SB451-SSA2, s. 75 10Section 75. 149.105 of the statutes is created to read:
SB451-SSA2,31,17 11149.105 Immunity. No cause of action of any nature may arise against, and
12no liability may be imposed upon, the authority, plan, or board; or any agent,
13employee, or director of any of them; or participating insurers; or the commissioner;
14or any of the commissioner's agents, employees, or representatives, for any act or
15omission by any of them in the performance of their powers and duties under this
16chapter, unless the person asserting liability proves that the act or omission
17constitutes willful misconduct.
SB451-SSA2, s. 76 18Section 76. Subchapter II (title) of chapter 149 [precedes 149.11] of the
19statutes is created to read:
SB451-SSA2,31,2020 CHAPTER 149
SB451-SSA2,31,2321 subchapter II
22 Health insurance risk-sharing
23 plan provisions
SB451-SSA2, s. 77 24Section 77. 149.11 of the statutes is repealed and recreated to read:
SB451-SSA2,32,3
1149.11 Administration of plan. (1) Authority. The authority shall be
2responsible for the operation of the plan and, subject to ss. 149.43 (2) and 149.47, may
3enter into contracts for the plan's administration.
SB451-SSA2,32,6 4(2) Fund. (a) The authority shall pay the operating and administrative
5expenses of the plan from the fund, which shall be outside the state treasury and
6which shall consist of all of the following:
SB451-SSA2,32,77 3. Federal moneys paid to the authority under s. 20.145 (5) (m).
SB451-SSA2,32,98 4. The moneys transferred under 2005 Wisconsin Act .... (this act), section 166
9(1).
SB451-SSA2,32,1010 5. The earnings resulting from investments under par. (b).
SB451-SSA2,32,1111 6. Any other moneys received by the authority from time to time.
SB451-SSA2,32,1512 (b) The authority controls the assets of the fund and shall select regulated
13financial institutions in this state that receive deposits in which to establish and
14maintain accounts for assets needed on a current basis. If practicable, the accounts
15shall earn interest.
SB451-SSA2,32,1716 (c) Moneys in the fund may be expended only for the purposes specified in par.
17(a).
SB451-SSA2, s. 78 18Section 78. 149.115 of the statutes is amended to read:
SB451-SSA2,32,23 19149.115 Rules relating to creditable coverage. The commissioner, in
20consultation with the department,
shall promulgate rules that specify how
21creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that
22determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The
23rules shall comply with section 2701 (c) of P.L. 104-191.
SB451-SSA2, s. 79 24Section 79. 149.12 (1) (intro.) of the statutes is amended to read:
SB451-SSA2,33,8
1149.12 (1) (intro.) Except as provided in subs. (1m) and, (2), and (3), the board
2or plan administrator authority shall certify as eligible a person who is covered by
3medicare Medicare because he or she is disabled under 42 USC 423, a person who
4submits evidence that he or she has tested positive for the presence of HIV, antigen
5or nonantigenic products of HIV, or an antibody to HIV, a person who is an eligible
6individual, and any person who receives and submits any of the following based
7wholly or partially on medical underwriting considerations within 9 months prior to
8making application for coverage by the plan:
SB451-SSA2, s. 80 9Section 80. 149.12 (1) (a) of the statutes is amended to read:
SB451-SSA2,33,1010 149.12 (1) (a) A notice of rejection of coverage from one 2 or more insurers.
SB451-SSA2, s. 81 11Section 81. 149.12 (1m) of the statutes is amended to read:
SB451-SSA2,33,1512 149.12 (1m) The board or plan administrator authority may not certify a
13person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the
14required notices were issued by an insurance intermediary who is not acting as an
15administrator, as defined in s. 633.01.
SB451-SSA2, s. 82 16Section 82. 149.12 (2) (f) of the statutes is renumbered 149.12 (2) (f) 1. and
17amended to read:
SB451-SSA2,33,1918 149.12 (2) (f) 1. No Except as provided in subd. 2., no person who is eligible for
19medical assistance is eligible for coverage under the plan.
SB451-SSA2, s. 83 20Section 83. 149.12 (2) (f) 2. of the statutes is created to read:
SB451-SSA2,33,2321 149.12 (2) (f) 2. Subdivision 1. does not apply to a person who is otherwise
22eligible for coverage under the plan and who is eligible for only any of the following
23types of medical assistance:
SB451-SSA2,33,2424 a. Family planning services under s. 49.45 (24r).
SB451-SSA2,34,2
1b. Care and services for the treatment of an emergency medical condition under
242 USC 1396b (v), as provided in s. 49.45 (27).
SB451-SSA2,34,33 c. Medical assistance under s. 49.46 (1) (a) 15.
SB451-SSA2,34,44 d. Ambulatory prenatal care under s. 49.465.
