Amendment SSA1-SB44

SB44-SSA1, s. 2067 Section 2067. 149.10 (8b) of the statutes is repealed.

SB44-SSA1, s. 2068 Section 2068. 149.14 (5) (e) of the statutes is amended to read:

SB44-SSA1,812,23 149.14 (5) (e) Subject to sub. (8) (b), the department may, by rule under s. 149.17 (4), establish for prescription drug coverage under sub. (3) (d) copayment amounts, coinsurance rates, and copayment and coinsurance out-of-pocket limits over which the plan will pay 100% of covered costs under sub. (3) (d). The department may provide subsidies for prescription drug copayment amounts paid by eligible persons under s. 149.165 (2) (a) 1. to 5. Any copayment amount, coinsurance rate, or out-of-pocket limit established under this paragraph is subject to the approval of the board. Copayments and coinsurance paid by an eligible person under this paragraph are separate from and do not count toward the deductible and covered costs not paid by the plan under pars. (a) to (c).

SB44-SSA1, s. 2069 Section 2069. 149.143 (1) (a) of the statutes is repealed.

SB44-SSA1, s. 2070 Section 2070. 149.143 (1) (b) (intro.) of the statutes is repealed.

SB44-SSA1, s. 2071 Section 2071. 149.143 (1) (b) 1. of the statutes is renumbered 149.143 (1) (am), and 149.143 (1) (am) 1., 2., 3. and 4., as renumbered, are amended to read:

SB44-SSA1,813,11 149.143 (1) (am) 1. First, from premiums from eligible persons with coverage under s. 149.14 (2) (a) set at a rate that is 140% to 150% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan and from eligible persons with coverage under s. 149.14 (2) (b) set in accordance with s. 149.14 (5m), including amounts received for premium and, deductible, and prescription drug copayment subsidies under s. 149.144 and under the transfer to the fund from the appropriation account under s. 20.435 (4) (ah), and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b).

SB44-SSA1,813,13 2. Second, from moneys specified under sub. (2m), to the extent that the amounts under subd. 1. a. are insufficient to pay 60% of plan costs.

SB44-SSA1,813,24 3. Third, by increasing premiums from eligible persons with coverage under s. 149.14 (2) (a) to more than the rate at which premiums were set under subd. 1. a. but not more than 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan and from eligible persons with coverage under s. 149.14 (2) (b) by a comparable amount in accordance with s. 149.14 (5m), including amounts received for premium and, deductible , and prescription drug copayment subsidies under s. 149.144 and under the transfer to the fund from the appropriation account under s. 20.435 (4) (ah), and by increasing premiums from eligible persons with coverage under s. 149.146 in accordance with s. 149.146 (2) (b), to the extent that the amounts under subd. 1. a. subds. 1. and b. 2. are insufficient to pay 60% of plan costs.

SB44-SSA1,814,5 4. Fourth, notwithstanding subd. 2. par. (bm), by increasing insurer assessments, excluding assessments under s. 149.144, and adjusting provider payment rates, subject to s. 149.142 (1) (b) and excluding adjustments to those rates under s. 149.144, in equal proportions and to the extent that the amounts under subd. 1. a. to c. subds. 1. to 3. are insufficient to pay 60% of plan costs.

SB44-SSA1, s. 2072 Section 2072. 149.143 (1) (b) 2. of the statutes is renumbered 149.143 (1) (bm).

SB44-SSA1, s. 2073 Section 2073. 149.143 (2) (a) (intro.) of the statutes is amended to read:

SB44-SSA1,814,12 149.143 (2) (a) (intro.) Prior to each plan year, the department shall estimate the operating and administrative costs of the plan and the costs of the premium reductions under s. 149.165 and, the deductible reductions under s. 149.14 (5) (a), and any prescription drug copayment reductions under s. 149.14 (5) (e) for the new plan year and do all of the following:

SB44-SSA1, s. 2074 Section 2074. 149.143 (2) (a) 1. a. of the statutes is amended to read:

SB44-SSA1,814,22 149.143 (2) (a) 1. a. Estimate the amount of enrollee premiums that would be received in the new plan year if the enrollee premiums were set at a level sufficient, when including amounts received for premium and, deductible, and prescription drug copayment subsidies under s. 149.144 and under the transfer to the fund from the appropriation account under s. 20.435 (4) (ah) and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to cover 60% of the estimated plan costs for the new plan year , after deducting from the estimated plan costs the amount available for transfer to the fund from the appropriation account under s. 20.435 (4) (af) for that plan year.

SB44-SSA1, s. 2075 Section 2075. 149.143 (2) (a) 1. b. of the statutes is amended to read:

SB44-SSA1,814,25 149.143 (2) (a) 1. b. Estimate the amount of enrollee premiums that will be received under sub. (1) (b) 1. a. (am) 1.

SB44-SSA1, s. 2076 Section 2076. 149.143 (2) (a) 2. of the statutes is amended to read:

SB44-SSA1,815,8 149.143 (2) (a) 2. After making the determinations under subd. 1., by rule set premium rates for the new plan year, including the rates under s. 149.146 (2) (b), in the manner specified in sub. (1) (b) 1. a. and c. (am) 1. and 3. and such that a rate for coverage under s. 149.14 (2) (a) is approved by the board and is not less than 140% nor more than 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan.

SB44-SSA1, s. 2077 Section 2077. 149.143 (2) (a) 3. of the statutes is amended to read:

SB44-SSA1,815,13 149.143 (2) (a) 3. By rule set the total insurer assessments under s. 149.13 for the new plan year by estimating and setting the assessments at the amount necessary to equal the amounts specified in sub. (1) (b) 1. d. and 2. a. (am) 4. and (bm) 1. and notify the commissioner of the amount.

SB44-SSA1, s. 2078 Section 2078. 149.143 (2) (a) 4. of the statutes is amended to read:

SB44-SSA1,815,18 149.143 (2) (a) 4. By the same rule as under subd. 3. adjust the provider payment rate for the new plan year, subject to s. 149.142 (1) (b), by estimating and setting the rate at the level necessary to equal the amounts specified in sub. (1) (b) 1. d. and 2. b. (am) 4. and (bm) 2. and as provided in s. 149.145.

SB44-SSA1, s. 2079 Section 2079. 149.143 (2) (b) of the statutes is amended to read:

SB44-SSA1,815,25 149.143 (2) (b) In setting the premium rates under par. (a) 2., the insurer assessment amount under par. (a) 3. and the provider payment rate under par. (a) 4. for the new plan year, the department shall include any increase or decrease necessary to reflect the amount, if any, by which the rates and amount set under par. (a) for the current plan year differed from the rates and amount which would have equaled the amounts specified in sub. (1) (b) (am) and (bm) in the current plan year.

SB44-SSA1, s. 2080 Section 2080. 149.143 (2m) (a) 1. of the statutes is amended to read:

SB44-SSA1,816,4 149.143 (2m) (a) 1. The amount of premiums received in a plan year from all eligible persons, including amounts received for premium and, deductible, and prescription drug copayment subsidies.

SB44-SSA1, s. 2081 Section 2081. 149.143 (2m) (a) 2. of the statutes is amended to read:

SB44-SSA1,816,9 149.143 (2m) (a) 2. The amount of premiums, including amounts received for premium and, deductible, and prescription drug copayment subsidies, necessary to cover 60% of the plan costs for the plan year, after deducting the amount transferred to the fund from the appropriation account under s. 20.435 (4) (af).

SB44-SSA1, s. 2082 Section 2082. 149.143 (2m) (b) 1. of the statutes is amended to read:

SB44-SSA1,816,15 149.143 (2m) (b) 1. To reduce premiums in succeeding plan years as provided in sub. (1) (b) 1. b. (am) 2. For eligible persons with coverage under s. 149.14 (2) (a), premiums may not be reduced below 140% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan.

SB44-SSA1, s. 2083 Section 2083. 149.143 (3) (a) of the statutes is amended to read:

SB44-SSA1,817,2 149.143 (3) (a) If, during a plan year, the department determines that the amounts estimated to be received as a result of the rates and amount set under sub. (2) (a) 2. to 4. and any adjustments in insurer assessments and the provider payment rate under s. 149.144 will not be sufficient to cover plan costs, the department may by rule increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year, subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (b) 2. a. (bm) 1., and by the same rule under which assessments are increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder of the plan year, subject to sub. (1) (b) 2. b. (bm) 2. and s. 149.142 (1) (b).

