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, s. 85 13Section 85. 149.12 (2) (g) of the statutes is created to read:
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, s. 86 3Section 86. 149.12 (3) (a) of the statutes is amended to read:
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AB844-ASA1, s. 87 10Section 87. 149.12 (3) (c) of the statutes is repealed.
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, s. 89 20Section 89. 149.13 (1) of the statutes is amended to read:
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, s. 90
1Section 90. 149.13 (3) (a) of the statutes is amended to read:
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, s. 91 7Section 91. 149.13 (3) (b) of the statutes is amended to read:
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, s. 92 15Section 92. 149.13 (4) of the statutes is amended to read:
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, s. 93 20Section 93. 149.14 (1) (a) of the statutes is amended to read:
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, s. 94 3Section 94. 149.14 (2) (a) of the statutes is amended to read:
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. 98 9Section 98. 149.14 (3) (c) 2. of the statutes is repealed.
AB844-ASA1, s. 99 10Section 99 . 149.14 (3) (c) 3. of the statutes is amended to read:
AB844-ASA1,38,1411 149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated
12by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats.,
13services for the chronically mentally ill in community support programs operated
14under s. 51.421.
AB844-ASA1, s. 100 15Section 100 . 149.14 (3) (c) 3. of the statutes, as affected by 2005 Wisconsin Act
16.... (this act), is amended to read:
AB844-ASA1,38,2017 149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated
18by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats.

191., services for the chronically mentally ill in community support programs operated
20under s. 51.421.
AB844-ASA1, s. 101 21Section 101. 149.14 (3) (d) of the statutes is amended to read:
AB844-ASA1,38,2222 149.14 (3) (d) Drugs requiring a physician's prescription, subject to sub. (4c).
AB844-ASA1, s. 102 23Section 102. 149.14 (3) (e) of the statutes is amended to read:
AB844-ASA1,39,524 149.14 (3) (e) Services For persons eligible for Medicare, services of a licensed
25skilled nursing facility for eligible persons eligible for medicare, to the extent

1required by s. 632.895 (3) and for not more than an aggregate 120 days during a
2calendar year, if the services are of the type which that would qualify as reimbursable
3services under medicare Medicare. Coverage under this paragraph which that is not
4required by s. 632.895 (3) is subject to the any deductible and coinsurance
5requirements under sub. (5) provided by the authority.
AB844-ASA1, s. 103 6Section 103. 149.14 (3) (f) of the statutes is created to read:
AB844-ASA1,39,87 149.14 (3) (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only
8to the extent required under s. 632.895 (2).
AB844-ASA1, s. 104 9Section 104. 149.14 (3) (m) of the statutes is amended to read:
AB844-ASA1,39,1210 149.14 (3) (m) Oral surgery for excision of partially or completely unerupted,
11impacted teeth and oral surgery with respect to the gums and other tissues of the
12mouth when not performed in connection with the extraction or repair of teeth.
AB844-ASA1, s. 105 13Section 105. 149.14 (3) (o) of the statutes is amended to read:
AB844-ASA1,39,1614 149.14 (3) (o) Transportation Emergency and other medically necessary
15transportation
provided by a licensed ambulance service to the nearest facility
16qualified to treat the a covered condition.
AB844-ASA1, s. 106 17Section 106. 149.14 (3) (p) of the statutes is renumbered 149.14 (3) (em).
AB844-ASA1, s. 107 18Section 107. 149.14 (4) of the statutes, as affected by 2005 Wisconsin Act ....
19(this act), is repealed and recreated to read:
AB844-ASA1,40,320 149.14 (4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority
21shall establish the plan design, after taking into consideration the levels of health
22insurance coverage provided in the state and medical economic factors, as
23appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit
24levels, deductibles, copayment and coinsurance requirements, exclusions, and
25limitations under the plan that the authority determines generally reflect and are

1commensurate with comprehensive health insurance coverage offered in the private
2individual market in the state. The authority may develop additional benefit designs
3that are responsive to market conditions.
AB844-ASA1, s. 108 4Section 108. 149.14 (4) (d) of the statutes is amended to read:
AB844-ASA1,40,85 149.14 (4) (d) That part of any charge for services or articles rendered or
6prescribed by a physician, dentist, or other health care personnel that exceeds the
7payment rate established by the department authority under s. 149.142 and reduced
8under ss. 149.143 and 149.144
or any charge not medically necessary.
AB844-ASA1, s. 109 9Section 109. 149.14 (4) (m) of the statutes is amended to read:
AB844-ASA1,40,1110 149.14 (4) (m) Experimental treatment, as determined by the department
11authority.
AB844-ASA1, s. 110 12Section 110. 149.14 (4c) of the statutes is repealed.
AB844-ASA1, s. 111 13Section 111. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and
14amended to read:
AB844-ASA1,40,2015 149.142 (2m) Payment is payment in full. Except for copayments, coinsurance,
16or deductibles required or authorized under the plan, a provider of a covered service
17or article shall accept as payment in full for the covered service or article the payment
18rate determined under ss. 149.142, 149.143 and 149.144 sub. (1) and may not bill an
19eligible person who receives the service or article for any amount by which the charge
20for the service or article is reduced under s. 149.142, 149.143 or 149.144 sub. (1).
AB844-ASA1, s. 112 21Section 112. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act ....
22(this act), is repealed and recreated to read:
AB844-ASA1,40,2523 149.14 (5) Deductible and copayment subsidies. (a) The authority shall
24establish and provide subsidies for deductibles paid by eligible persons with coverage
25under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.
AB844-ASA1,41,2
1(b) The authority may provide subsidies for prescription drug copayment
2amounts paid by eligible persons specified in par. (a).
AB844-ASA1, s. 113 3Section 113. 149.14 (5) (b) of the statutes is amended to read:
AB844-ASA1,41,74 149.14 (5) (b) Except as provided in pars. (c) and (e) par. (c), if the covered costs
5incurred by the eligible person exceed the deductible for major medical expense
6coverage in a calendar year, the plan shall pay at least 80% of any additional covered
7costs incurred by the person during the calendar year.
AB844-ASA1, s. 114 8Section 114. 149.14 (5) (c) of the statutes is amended to read:
AB844-ASA1,41,149 149.14 (5) (c) Except as provided in par. (e), if If the aggregate of the covered
10costs not paid by the plan under par. (b) and the deductible exceeds $500 for an
11eligible person receiving medicare, $2,000 for any other eligible person during a
12calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100%
13of all covered costs incurred by the eligible person during the calendar year after the
14payment ceilings under this paragraph are exceeded.
AB844-ASA1, s. 115 15Section 115. 149.14 (5) (d) of the statutes is repealed.
AB844-ASA1, s. 116 16Section 116. 149.14 (5) (e) of the statutes is repealed.
AB844-ASA1, s. 117 17Section 117. 149.14 (5m) of the statutes is repealed.
AB844-ASA1, s. 118 18Section 118. 149.14 (6) (a) of the statutes is repealed.
AB844-ASA1, s. 119 19Section 119. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).
AB844-ASA1, s. 120 20Section 120. 149.14 (7) (b) of the statutes is amended to read:
AB844-ASA1,41,2421 149.14 (7) (b) The department authority has a cause of action against an
22eligible participant for the recovery of the amount of benefits paid which that are not
23for covered expenses under the plan. Benefits under the plan may be reduced or
24refused as a setoff against any amount recoverable under this paragraph.
AB844-ASA1, s. 121 25Section 121. 149.14 (7) (c) of the statutes is amended to read:
AB844-ASA1,42,4
1149.14 (7) (c) The department authority is subrogated to the rights of an
2eligible person to recover special damages for illness or injury to the person caused
3by the act of a 3rd person to the extent that benefits are provided under the plan.
4Section 814.03 (3) applies to the department under this paragraph.
AB844-ASA1, s. 122 5Section 122. 149.14 (8) of the statutes is repealed.
AB844-ASA1, s. 123 6Section 123. 149.141 of the statutes is created to read:
AB844-ASA1,42,9 7149.141 Premiums. (1) Percentage of costs. Except as provided in sub. (2),
8the authority shall set premium rates for coverage under the plan at a level that is
9sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).
AB844-ASA1,42,11 10(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
11applicable to individual standard risks.
AB844-ASA1, s. 124 12Section 124. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
13amended to read:
AB844-ASA1,42,2414 149.142 (1) Establishment of rates. Except as provided in par. (b), the
15department
The authority shall establish provider payment rates for covered
16expenses that consist of the allowable charges paid under s. 49.46 (2) for the services
17and articles provided plus an enhancement determined by the department authority.
18The rates shall be based on the allowable charges paid under s. 49.46 (2), projected
19plan costs, and trend factors. Using the same methodology that applies to medical
20assistance under subch. IV of ch. 49, the department authority shall establish
21hospital outpatient per visit reimbursement rates and hospital inpatient
22reimbursement rates that are specific to diagnostically related groups of eligible
23persons. The adjustments to the usual and customary rates shall be sufficient to
24cover 20 percent of plan costs, as provided in s. 149.143 (3).
AB844-ASA1, s. 125 25Section 125. 149.142 (1) (b) of the statutes is repealed.
AB844-ASA1, s. 126
1Section 126. 149.142 (2) of the statutes is repealed.
AB844-ASA1, s. 127 2Section 127. 149.143 of the statutes is repealed and recreated to read:
AB844-ASA1,43,8 3149.143 Payment of plan costs. (1) Costs excluding subsidies. The
4authority shall pay plan costs, excluding any premium, deductible, and copayment
5subsidies, first from federal funds, if any, that are transferred to the fund under s.
620.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in
7a policy year. The remainder of the plan costs, excluding premium, deductible, and
8copayment subsidy costs, shall be paid as follows:
AB844-ASA1,43,99 (a) Sixty percent from premiums paid by eligible persons.
AB844-ASA1,43,1010 (b) Twenty percent from insurer assessments under s. 149.13.
AB844-ASA1,43,1211 (c) Twenty percent from adjustments to provider payment rates under s.
12149.142.
AB844-ASA1,43,16 13(2) Subsidy costs. The authority shall pay for premium, deductible, and
14copayment subsidies in a policy year first from federal funds, if any, that are
15transferred to the fund under s. 20.145 (5) (m) in that year. The remainder of the
16subsidy costs shall be paid as follows:
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