SB451-SSA2,39,126
149.14
(3) (e)
Services For persons eligible for Medicare, services of a licensed
7skilled nursing facility
for eligible persons eligible for medicare, to the extent
8required by s. 632.895 (3) and for not more than an aggregate 120 days during a
9calendar year, if the services are of the type
which
that would qualify as reimbursable
10services under
medicare Medicare. Coverage under this paragraph
which that is not
11required by s. 632.895 (3) is subject to
the any deductible and coinsurance
12requirements
under sub. (5) provided by the authority.
SB451-SSA2,39,1514
149.14
(3) (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only
15to the extent required under s. 632.895 (2).
SB451-SSA2,39,1917
149.14
(3) (m) Oral surgery for
excision of partially or completely unerupted,
18impacted teeth and oral surgery with respect to
the gums and other tissues of the
19mouth when not performed in connection with the extraction or repair of teeth.
SB451-SSA2,39,2321
149.14
(3) (o)
Transportation Emergency and other medically necessary
22transportation provided by a licensed ambulance service to the nearest facility
23qualified to treat
the a covered condition.
SB451-SSA2, s. 106
24Section
106. 149.14 (3) (p) of the statutes is renumbered 149.14 (3) (em).
SB451-SSA2, s. 107
1Section
107. 149.14 (4) of the statutes, as affected by 2005 Wisconsin Act ....
2(this act), is repealed and recreated to read:
SB451-SSA2,40,113
149.14
(4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority
4shall establish the plan design, after taking into consideration the levels of health
5insurance coverage provided in the state and medical economic factors, as
6appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit
7levels, deductibles, copayment and coinsurance requirements, exclusions, and
8limitations under the plan that the authority determines generally reflect and are
9commensurate with comprehensive health insurance coverage offered in the private
10individual market in the state. The authority may develop additional benefit designs
11that are responsive to market conditions.
SB451-SSA2,40,1613
149.14
(4) (d) That part of any charge for services or articles rendered or
14prescribed by a physician, dentist
, or other health care personnel that exceeds the
15payment rate established by the
department authority under s. 149.142
and reduced
16under ss. 149.143 and 149.144 or any charge not medically necessary.
SB451-SSA2,40,1918
149.14
(4) (m) Experimental treatment, as determined by the
department 19authority.
SB451-SSA2, s. 111
21Section
111. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and
22amended to read:
SB451-SSA2,41,323
149.142
(2m) Payment is payment in full. Except for copayments, coinsurance
, 24or deductibles required or authorized under the plan, a provider of a covered service
25or article shall accept as payment in full for the covered service or article the payment
1rate determined under
ss. 149.142, 149.143 and 149.144 sub. (1) and may not bill an
2eligible person who receives the service or article for any amount by which the charge
3for the service or article is reduced under
s. 149.142, 149.143 or 149.144 sub. (1).
SB451-SSA2, s. 112
4Section
112. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act ....
5(this act), is repealed and recreated to read:
SB451-SSA2,41,86
149.14
(5) Deductible and copayment subsidies. (a) The authority shall
7establish and provide subsidies for deductibles paid by eligible persons with coverage
8under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.
SB451-SSA2,41,109
(b) The authority may provide subsidies for prescription drug copayment
10amounts paid by eligible persons specified in par. (a).
SB451-SSA2,41,1512
149.14
(5) (b) Except as provided in
pars. (c) and (e) par. (c), if the covered costs
13incurred by the eligible person exceed the deductible for major medical expense
14coverage in a calendar year, the plan shall pay at least 80% of any additional covered
15costs incurred by the person during the calendar year.
SB451-SSA2,41,2217
149.14
(5) (c)
Except as provided in par. (e), if If the aggregate of the covered
18costs not paid by the plan under par. (b) and the deductible exceeds $500 for an
19eligible person receiving medicare, $2,000 for any other eligible person during a
20calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100%
21of all covered costs incurred by the eligible person during the calendar year after the
22payment ceilings under this paragraph are exceeded.
SB451-SSA2,42,74
149.14
(7) (b) The
department authority has a cause of action against an
5eligible participant for the recovery of the amount of benefits paid
which that are not
6for covered expenses under the plan. Benefits under the plan may be reduced or
7refused as a setoff against any amount recoverable under this paragraph.
SB451-SSA2,42,129
149.14
(7) (c) The
department authority is subrogated to the rights of an
10eligible person to recover special damages for illness or injury to the person caused
11by the act of a 3rd person to the extent that benefits are provided under the plan.
12Section 814.03 (3) applies to the department under this paragraph.
SB451-SSA2,42,17
15149.141 Premiums. (1)
Percentage of costs. Except as provided in sub. (2),
16the authority shall set premium rates for coverage under the plan at a level that is
17sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).
SB451-SSA2,42,19
18(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
19applicable to individual standard risks.
SB451-SSA2, s. 124
20Section
124. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
21amended to read:
SB451-SSA2,43,722
149.142
(1) Establishment of rates.
Except as provided in par. (b), the
23department The authority shall establish
provider payment rates for covered
24expenses that consist of the allowable charges paid under s. 49.46 (2) for the services
25and articles provided plus an enhancement determined by the
department authority.
1The rates shall be based on the allowable charges paid under s. 49.46 (2), projected
2plan costs
, and trend factors. Using the same methodology that applies to medical
3assistance under subch. IV of ch. 49, the
department
authority shall establish
4hospital outpatient per visit reimbursement rates and hospital inpatient
5reimbursement rates that are specific to diagnostically related groups of eligible
6persons.
The adjustments to the usual and customary rates shall be sufficient to
7cover the portion of plan costs specified in s. 149.143 (1) (c) and (2) (b).
SB451-SSA2, s. 127
10Section
127. 149.143 of the statutes is repealed and recreated to read:
SB451-SSA2,43,16
11149.143 Payment of plan costs. (1) Costs excluding subsidies. The
12authority shall pay plan costs, excluding any premium, deductible, and copayment
13subsidies, first from federal funds, if any, that are transferred to the fund under s.
1420.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in
15a policy year. The remainder of the plan costs, excluding premium, deductible, and
16copayment subsidy costs, shall be paid as follows:
SB451-SSA2,43,1717
(a) Sixty percent from premiums paid by eligible persons.
SB451-SSA2,43,1818
(b) Twenty percent from insurer assessments under s. 149.13.
SB451-SSA2,43,2019
(c) Twenty percent from adjustments to provider payment rates under s.
20149.142.
SB451-SSA2,43,24
21(2) Subsidy costs. The authority shall pay for premium, deductible, and
22copayment subsidies in a policy year first from federal funds, if any, that are
23transferred to the fund under s. 20.145 (5) (m) in that year. The remainder of the
24subsidy costs shall be paid as follows:
SB451-SSA2,43,2525
(a) Fifty percent from insurer assessments under s. 149.13.
SB451-SSA2,44,1
1(b) Fifty percent from adjustments to provider payment rates under s. 149.142.
SB451-SSA2, s. 130
4Section
130. 149.146 (1) (a) and (b) of the statutes are consolidated,
5renumbered 149.14 (2) (c) 1. and amended to read:
SB451-SSA2,44,206
149.14
(2) (c) 1.
Beginning on January 1, 1998, in In addition to the coverage
7required under
s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons
8who are not eligible for
medicare Medicare a choice of coverage, as described in
9section 2744 (a) (1) (
C), P.L.
104-191. Any such choice of coverage shall be major
10medical expense coverage.
(b) An eligible person
under par. (a) who is not eligible
11for Medicare may elect once each year, at the time and according to procedures
12established by the
department authority, among the coverages offered under this
13section and s. 149.14 paragraph and par. (a). If an eligible person elects new
14coverage, any preexisting condition exclusion imposed under the new coverage is met
15to the extent that the eligible person has been previously and continuously covered
16under
this chapter the plan. No preexisting condition exclusion may be imposed on
17an eligible person who elects new coverage if the person was an eligible individual
18when first covered under
this chapter the plan and the person remained
19continuously covered under
this chapter the plan up to the time of electing the new
20coverage.
SB451-SSA2, s. 131
21Section
131. 149.146 (2) (a) of the statutes is renumbered 149.14 (2) (c) 2. and
22amended to read:
SB451-SSA2,45,323
149.14
(2) (c) 2.
Except as specified by the department, the terms of coverage
24under s. 149.14, including deductible reductions under s. 149.14 (5) (a) and
25prescription drug copayment reductions under s. 149.14 (5) (e), do not apply to the
1coverage offered under this section. Premium reductions under s. 149.165
and
2deductible subsidies and prescription drug copayment subsidies under s. 149.14 (5) 3do not apply to the coverage offered under this
section paragraph.
SB451-SSA2,45,129
149.165
(1) Except as provided in s. 149.146 (2) (a), the department The
10authority shall reduce the premiums established under
s. 149.11 in conformity with
11ss. 149.14 (5m), 149.143 and 149.17 s. 149.141 for the eligible persons and in the
12manner set forth in subs. (2) and (3).
SB451-SSA2, s. 137
13Section
137. 149.165 (2) (a) (intro.) of the statutes is amended to read:
SB451-SSA2,45,1814
149.165
(2) (a) (intro.) Subject to sub. (3m), if the household income, as defined
15in s. 71.52 (5) and as determined under sub. (3), of an eligible person with coverage
16under s. 149.14 (2) (a) is equal to or greater than the first amount and less than the
172nd amount listed in any of the following, the
department authority shall reduce the
18premium for the eligible person to the rate shown after the amounts:
SB451-SSA2,46,320
149.165
(2) (bc) Subject to sub. (3m), if the household income, as defined in s.
2171.52 (5) and as determined under sub. (3), of an eligible person with coverage under
22s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd
23amount listed in par. (a) 1., 2., 3., 4.
, or 5., the
department authority shall reduce the
24premium established for the eligible person by the same percentage as the
25department authority reduces, under par. (a), the premium established for an
1eligible person with coverage under s. 149.14 (2) (a) who has a household income
2specified in the same subdivision under par. (a) as the household income of the
3eligible person with coverage under s. 149.14 (2) (b).
SB451-SSA2,46,75
149.165
(3) (a) Subject to par. (b), the
department authority shall establish and
6implement the method for determining the household income of an eligible person
7under sub. (2).
SB451-SSA2, s. 140
8Section
140. 149.165 (3) (b) (intro.) of the statutes is amended to read:
SB451-SSA2,46,129
149.165
(3) (b) (intro.) In determining household income under sub. (2), the
10department authority shall consider information submitted by an eligible person on
11a completed federal profit or loss from farming form, schedule F, if all of the following
12apply:
SB451-SSA2,46,1714
149.165
(3m) The
board authority may approve adjustment of the household
15income dollar amounts listed in sub. (2) (a) 1. to 5., except for the first dollar amount
16listed in sub. (2) (a) 1., to reflect changes in the consumer price index for all urban
17consumers, U.S. city average, as determined by the U.S. department of labor.
SB451-SSA2,46,2120
149.17
(1) Subject to
ss. 149.14 (5m),
s. 149.143
and 149.146 (2) (b), a rating
21plan calculated in accordance with generally accepted actuarial principles.
SB451-SSA2,47,3
1149.18 Chapters 600 to 645 applicable. Except as otherwise provided in this
2chapter subchapter, the plan shall comply and be administered in compliance with
3chs. 600 to 645.
SB451-SSA2, s. 150
6Section
150. Subchapter III of chapter 149 [precedes 149.40] of the statutes
7is created to read:
SB451-SSA2,47,119
Subchapter III
10
Health Insurance Risk-Sharing
11
Plan Authority
SB451-SSA2,47,12
12149.40 Definitions. In this subchapter:
SB451-SSA2,47,13
13(1) "Authority" means the Health Insurance Risk-Sharing Plan Authority.
SB451-SSA2,47,14
14(2) "Board" means the board of directors of the authority.
SB451-SSA2,47,20
15149.41 Creation and organization of authority. (1) There is created a
16public body corporate and politic to be known as the "Health Insurance Risk-Sharing
17Plan Authority." The board of directors of the authority shall consist of the
18commissioner of insurance, or his or her designee, as a nonvoting member, and the
19following members, who shall be nominated by the governor, and with the advice and
20consent of the senate appointed, for 3-year terms:
SB451-SSA2,47,2121
(a) Four members who represent insurers participating in the plan.