SB451-SSA2,34,65 e. Medicare premium, coinsurance, and deductible payments under s. 49.46 (2)
6(c) 2. or 3., 49.468 (1) (b) or (c), or 49.47 (6) (a) 6. b. or c.
SB451-SSA2,34,87 f. Medicare premium payments under s. 49.46 (2) (cm), 49.468 (1m) or (2), or
849.47 (6) (a) 6m.
SB451-SSA2, s. 84 9Section 84. 149.12 (2) (g) of the statutes is created to read:
SB451-SSA2,34,1110 149.12 (2) (g) A person is not eligible for coverage under the plan if the person
11is eligible for any of the following:
SB451-SSA2,34,1212 1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.
SB451-SSA2,34,1413 2. Medical assistance provided as part of a family care benefit, as defined in s.
1446.2805 (4).
SB451-SSA2,34,16153. Services provided under a waiver requested under 2001 Wisconsin Act 16,
16section 9123 (16rs), or 2003 Wisconsin Act 33, section 9124 (8c).
SB451-SSA2,34,1817 4. Services provided under the program of all-inclusive care for persons aged
1855 or older authorized under 42 USC 1396u-4.
SB451-SSA2,34,2019 5. Services provided under the demonstration program under a federal waiver
20authorized under 42 USC 1315.
SB451-SSA2,34,2221 6. Health care coverage under the Badger Care health care program under s.
2249.665.
SB451-SSA2, s. 85 23Section 85. 149.12 (3) (a) of the statutes is amended to read:
SB451-SSA2,35,424 149.12 (3) (a) Except as provided in pars. (b) to (c) and (bm), no person is eligible
25for coverage under the plan for whom a premium, deductible, or coinsurance amount

1is paid or reimbursed by a federal, state, county, or municipal government or agency
2as of the first day of any term for which a premium amount is paid or reimbursed and
3as of the day after the last day of any term during which a deductible or coinsurance
4amount is paid or reimbursed.
SB451-SSA2, s. 86 5Section 86. 149.12 (3) (c) of the statutes is repealed.
SB451-SSA2, s. 87 6Section 87. 149.12 (4) and (5) of the statutes are created to read:
SB451-SSA2,35,127 149.12 (4) Subject to subs. (1m), (2), and (3), the authority may establish
8criteria that would enable additional persons to be eligible for coverage under the
9plan. The authority shall ensure that any expansion of eligibility is consistent with
10the purpose of the plan to provide health care coverage for those who are unable to
11obtain health insurance in the private market and does not endanger the solvency
12of the plan.
SB451-SSA2,35,14 13(5) The authority shall establish policies for determining and verifying the
14continued eligibility of an eligible person.
SB451-SSA2, s. 88 15Section 88. 149.13 (1) of the statutes is amended to read:
SB451-SSA2,35,2016 149.13 (1) Every insurer shall participate in the cost of administering the plan,
17except the commissioner may by rule exempt as a class those insurers whose share
18as determined under sub. (2) would be so minimal as to not exceed the estimated cost
19of levying the assessment. The commissioner shall advise the department authority
20of the insurers participating in the cost of administering the plan.
SB451-SSA2, s. 89 21Section 89. 149.13 (3) (a) of the statutes is amended to read:
SB451-SSA2,36,222 149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be
23determined annually by the commissioner based on annual statements and other
24reports filed by the insurer with the commissioner. The commissioner shall assess

1an insurer for the insurer's proportion of participation based on the total
2assessments estimated by the department under s. 149.143 (2) (a) 3. authority.
SB451-SSA2, s. 90 3Section 90. 149.13 (3) (b) of the statutes is amended to read:
SB451-SSA2,36,104 149.13 (3) (b) If the department authority or the commissioner finds that the
5commissioner's authority to require insurers to report under chs. 600 to 646 and 655
6is not adequate to permit the department, the commissioner or the board authority
7to carry out the department's, commissioner's or board's authority's responsibilities
8under this chapter subchapter, the commissioner shall promulgate rules requiring
9insurers to report the information necessary for the department, commissioner and
10board authority to make the determinations required under this chapter subchapter.
SB451-SSA2, s. 91 11Section 91 . 149.13 (4) of the statutes is amended to read:
SB451-SSA2,36,1712 149.13 (4) Notwithstanding subs. (1) to (3), the department, with the
13agreement of the commissioner, may perform various administrative functions
14related to the assessment of insurers participating in the cost of administering the
15plan. Neither the commissioner nor the department may assess any type of
16insurance that was not being assessed as of December 1, 2005, or any type of insurer
17that was not being assessed as December 1, 2005.
SB451-SSA2, s. 92 18Section 92 . 149.13 (4) of the statutes, as affected by 2005 Wisconsin Act ....
19(this act), is amended to read:
SB451-SSA2,36,2520 149.13 (4) Notwithstanding subs. (1) to (3), the department authority, with the
21agreement of the commissioner, may perform various administrative functions
22related to the assessment of insurers participating in the cost of administering the
23plan. Neither the commissioner nor the department authority may assess any type
24of insurance that was not being assessed as of December 1, 2005, or any type of
25insurer that was not being assessed as December 1, 2005.
SB451-SSA2, s. 93
1Section 93. 149.14 (1) (a) of the statutes is amended to read:
SB451-SSA2,37,82 149.14 (1) (a) The plan shall offer coverage for each eligible person in an
3annually renewable policy the coverage specified in this section for each eligible
4person
. If an eligible person is also eligible for medicare Medicare coverage, the plan
5shall not pay or reimburse any person for expenses paid for by medicare Medicare.
6If an eligible person is eligible for a type of medical assistance specified in s. 149.12
7(2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by
8Medical Assistance
.
SB451-SSA2, s. 94 9Section 94. 149.14 (2) (a) of the statutes is amended to read:
SB451-SSA2,37,1610 149.14 (2) (a) The plan shall provide every eligible person who is not eligible
11for medicare Medicare with major medical expense coverage. Major medical expense
12coverage offered under the plan under this section shall pay an eligible person's
13covered expenses, subject to sub. (3) and deductible, copayment, and coinsurance
14payments authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered
15individual. The maximum limit under this paragraph shall not be altered by the
16board, and no actuarially equivalent benefit may be substituted by the board.
SB451-SSA2, s. 95 17Section 95. 149.14 (3) (intro.) of the statutes is amended to read:
SB451-SSA2,38,618 149.14 (3) Covered expenses. (intro.) Except as provided in sub. (4), except
19as restricted by cost containment provisions under s. 149.17 (4) and except as
20reduced by the department under ss. 149.143 and 149.144, covered
Covered expenses
21for the coverage under this section the plan shall be the payment rates established
22by the department under s. 149.142 authority for the services provided by persons
23licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in
24sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and
25except as reduced by the department under ss. 149.143 and 149.144, covered
Covered

1expenses for the coverage under this section the plan shall also be the payment rates
2established by the department under s. 149.142 authority for, at a minimum, the
3following services and articles if the service or article is prescribed by a physician
4who is licensed under ch. 448 or in another state and who is certified under s. 49.45
5(2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45
6(2) (a) 11.:
SB451-SSA2, s. 96 7Section 96. 149.14 (3) (b) of the statutes is repealed and recreated to read:
SB451-SSA2,38,98 149.14 (3) (b) Professional services for the diagnosis or treatment of injuries,
9illnesses, or conditions, other than mental or dental.
SB451-SSA2, s. 97 10Section 97. 149.14 (3) (c) 1. of the statutes is repealed and recreated to read:
SB451-SSA2,38,1411 149.14 (3) (c) 1. Inpatient hospital services, as defined in s. 632.89 (1) (d),
12outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment
13arrangements, as defined in s. 632.89 (1) (f), at least to the extent required under s.
14632.89.
SB451-SSA2, s. 98 15Section 98. 149.14 (3) (c) 2. of the statutes is repealed.
SB451-SSA2, s. 99 16Section 99 . 149.14 (3) (c) 3. of the statutes is amended to read:
SB451-SSA2,38,2017 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.,
19services for the chronically mentally ill in community support programs operated
20under s. 51.421.
SB451-SSA2, s. 100 21Section 100 . 149.14 (3) (c) 3. of the statutes, as affected by 2005 Wisconsin Act
22.... (this act), is amended to read:
SB451-SSA2,39,223 149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated
24by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats.


11., services for the chronically mentally ill in community support programs operated
2under s. 51.421.
SB451-SSA2, s. 101 3Section 101. 149.14 (3) (d) of the statutes is amended to read:
SB451-SSA2,39,44 149.14 (3) (d) Drugs requiring a physician's prescription, subject to sub. (4c).
SB451-SSA2, s. 102 5Section 102. 149.14 (3) (e) of the statutes is amended to read:
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, s. 103 13Section 103. 149.14 (3) (f) of the statutes is created to read:
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, s. 104 16Section 104. 149.14 (3) (m) of the statutes is amended to read:
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, s. 105 20Section 105. 149.14 (3) (o) of the statutes is amended to read:
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, s. 108 12Section 108. 149.14 (4) (d) of the statutes is amended to read:
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, s. 109 17Section 109. 149.14 (4) (m) of the statutes is amended to read:
SB451-SSA2,40,1918 149.14 (4) (m) Experimental treatment, as determined by the department
19authority.
SB451-SSA2, s. 110 20Section 110. 149.14 (4c) of the statutes is repealed.
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