Amendment CSA1-SB40

SB40-CSA1,760,7 2. Except as provided in subds. 3. and 4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line.

SB40-CSA1,760,12 3. Except as provided in subd. 4., a recipient who is an unborn child, or a pregnant woman eligible under sub. (4) (b) 1., whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for an adult with a family income of 300 percent of the poverty line.

SB40-CSA1,760,13 4. None of the following shall pay a premium:

SB40-CSA1,760,15 a. A child who is a Native American or an Alaskan Native with a family income that does not exceed 300 percent of the poverty line.

SB40-CSA1,760,16 b. A child who is eligible under sub. (4) (a) 2. or (b) 2.

SB40-CSA1,760,17 c. A child whose family income does not exceed 200 percent of the poverty line.

SB40-CSA1,760,19 d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.

SB40-CSA1,760,20 e. A child who obtains eligibility under sub. (7) (b) 2.

SB40-CSA1,760,21 f. An individual who is eligible under sub. (4) (a) 5.

SB40-CSA1,760,25 5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) or (4) (c) does not pay a premium when due, the recipient's coverage terminates and the recipient is not eligible for BadgerCare Plus for 6 calendar months following the date on which the recipient's coverage terminated.

SB40-CSA1,761,3 (11) Benchmark plan benefits and copayments. Recipients who are not eligible for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following benefits and pay the following copayments:

SB40-CSA1,761,6 (a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and subject to the Badger Rx Gold program discounts.

SB40-CSA1,761,8 (b) Physicians' services, including one annual routine physical examination, with a copayment of no more than $15 per visit.

SB40-CSA1,761,12 (c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.

SB40-CSA1,761,17 (d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall require a copayment of no more than $75.

SB40-CSA1,761,18 (e) Laboratory and X-ray services, including mammography.

SB40-CSA1,761,19 (f) Home health services, limited to 60 visits per year.

SB40-CSA1,761,22 (g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,761,25 (h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,762,3 (i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,762,6 (j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,762,10 (k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6).

SB40-CSA1,762,13 (L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided.

SB40-CSA1,762,16 (m) Transportation to obtain emergency medical care only, as medically necessary, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,762,18 (n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.

SB40-CSA1,762,23 (o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.

SB40-CSA1,762,24 (p) Early childhood developmental services, for children under 6 years of age.

SB40-CSA1,762,25 (q) Smoking cessation treatment, for pregnant women only.

SB40-CSA1,763,1 (r) Prenatal care coordination, for pregnant women at high risk only.

SB40-CSA1,763,11 (11m) Provider payments and requirements. The provider of a service or equipment under sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under sub. (11) to a recipient who is unable to share costs as specified in sub. (11), the recipient is not relieved of liability for those costs.

SB40-CSA1,763,14 (12) Rules; notice of effective date. (a) 1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.

SB40-CSA1,763,22 2. The department may promulgate emergency rules under s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.

SB40-CSA1,764,2 (b) If the amendments to the state plan submitted under sub. (2) are approved and a waiver that is consistent with all of the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.

SB40-CSA1, s. 1608 Section 1608. 49.473 (2) (a) of the statutes is amended to read:

SB40-CSA1,764,6 49.473 (2) (a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health care coverage under s. 49.665.

SB40-CSA1, s. 1610 Section 1610. 49.475 (1) (a) of the statutes is renumbered 49.475 (1) (ar).

SB40-CSA1, s. 1611 Section 1611. 49.475 (1) (ag) of the statutes is created to read:

SB40-CSA1,764,10 49.475 (1) (ag) "Covered entity" means any of the following that is not an insurer:

SB40-CSA1,764,11 1. A nonprofit hospital, as defined in s. 46.21 (2) (m).

SB40-CSA1,764,15 2. An employer, as defined in s. 101.01 (4), labor union, or other group of persons organized in this state if the employer, labor union, or other group provides prescription drug coverage to covered individuals who reside or are employed in this state.

SB40-CSA1,764,17 3. A comprehensive or limited health care benefits program administered by the state that provides prescription drug coverage.

SB40-CSA1, s. 1612 Section 1612. 49.475 (1) (am) of the statutes is created to read:

SB40-CSA1,764,22 49.475 (1) (am) "Covered individual" means an individual who is a member, participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary of a covered entity, or a dependent of the individual, and who receives prescription drug coverage from or through the covered entity.

SB40-CSA1, s. 1613 Section 1613. 49.475 (1) (c) of the statutes is created to read:

SB40-CSA1,765,3 49.475 (1) (c) "Pharmacy benefits management" means the procurement of prescription drugs at a negotiated rate for dispensation in this state to covered individuals; the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals; or any of the following services provided in the administration of pharmacy benefits:

SB40-CSA1,765,4 1. Dispensation of prescription drugs by mail.

SB40-CSA1,765,6 2. Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals.

SB40-CSA1,765,7 3. Clinical formulary development and management services.

SB40-CSA1,765,8 4. Rebate contracting and administration.

SB40-CSA1,765,10 5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.

SB40-CSA1, s. 1614 Section 1614. 49.475 (1) (d) of the statutes is created to read:

SB40-CSA1,765,13 49.475 (1) (d) "Pharmacy benefits manager" means a person that performs pharmacy benefits management functions.

SB40-CSA1, s. 1615 Section 1615. 49.475 (1) (e) of the statutes is created to read:

SB40-CSA1,765,16 49.475 (1) (e) "Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:

SB40-CSA1,765,18 1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.

SB40-CSA1,765,19 2. An enrollee of family care.

SB40-CSA1,765,20 3. A recipient of the Badger Care health care program.

SB40-CSA1,765,21 4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.

SB40-CSA1,765,23 5. A participant in the program of prescription drug assistance for elderly persons under s. 49.688.

SB40-CSA1,765,24 6. A woman who receives services that are reimbursed under s. 255.06.

SB40-CSA1, s. 1616 Section 1616. 49.475 (1) (f) of the statutes is created to read:

SB40-CSA1,766,3 49.475 (1) (f) "Third party" means an entity that by statute, rule, or contract is responsible for payment of a claim for a health care item or service. "Third party" includes all of the following:

SB40-CSA1,766,4 1. An insurer.

SB40-CSA1,766,6 2. An employee benefit plan described in 29 USC 1003 (a) that is not exempt under 29 USC 1003 (b) and is not a multiple employer welfare arrangement.

SB40-CSA1,766,7 3. A service benefit plan, as specified in 42 USC 1396a (25) (I).

SB40-CSA1,766,8 4. A pharmacy benefits manager.

SB40-CSA1, s. 1617 Section 1617. 49.475 (2) of the statutes is repealed and recreated to read:

SB40-CSA1,766,11 49.475 (2) Requirements of 3rd parties. As a condition of doing business in this state, a 3rd party shall do all of the following:

SB40-CSA1,766,14 (a) Upon the department's request and in the manner prescribed by the department, provide information to the department necessary for the department to ascertain all of the following with respect to a recipient:

SB40-CSA1,766,16 1. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.

SB40-CSA1,766,19 2. If subd. 1. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.

SB40-CSA1,766,23 (b) Accept assignment to the department of a right of a recipient to receive 3rd-party payment for an item or service for which payment under medical assistance has been made and accept the department's right to recover any 3rd-party payment made for which assignment has not been accepted.

SB40-CSA1,767,3 (c) Respond to an inquiry by the department concerning a claim for payment of a health care item or service if the department submits the inquiry less than 36 months after the date on which the health care item or service was provided.

SB40-CSA1,767,7 (d) If all of the following apply, agree not to deny a claim submitted by the department under par. (b) solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:

SB40-CSA1,767,9 1. The department submits the claim less than 36 months after the date on which the health care item or service was provided.

SB40-CSA1,767,12 2. Action by the department to enforce the department's rights under this section with respect to the claim is commenced less than 72 months after the department submits the claim.

SB40-CSA1, s. 1618 Section 1618. 49.475 (3) (intro.) of the statutes is amended to read:

SB40-CSA1,767,16 49.475 (3) Written agreement. (intro.) Upon requesting an insurer a 3rd party to provide the information under sub. (2) (a), the department and the 3rd party shall enter into a written agreement with the insurer that satisfies all of the following:

SB40-CSA1, s. 1619 Section 1619. 49.475 (3) (a) of the statutes is amended to read:

SB40-CSA1,767,19 49.475 (3) (a) Identifies in detail the detailed format of the information to be disclosed provided to the department.

SB40-CSA1, s. 1620 Section 1620. 49.475 (3) (c) of the statutes is amended to read:

SB40-CSA1,767,22 49.475 (3) (c) Specifies how the insurer's 3rd party's reimbursable costs under sub. (5) will be determined and specifies the manner of payment.

SB40-CSA1, s. 1621 Section 1621. 49.475 (4) (a) of the statutes is amended to read:

SB40-CSA1,768,2 49.475 (4) (a) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer 3rd party to disclose information under this section.

SB40-CSA1, s. 1622 Section 1622. 49.475 (4) (b) of the statutes is amended to read:

SB40-CSA1,768,7 49.475 (4) (b) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 30 days after receiving the department's request if the department has previously requested the insurer 3rd party to disclose information under this section.

SB40-CSA1, s. 1623 Section 1623. 49.475 (4) (d) of the statutes is created to read:

SB40-CSA1,768,10 49.475 (4) (d) If a 3rd party other than an insurer fails to comply with par. (a) or (b), the department may so notify the attorney general.

SB40-CSA1, s. 1624 Section 1624. 49.475 (5) of the statutes is amended to read: