AB844-ASA1,29,1918
subchapter I
19
General provisions
AB844-ASA1,29,22
21149.10 Definitions. (intro.) In this chapter
, unless the context requires
22otherwise:
AB844-ASA1,29,2524
149.10
(1) "Authority" means the Health Insurance Risk-Sharing Plan
25Authority.
AB844-ASA1,30,32
149.10
(2) "Board" means the board of
governors established under s. 149.15 3directors of the authority.
AB844-ASA1, s. 67
4Section
67. 149.10 (2j) (a) 3. of the statutes is amended to read:
AB844-ASA1,30,65
149.10
(2j) (a) 3. Part A
or, part B
, or part D of title XVIII of the federal Social
6Security Act.
AB844-ASA1,30,129
149.10
(2t) (c) The individual does not have creditable coverage and is not
10eligible for coverage under a group health plan, part A
or
, part B
, or part D of title
11XVIII of the federal Social Security Act or a state plan under title XIX of the federal
12Social Security Act or any successor program.
AB844-ASA1,30,1614
149.10
(3) "Eligible person" means a resident
of this state who qualifies under
15s. 149.12 whether or not the person is legally responsible for the payment of medical
16expenses incurred on the person's behalf.
AB844-ASA1,30,1918
149.10
(3e) "Fund" means the
health insurance risk-sharing plan Health
19Insurance Risk-Sharing Plan fund
under s. 149.11 (2).
AB844-ASA1,30,2221
149.10
(7) "Medicare" means coverage under
both part A
and, part B
, and part
22D of Title XVIII of the federal social security act,
42 USC 1395 et seq., as amended.
AB844-ASA1,30,2524
149.10
(8) "Plan" means the health care insurance plan established and
25administered under
subchapter II of this chapter.
AB844-ASA1,31,122
149.10
(9) "Resident" means a person who has been legally domiciled in this
3state for a period of at least
30 days 3 months or, with respect to an eligible individual,
4an individual who resides in this state. For purposes of this chapter, legal domicile
5is established by living in this state and obtaining a Wisconsin motor vehicle
6operator's license, registering to vote in Wisconsin
, or filing a Wisconsin income tax
7return. A child is legally domiciled in this state if the child lives in this state and if
8at least one of the child's parents or the child's guardian is legally domiciled in this
9state. A person with a developmental disability or another disability
which that 10prevents the person from obtaining a Wisconsin motor vehicle operator's license,
11registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally
12domiciled in this state by living in this state.
AB844-ASA1,31,21
15149.105 Immunity. No cause of action of any nature may arise against, and
16no liability may be imposed upon, the authority, plan, or board; or any agent,
17employee, or director of any of them; or participating insurers; or the commissioner;
18or any of the commissioner's agents, employees, or representatives, for any act or
19omission by any of them in the performance of their powers and duties under this
20chapter, unless the person asserting liability proves that the act or omission
21constitutes willful misconduct.
AB844-ASA1, s. 77
22Section
77. Subchapter II (title) of chapter 149 [precedes 149.11] of the
23statutes is created to read:
AB844-ASA1,32,3
1subchapter II
2
Health insurance risk-sharing
3
plan provisions
AB844-ASA1, s. 78
4Section
78. 149.11 of the statutes is repealed and recreated to read:
AB844-ASA1,32,7
5149.11 Administration of plan. (1) Authority. The authority shall be
6responsible for the operation of the plan and, subject to ss. 149.143 (2) and 149.47,
7may enter into contracts for the plan's administration.
AB844-ASA1,32,10
8(2) Fund. (a) The authority shall pay the operating and administrative
9expenses of the plan from the fund, which shall be outside the state treasury and
10which shall consist of all of the following:
AB844-ASA1,32,1111
3. Federal moneys paid to the authority under s. 20.145 (5) (m).
AB844-ASA1,32,1312
4. The moneys transferred under 2005 Wisconsin Act .... (this act), section 166
13(1).
AB844-ASA1,32,1414
5. The earnings resulting from investments under par. (b).
AB844-ASA1,32,1515
6. Any other moneys received by the authority from time to time.
AB844-ASA1,32,1916
(b) The authority controls the assets of the fund and shall select regulated
17financial institutions in this state that receive deposits in which to establish and
18maintain accounts for assets needed on a current basis. If practicable, the accounts
19shall earn interest.
AB844-ASA1,32,2120
(c) Moneys in the fund may be expended only for the purposes specified in par.
21(a).
AB844-ASA1,33,2
23149.115 Rules relating to creditable coverage. The commissioner
, in
24consultation with the department, shall promulgate rules that specify how
25creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that
1determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The
2rules shall comply with section 2701 (c) of P.L.
104-191.
AB844-ASA1, s. 80
3Section
80. 149.12 (1) (intro.) of the statutes is amended to read:
AB844-ASA1,33,114
149.12
(1) (intro.) Except as provided in subs. (1m)
and, (2)
, and (3), the
board 5or plan administrator authority shall certify as eligible a person who is covered by
6medicare Medicare because he or she is disabled under
42 USC 423, a person who
7submits evidence that he or she has tested positive for the presence of HIV, antigen
8or nonantigenic products of HIV
, or an antibody to HIV, a person who is an eligible
9individual, and any person who receives and submits any of the following based
10wholly or partially on medical underwriting considerations within 9 months prior to
11making application for coverage by the plan:
AB844-ASA1,33,1313
149.12
(1) (a) A notice of rejection of coverage from
one 2 or more insurers.
AB844-ASA1,33,1815
149.12
(1m) The
board or plan administrator authority may not certify a
16person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the
17required notices were issued by an insurance intermediary who is not acting as an
18administrator, as defined in s. 633.01.
AB844-ASA1, s. 83
19Section
83. 149.12 (2) (f) of the statutes is renumbered 149.12 (2) (f) 1. and
20amended to read:
AB844-ASA1,33,2221
149.12
(2) (f) 1.
No Except as provided in subd. 2., no person who is eligible for
22medical assistance is eligible for coverage under the plan.
AB844-ASA1, s. 84
23Section
84. 149.12 (2) (f) 2. of the statutes is created to read:
AB844-ASA1,34,3
1149.12
(2) (f) 2. Subdivision 1. does not apply to a person who is otherwise
2eligible for coverage under the plan and who is eligible for only any of the following
3types of medical assistance:
AB844-ASA1,34,44
a. Family planning services under s. 49.45 (24r).
AB844-ASA1,34,65
b. Care and services for the treatment of an emergency medical condition under
642 USC 1396b (v), as provided in s. 49.45 (27).
AB844-ASA1,34,77
c. Medical assistance under s. 49.46 (1) (a) 15.
AB844-ASA1,34,88
d. Ambulatory prenatal care under s. 49.465.
AB844-ASA1,34,109
e. Medicare premium, coinsurance, and deductible payments under s. 49.46 (2)
10(c) 2. or 3., 49.468 (1) (b) or (c), or 49.47 (6) (a) 6. b. or c.
AB844-ASA1,34,1211
f. Medicare premium payments under s. 49.46 (2) (cm), 49.468 (1m) or (2), or
1249.47 (6) (a) 6m.
AB844-ASA1,34,1514
149.12
(2) (g) A person is not eligible for coverage under the plan if the person
15is eligible for any of the following:
AB844-ASA1,34,1616
1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.
AB844-ASA1,34,1817
2. Medical assistance provided as part of a family care benefit, as defined in s.
1846.2805 (4).
AB844-ASA1,34,20193. Services provided under a waiver requested under
2001 Wisconsin Act 16,
20section
9123 (16rs), or
2003 Wisconsin Act 33, section
9124 (8c).
AB844-ASA1,34,2221
4. Services provided under the program of all-inclusive care for persons aged
2255 or older authorized under
42 USC 1396u-4.
AB844-ASA1,34,2423
5. Services provided under the demonstration program under a federal waiver
24authorized under
42 USC 1315.
AB844-ASA1,35,2
16. Health care coverage under the Badger Care health care program under s.
249.665.
AB844-ASA1,35,94
149.12
(3) (a) Except as provided in pars. (b)
to (c) and (bm), no person is eligible
5for coverage under the plan for whom a premium, deductible
, or coinsurance amount
6is paid or reimbursed by a federal, state, county
, or municipal government or agency
7as of the first day of any term for which a premium amount is paid or reimbursed and
8as of the day after the last day of any term during which a deductible or coinsurance
9amount is paid or reimbursed.
AB844-ASA1, s. 88
11Section
88. 149.12 (4) and (5) of the statutes are created to read:
AB844-ASA1,35,1712
149.12
(4) Subject to subs. (1m), (2), and (3), the authority may establish
13criteria that would enable additional persons to be eligible for coverage under the
14plan. The authority shall ensure that any expansion of eligibility is consistent with
15the purpose of the plan to provide health care coverage for those who are unable to
16obtain health insurance in the private market and does not endanger the solvency
17of the plan.