SB44-SSA1, s. 2084 Section 2084. 149.143 (3) (b) of the statutes is amended to read:

SB44-SSA1,817,10 149.143 (3) (b) If the department increases premium rates and insurer assessments and adjusts the provider payment rate under par. (a) and determines that there will still be a deficit and that premium rates have been increased to the maximum extent allowable under par. (a), the department may further adjust, in equal proportions, assessments set under sub. (2) (a) 3. and the provider payment rate set under sub. (2) (a) 4., without regard to sub. (1) (b) 2. (bm) but subject to s. 149.142 (1) (b).

SB44-SSA1, s. 2085 Section 2085. 149.144 of the statutes is amended to read:

SB44-SSA1,818,2 149.144 Adjustments to insurer assessments and provider payment rates for premium and, deductible , and prescription drug copayment reductions. If the moneys transferred to the fund under the appropriation under s. 20.435 (4) (ah) are insufficient to reimburse the plan for premium reductions under s. 149.165 and deductible reductions under s. 149.14 (5) (a), or the department determines that the moneys transferred or to be transferred to the fund under the appropriation under s. 20.435 (4) (ah) will be insufficient to reimburse the plan for premium reductions under s. 149.165 and deductible reductions under s. 149.14 (5) (a), the The department may shall, by rule, adjust in equal proportions the amount of the assessment set under s. 149.143 (2) (a) 3. and the provider payment rate set under s. 149.143 (2) (a) 4., subject to ss. 149.142 (1) (b) and 149.143 (1) (b) 1. (am), sufficient to reimburse the plan for premium reductions under s. 149.165 and, deductible reductions under s. 149.14 (5) (a). If the department makes the adjustment under this section, the, and any prescription drug copayment reductions under s. 149.14 (5) (e). The department shall notify the commissioner so that the commissioner may levy any increase in insurer assessments.

SB44-SSA1, s. 2086 Section 2086. 149.145 of the statutes is amended to read:

SB44-SSA1,818,15 149.145 Program budget. The department, in consultation with the board, shall establish a program budget for each plan year. The program budget shall be based on the provider payment rates specified in s. 149.142 and in the most recent provider contracts that are in effect and on the funding sources specified in s. ss. 149.143 (1) and 149.144, including the methodologies specified in ss. 149.143, 149.144, and 149.146 for determining premium rates, insurer assessments, and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b) and subject to s. 149.142 (1) (b), from the program budget the department shall derive the actual provider payment rate for a plan year that reflects the providers' proportional share of the plan costs, consistent with ss. 149.143 and 149.144. The department may not implement a program budget established under this section unless it is approved by the board.

SB44-SSA1, s. 2087 Section 2087. 149.146 (2) (a) of the statutes is amended to read:

SB44-SSA1,818,21 149.146 (2) (a) 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 do not apply to the coverage offered under this section.

SB44-SSA1, s. 2088 Section 2088. 149.16 (1) of the statutes is repealed.

SB44-SSA1, s. 2089 Section 2089. 149.16 (1m) of the statutes is created to read:

SB44-SSA1,818,25 149.16 (1m) The plan administrator may be selected by the department in a competitive bidding process.

SB44-SSA1, s. 2090 Section 2090. 149.16 (4) of the statutes is amended to read:

SB44-SSA1,819,4 149.16 (4) The If the plan administrator is the fiscal agent under s. 49.45 (2) (b) 2., the plan administrator shall account for costs related to the plan separately from costs related to medical assistance under subch. IV of ch. 49.

SB44-SSA1, s. 2091 Section 2091. 149.165 (4) of the statutes is amended to read:

SB44-SSA1,819,9 149.165 (4) The department shall reimburse the plan for premium reductions under sub. (2) and, deductible reductions under s. 149.14 (5) (a) with moneys transferred to the fund, and prescription drug copayment reductions under s. 149.14 (5) (e) from the appropriation account under s. 20.435 (4) (ah) (v).

SB44-SSA1, s. 2092 Section 2092. 150.963 (3) (e) of the statutes is amended to read:

SB44-SSA1,819,14 150.963 (3) (e) Accept on behalf of the state and deposit with the state treasurer secretary of administration any grant, gift, or contribution made to assist in meeting the cost of carrying out the purposes of this subchapter, and expend those funds for the purposes of this subchapter.

SB44-SSA1, s. 2092c Section 2092c. 153.01 (4j) of the statutes is created to read:

SB44-SSA1,819,19 153.01 (4j) "Entity" means a nonstock corporation organized under ch. 181 that is described in section 501 (c) (6) of the Internal Revenue Code and is exempt from federal income tax under section 501 (a) of the Internal Revenue Code, and that does all of the following:

SB44-SSA1,819,20 (a) Represents at least 70% of the hospitals in Wisconsin.

SB44-SSA1,819,22 (b) Receives oversight with respect to services performed by the entity under this chapter from a group that is composed of all of the following:

SB44-SSA1,819,24 1. The secretary of health and family services, who shall serve as chairperson and nonvoting member of the group.

SB44-SSA1,819,25 2. Two members designated by Wisconsin Manufacturers and Commerce, Inc.

SB44-SSA1,820,1 3. Two members designated by the Wisconsin Association of Health Plans, Inc.

SB44-SSA1,820,2 4. One member designated by the Wisconsin State AFL-CIO.

SB44-SSA1,820,3 5. Two members designated by the Wisconsin Hospital Association, Inc.

SB44-SSA1,820,4 6. One member designated by the speaker of the assembly.

SB44-SSA1,820,5 7. One member designated by the senate majority leader.

SB44-SSA1, s. 2092d Section 2092d. 153.05 (1) of the statutes is amended to read:

SB44-SSA1,820,10 153.05 (1) In order to provide to hospitals, health care providers, insurers, consumers, governmental agencies and others information concerning health care providers and uncompensated health care services, and in order to provide information to assist in peer review for the purpose of quality assurance, the:

SB44-SSA1,820,14 (a) The department shall collect from health care providers other than hospitals and ambulatory surgery centers, analyze, and disseminate health care information, as adjusted for case mix and severity, in language that is understandable to lay persons laypersons.

SB44-SSA1, s. 2092e Section 2092e. 153.05 (1) (b) of the statutes is created to read:

SB44-SSA1,820,24 153.05 (1) (b) The entity under contract under sub. (2m) (a) shall collect from hospitals and ambulatory surgery centers the health care information required of hospitals and ambulatory surgery centers by the department under ch. 153, 2001 stats., and the rules promulgated under ch. 153, 2001 stats., including, by the date that is 18 months after the date of the contract under sub. (2m) (a), all outpatient hospital-based services. The entity shall analyze and disseminate that health care information, as adjusted for case mix and severity, in the manner required under this chapter, under ch. 153, 2001 stats., and under the rules promulgated under ch. 153, 2001 stats., and in language that is understandable to laypersons.

SB44-SSA1, s. 2092f Section 2092f. 153.05 (2m) of the statutes is created to read:

SB44-SSA1,821,11 153.05 (2m) (a) Notwithstanding s. 16.75 (1), (2), and (3m), by the date that is the first day of the 2nd month after the effective date of this paragraph .... [revisor inserts date], the department of administration shall, from the appropriation under s. 20.505 (1) (im), contract with an entity to perform services under this chapter that are specified for the entity with respect to the collection, analysis, and dissemination of health care information of hospitals and ambulatory surgery centers. The department of administration may not, by this contract, require from the entity any collection, analysis, or dissemination of health care information of hospitals and ambulatory surgery centers that is in addition to that required under this chapter, and may include in the contract only terms standard to contracts with the department of administration under subch. IV of ch. 16.

SB44-SSA1,821,21 (b) Biennially, the group specified under s. 153.01 (4j) (b) shall review the entity's performance, including the timeliness and quality of the reports generated by the entity. If the group is dissatisfied with the entity's performance, the group may recommend to the department of administration that that department use a competitive request-for-proposal process to solicit offers from other organizations for performance of the services. If no organization responds to the request for proposal, the department of health and family services shall perform the services specified for the entity with respect to the collection, analysis, and dissemination of health care information of hospitals and ambulatory surgery centers under this chapter.

SB44-SSA1,822,2 (c) By April 1, 2004, and annually thereafter, the secretary of health and family services, as chairperson of the group specified under s. 153.01 (4j) (b), shall submit to the chief clerk of each house of the legislature for distribution to the legislature under s. 13.172 (2), a report concerning the content and number of reports and currency of information and reports generated in the previous calendar year by the entity under contract under s. 153.05 (2m).

SB44-SSA1, s. 2092g Section 2092g. 153.05 (3) of the statutes is renumbered 153.05 (3) (a) and amended to read:

SB44-SSA1,822,8 153.05 (3) (a) Upon request of the department for health care information relating to health care providers other than hospitals and ambulatory surgery centers, state agencies shall provide that health care information to the department for use in preparing reports under this chapter.

SB44-SSA1, s. 2092h Section 2092h. 153.05 (3) (b) of the statutes is created to read:

SB44-SSA1,822,13 153.05 (3) (b) Upon request of the entity under contract under sub. (2m) (a) for health care information relating to hospitals and ambulatory surgery centers, state agencies shall provide that health care information to the entity for use in preparing reports under this chapter.

SB44-SSA1, s. 2092i Section 2092i. 153.05 (5) of the statutes is renumbered 153.05 (5) (a) and amended to read:

SB44-SSA1,822,20 153.05 (5) (a) Unless sub. (13) (a) applies, the department may require health care providers other than hospitals and ambulatory surgery centers to submit to the department information specified by rule under s. 153.75 (1) (n) for the preparation of reports, plans, and recommendations in the form specified by the department by rule.

SB44-SSA1, s. 2092j Section 2092j. 153.05 (5) (b) of the statutes is created to read:

SB44-SSA1,822,25 153.05 (5) (b) Unless sub. (13) (b) applies, the entity under contract under sub. (2m) (a) may require hospitals and ambulatory surgery centers to submit to the entity information for the preparation of reports, plans, and recommendations in the form specified by the entity.

SB44-SSA1, s. 2092k Section 2092k. 153.05 (6) of the statutes is amended to read:

SB44-SSA1,823,5 153.05 (6) The department may contract with a public or private entity organization that is not a major purchaser, payer or provider of health care services in this state for the provision of data processing services for the collection, analysis and dissemination of health care information under sub. (1) (a).

SB44-SSA1, s. 2092L Section 2092L. 153.05 (6r) of the statutes is amended to read:

SB44-SSA1,823,19 153.05 (6r) The department shall study and, based on the results of the study, may develop and implement a voluntary system of health care plan reporting that enables purchasers and consumers to assess the performance of health care plans and the health care providers, other than hospitals and ambulatory surgery centers, that are employed or reimbursed by the health care plans. The department shall undertake the study and any development and implementation in cooperation with private health care purchasers, the board, the department of employee trust funds, the office of the commissioner of insurance, the interagency coordinating council created under s. 15.107 (7), major associations of health care providers, health care plans and consumers. If implemented, the department shall operate the system in a manner so as to enable purchasers, consumers, the public, the governor and legislators to assess the performance of health care plans and health care providers other than hospitals and ambulatory surgery centers.

SB44-SSA1, s. 2093bg Section 2093bg. 153.05 (8) of the statutes is renumbered 153.05 (8) (a) and amended to read:

SB44-SSA1,824,9 153.05 (8) (a) Unless sub. (13) (a) applies, the department shall collect, analyze and disseminate, in language that is understandable to lay persons laypersons, claims information and other health care information, as adjusted for case mix and severity, under the provisions of this chapter, as determined by rules promulgated by the department, from health care providers, other than hospitals and ambulatory surgery centers, specified by rules promulgated by the department. Data from those health care providers may be obtained through sampling techniques in lieu of collection of data on all patient encounters and data collection procedures shall minimize unnecessary duplication and administrative burdens. If the department collects health care provider-specific data from health care plans data that is specific to health care providers other than hospitals and ambulatory surgery centers, the department shall attempt to avoid collecting the same data from those health care providers.

SB44-SSA1, s. 2093bh Section 2093bh. 153.05 (8) (b) of the statutes is created to read:

SB44-SSA1,824,18 153.05 (8) (b) Unless sub. (13) (b) applies, the entity under contract under sub. (2m) (a) shall collect, analyze, and disseminate, in language that is understandable to laypersons, claims information and other health care information, as adjusted for case mix and severity, under the provisions of this chapter, from hospitals and ambulatory surgery centers. Data from hospitals and ambulatory surgery centers may be obtained through sampling techniques in lieu of collection of data on all patient encounters, and data collection procedures shall minimize unnecessary duplication and administrative burdens.

SB44-SSA1, s. 2093c Section 2093c. 153.05 (9) of the statutes is renumbered 153.05 (9) (a) and amended to read:

SB44-SSA1,824,24 153.05 (9) (a) The department shall provide orientation and training to health care providers, other than hospitals and ambulatory surgery centers, who submit data under this chapter, to explain the process of data collection and analysis and the procedures for data verification, comment, interpretation, and release.

SB44-SSA1, s. 2093d Section 2093d. 153.05 (9) (b) of the statutes is created to read: