 2. and 149.146 (2) (am) 3.; and to create 149.14 (5) (c) 2., 149.14 (5) (e) 2. and 149.146 (2) (am) 5. of the statutes; relating to: copayments or coinsurance for prescription drug coverage, deductibles, coinsurance, and out-of-pocket limits under the health insurance risk-sharing plan and providing an exemption from emergency rule procedures.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB265-ASA1, s. 1 Section 1. 149.14 (5) (title) of the statutes is amended to read:

AB265-ASA1,1,11 149.14 (5) (title) Deductibles, copayments and, coinsurance, and out-of-pocket limits.

AB265-ASA1, s. 2 Section 2. 149.14 (5) (a) of the statutes is amended to read:

AB265-ASA1,2,16 149.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this chapter for major medical expense coverage required under this section. The deductible shall apply only to covered costs other than those under sub. (3) (d), for which copayments or coinsurance shall apply. For coverage offered to those persons who are 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 deductible amount shall be $250. The deductible amounts for all other eligible persons shall be dependent upon household income as determined under s. 149.165. For eligible persons under s. 149.165 (2) (a) 1., the deductible shall be $500 $250. For eligible persons under s. 149.165 (2) (a) 2., the deductible shall be $600 $300. For eligible persons under s. 149.165 (2) (a) 3., the deductible shall be $700 $350. For eligible persons under s. 149.165 (2) (a) 4., the deductible shall be $800 $400. For all other eligible persons who are not eligible for medicare, the deductible shall be $1,000 $500. 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.

AB265-ASA1, s. 3 Section 3. 149.14 (5) (b) of the statutes is amended to read:

AB265-ASA1,2,22 149.14 (5) (b) Except as provided in par. (c) 1., if the covered costs other than those under sub. (3) (d) that are incurred by the an eligible person who is not eligible for medicare exceed the deductible for major medical expense coverage in a calendar year, the plan shall pay at least 80% of any additional covered costs other than those under sub. (3) (d) that are incurred by the eligible person during the calendar year.

AB265-ASA1, s. 4 Section 4. 149.14 (5) (c) of the statutes is renumbered 149.14 (5) (c) 1. and amended to read:

AB265-ASA1,3,8 149.14 (5) (c) 1. If the aggregate of the covered costs other than those under sub. (3) (d) that are not paid by the plan under par. (b) and the deductible exceeds $500 for an eligible person receiving medicare, $2,000 for any other $1,000 during a calendar year for an eligible person during a calendar year or $4,000 who is not eligible for medicare, or $2,000 for all such eligible persons in a family, the plan shall pay 100% of all covered costs other than those under sub. (3) (d) that are incurred by the eligible person during the calendar year after the applicable payment ceilings ceiling under this paragraph are subdivision is exceeded.

AB265-ASA1, s. 5 Section 5. 149.14 (5) (c) 2. of the statutes is created to read:

AB265-ASA1,3,14 149.14 (5) (c) 2. If the covered costs other than those under sub. (3) (d) that are incurred during a calendar year by an eligible person who is eligible for medicare exceed the deductible, the plan shall pay 100% of all covered costs other than those under sub. (3) (d) that are incurred by the eligible person during the calendar year after the deductible is exceeded.

AB265-ASA1, s. 6 Section 6. 149.14 (5) (d) of the statutes is repealed.

AB265-ASA1, s. 7 Section 7. 149.14 (5) (e) of the statutes is renumbered 149.14 (5) (e) 1. and amended to read:

AB265-ASA1,3,23 149.14 (5) (e) 1. Subject to sub. (8) (b), the department may, by rule under s. 149.17 (4), establish copayments copayment amounts or coinsurance rates for prescription drug coverage under sub. (3) (d). Any copayment amounts or rates amount or coinsurance rate established are is subject to the approval of the board. Copayments paid by an eligible person under this paragraph shall count toward the deductible and covered costs not paid by the plan under pars. (a) to (c).

AB265-ASA1, s. 8 Section 8. 149.14 (5) (e) 2. of the statutes is created to read:

AB265-ASA1,4,4 149.14 (5) (e) 2. The plan shall pay 100% of all covered costs under sub. (3) (d) that are incurred during a calendar year by each of the following eligible persons after the eligible person has paid the following amount in copayments or coinsurance for covered costs under sub. (3) (d) in the calendar year:

AB265-ASA1,4,5 a. An eligible person who is eligible for medicare, $250.

AB265-ASA1,4,6 b. An eligible person under s. 149.165 (2) (a) 1., $250.

AB265-ASA1,4,7 c. An eligible person under s. 149.165 (2) (a) 2., $300.

AB265-ASA1,4,8 d. An eligible person under s. 149.165 (2) (a) 3., $350.

AB265-ASA1,4,9 e. An eligible person under s. 149.165 (2) (a) 4., $400.

AB265-ASA1,4,10 f. Any other eligible person who is not eligible for medicare, $500.

AB265-ASA1, s. 9 Section 9. 149.146 (2) (am) 1. of the statutes is amended to read:

AB265-ASA1,4,16 149.146 (2) (am) 1. For all eligible persons with coverage under this section, the deductible, which shall apply only to covered costs other than for prescription drugs, shall be $2,500 $1,250. 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.

AB265-ASA1, s. 10 Section 10. 149.146 (2) (am) 2. of the statutes is amended to read:

AB265-ASA1,4,22 149.146 (2) (am) 2. Except as provided in subd. 3., if the covered costs other than for prescription drugs that are incurred by the an 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 other than for prescription drugs that are incurred by the eligible person during the calendar year.

AB265-ASA1, s. 11 Section 11. 149.146 (2) (am) 3. of the statutes is amended to read:

AB265-ASA1,5,5 149.146 (2) (am) 3. If the aggregate of the covered costs other than for prescription drugs that are not paid by the plan under subd. 2. and the deductible exceeds $3,500 $1,750 for any eligible person during a calendar year or $7,000 $3,500 for all eligible persons in a family, the plan shall pay 100% of all covered costs other than for prescription drugs that are incurred by the eligible person during the calendar year after the applicable payment ceilings ceiling under this subdivision are is exceeded.

AB265-ASA1, s. 12 Section 12. 149.146 (2) (am) 4. of the statutes is repealed.

AB265-ASA1, s. 13 Section 13. 149.146 (2) (am) 5. of the statutes is created to read:

AB265-ASA1,5,14 149.146 (2) (am) 5. Subject to s. 149.14 (8) (b), the department may, by rule under s. 149.17 (4), establish copayment amounts or coinsurance rates for prescription drug coverage under this section. Any copayment amount or coinsurance rate established is subject to the approval of the board. The plan shall pay 100% of all covered costs for prescription drugs that are incurred by an eligible person during a calendar year after the eligible person has paid $1,250 in copayments or coinsurance for prescription drug coverage in the calendar year.

AB265-ASA1, s. 14 Section 14. Nonstatutory provisions.

AB265-ASA1,5,24 (1) Rules on drug copayments. The department of health and family services may use the procedure under section 227.24 of the statutes to promulgate rules authorized under section 149.14 (5) (e) 1. of the statutes, as affected by this act, and section 149.146 (2) (am) 5. of the statutes, as created by this act. Notwithstanding section 227.24 (1) (a), (2) (b), and (3) of the statutes, the department is not required to provide evidence that promulgating a rule under this subsection as an emergency rule is necessary for the preservation of public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subsection.

AB265-ASA1, s. 15 Section 15. Initial applicability.

AB265-ASA1,6,2 (1) This act first applies to policies under the health insurance risk-sharing plan that are issued or renewed on the effective date of this subsection.

AB265-ASA1,6,3 (End)