AB844-ASA1,35,19
18(5) The authority shall establish policies for determining and verifying the
19continued eligibility of an eligible person.
AB844-ASA1,35,2521
149.13
(1) Every insurer shall participate in the cost of administering the plan,
22except the commissioner may by rule exempt as a class those insurers whose share
23as determined under sub. (2) would be so minimal as to not exceed the estimated cost
24of levying the assessment. The commissioner shall advise the
department authority 25of the insurers participating in the cost of administering the plan.
AB844-ASA1,36,62
149.13
(3) (a) Each insurer's proportion of participation under sub. (2) shall be
3determined annually by the commissioner based on annual statements and other
4reports filed by the insurer with the commissioner. The commissioner shall assess
5an insurer for the insurer's proportion of participation based on the total
6assessments estimated by the
department under s. 149.143 (2) (a) 3. authority.
AB844-ASA1,36,148
149.13
(3) (b) If the
department
authority or the commissioner finds that the
9commissioner's authority to require insurers to report under chs. 600 to 646 and 655
10is not adequate to permit
the department, the commissioner or the
board authority 11to carry out the
department's, commissioner's or
board's authority's responsibilities
12under this
chapter subchapter, the commissioner shall promulgate rules requiring
13insurers to report the information necessary for the
department, commissioner and
14board authority to make the determinations required under this
chapter subchapter.
AB844-ASA1,36,1916
149.13
(4) Notwithstanding subs. (1) to (3), the
department authority, with the
17agreement of the commissioner, may perform various administrative functions
18related to the assessment of insurers participating in the cost of administering the
19plan.
AB844-ASA1,37,221
149.14
(1) (a) The plan shall offer
coverage for each eligible person in an
22annually renewable policy
the coverage specified in this section for each eligible
23person. If an eligible person is also eligible for
medicare Medicare coverage, the plan
24shall not pay or reimburse any person for expenses paid for by
medicare Medicare.
25If an eligible person is eligible for a type of medical assistance specified in s. 149.12
1(2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by
2Medical Assistance.
AB844-ASA1,37,104
149.14
(2) (a) The plan shall provide every eligible person who is not eligible
5for
medicare Medicare with major medical expense coverage. Major medical expense
6coverage offered under the plan under this section shall pay an eligible person's
7covered expenses, subject to
sub. (3) and deductible, copayment
, and coinsurance
8payments
authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered
9individual.
The maximum limit under this paragraph shall not be altered by the
10board, and no actuarially equivalent benefit may be substituted by the board.
AB844-ASA1, s. 95
11Section
95. 149.14 (3) (intro.) of the statutes is amended to read:
AB844-ASA1,37,2512
149.14
(3) Covered expenses. (intro.)
Except as provided in sub. (4), except
13as restricted by cost containment provisions under s. 149.17 (4) and except as
14reduced by the department under ss. 149.143 and 149.144, covered
Covered expenses
15for
the coverage under
this section
the plan shall be the payment rates established
16by the
department under s. 149.142 authority for
the services provided by persons
17licensed under ch. 446 and certified under s. 49.45 (2) (a) 11.
Except as provided in
18sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and
19except as reduced by the department under ss. 149.143 and 149.144, covered Covered 20expenses for
the coverage under
this section the plan shall also be the payment rates
21established by the
department under s. 149.142 authority for
, at a minimum, the
22following services and articles if the service or article is prescribed by a physician
23who is licensed under ch. 448 or in another state and who is certified under s. 49.45
24(2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45
25(2) (a) 11.:
AB844-ASA1, s. 96
1Section
96. 149.14 (3) (b) of the statutes is repealed and recreated to read:
AB844-ASA1,38,32
149.14
(3) (b) Professional services for the diagnosis or treatment of injuries,
3illnesses, or conditions, other than mental or dental.
AB844-ASA1, s. 97
4Section
97. 149.14 (3) (c) 1. of the statutes is repealed and recreated to read:
AB844-ASA1,38,85
149.14
(3) (c) 1. Inpatient hospital services, as defined in s. 632.89 (1) (d),
6outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment
7arrangements, as defined in s. 632.89 (1) (f), only to the extent required under s.
8632.89.
AB844-ASA1, s. 99
10Section
99
. 149.14 (3) (c) 3. of the statutes is amended to read:
