Amendment SA1-SSA1-SB40

SB40-SSA1-SA1,241,21 529. Page 1327, line 2: after that line insert:

SB40-SSA1-SA1,241,22 " Section 3069b. Chapter 260 of the statutes is created to read:

SB40-SSA1-SA1,241,23 Chapter 260

SB40-SSA1-SA1,241,24 Healthy Wisconsin Plan

SB40-SSA1-SA1,242,1 260.01 Definitions. In this chapter, except as otherwise provided:

SB40-SSA1-SA1,242,2 (1) "Authority" means the Healthy Wisconsin Authority.

SB40-SSA1-SA1,242,3 (2) "Board" means the board of trustees of the authority.

SB40-SSA1-SA1,242,8 (3) "Health care network" means a provider-driven, coordinated group of health care providers comprised of primary care physicians, medical specialists, physician assistants, nurses, clinics, one or more hospitals, and other health care providers and facilities, including providers and facilities that specialize in mental health services and alcohol or other drug abuse treatment.

SB40-SSA1-SA1,242,12 (4) "Medical inflation" means changes in the consumer price index for all consumers, U.S. city average, for the medical care group, including medical care commodities and medical care services, as determined by the U.S. department of labor.

SB40-SSA1-SA1,242,13 (5) "Plan" means the Healthy Wisconsin Plan.

SB40-SSA1-SA1,242,22 (6) "Primary care provider" means a health care provider who is identified as the key professional responsible for coordinating all medical care for a given participant, including referral to a specialist. "Primary care provider" includes general practice physicians, family practitioners, internists, pediatricians, obstetricians and gynecologists, advanced practice nurses, certified nurse midwives, and physician assistants. "Primary care provider" may also include a specialist who is treating a person with a chronic medical condition or special health care needs for which regular treatment by a specialist is medically necessary or a specialist who is treating a disabled person.

SB40-SSA1-SA1,243,7 260.05 Creation and organization of authority. (1) Creation and membership of board. There is created a public body corporate and politic to be known as the "Healthy Wisconsin Authority." The nonvoting members of the board shall consist of the secretary of employee trust funds and 4 representatives from the advisory committee under s. 260.49 who are health care personnel and administrators, selected by the advisory committee. The secretary of employee trust funds shall serve as the initial chairperson of the board until such time as the board elects a chairperson from its voting membership. The board shall also consist of the following voting members, nominated by the governor and with the advice and consent of the senate appointed, for staggered 6-year terms:

SB40-SSA1-SA1,243,9 (a) Four members selected from a list of names submitted by statewide labor or union coalitions. One of these members shall be a public employee.

SB40-SSA1-SA1,243,12 (b) Four members selected from a list of names submitted by statewide business and employer organizations. One of these members shall be a public employer.

SB40-SSA1-SA1,243,14 (c) One member selected from a list of names submitted by statewide public school teacher labor organizations.

SB40-SSA1-SA1,243,16 (d) One member selected from a list of names submitted by statewide small business organizations.

SB40-SSA1-SA1,243,18 (e) Two members who are farmers, selected from a list of names submitted by statewide general farm organizations.

SB40-SSA1-SA1,243,19 (f) One member who is a self-employed person.

SB40-SSA1-SA1,243,21 (g) Three members selected from a list of names submitted by statewide health care consumer organizations.

SB40-SSA1-SA1,243,23 (2) Terms of office; vacancies; quorum; business. (a) The terms of all members of the board shall expire on July 1.

SB40-SSA1-SA1,244,5 (b) Each member of the board shall hold office until a successor is appointed and qualified unless the member vacates or is removed from his or her office. A member who serves as a result of holding another office or position vacates his or her office as a member when he or she vacates the other office or position. A member who ceases to qualify for office vacates his or her office. A vacancy on the board shall be filled in the same manner as the original appointment to the board for the remainder of the unexpired term, if any.

SB40-SSA1-SA1,244,10 (c) A majority of the members of the board constitutes a quorum for the purpose of conducting its business and exercising its powers and for all other purposes, notwithstanding the existence of any vacancies. Action may be taken by the board upon a vote of a majority of the members present. Meetings of the members of the board may be held anywhere within or without the state.

SB40-SSA1-SA1,244,14 (3) Board member responsibility as trustee. Each member of the board shall be responsible for taking care that the highest level of independence and judgment is exercised at all times in administering the plan and overseeing the individuals and organizations selected to implement the plan.

SB40-SSA1-SA1,244,15 (4) Duties. The board shall:

SB40-SSA1-SA1,244,19 (a) Establish and administer a health care system in this state that ensures that all eligible persons have access to high quality, timely, and affordable health care. In establishing and administering the health care system, except as otherwise provided by law, the board shall seek to attain all of the following goals:

SB40-SSA1-SA1,244,21 1. Every resident of this state shall have access to affordable, comprehensive health care services.

SB40-SSA1-SA1,244,23 2. Health care reform shall maintain and improve choice of health care providers and high quality health care services in this state.

SB40-SSA1-SA1,244,25 3. Health care reform shall implement cost containment strategies that retain and assure affordable coverage for all residents of this state.

SB40-SSA1-SA1,245,1 (b) Establish, fund, and manage the plan as provided in this chapter.

SB40-SSA1-SA1,245,5 (c) Appoint an executive director, who shall serve at the pleasure of the board. The board may delegate to one or more of its members or its executive director any powers and duties the board considers proper. The executive director shall receive such compensation as may be determined by the board.

SB40-SSA1-SA1,245,9 (d) Provide for mechanisms to enroll every eligible resident in this state under the plan. Contracts entered into by the board with providers shall include provisions to enroll all eligible persons at the point of service, and outreach programs to assure every eligible person becomes enrolled in the plan.

SB40-SSA1-SA1,245,11 (e) Create a program for consumer protection and a process to resolve disputes with providers.

SB40-SSA1-SA1,245,15 (f) Establish an independent and binding appeals process for resolving disputes over eligibility and other determinations made by the board. Any person who is adversely affected by a board eligibility determination or any other determination is entitled to judicial review of the determination.

SB40-SSA1-SA1,245,17 (g) Submit an annual report on its activities to the governor and chief clerk of each house of the legislature, for distribution under s. 13.172 (2).

SB40-SSA1-SA1,245,21 (h) Contract for annual, independent, program evaluations and financial audits that measure the extent to which the plan is achieving the goals under par. (a) 1. to 3. The board may not enter into a contract with the same auditor for more than 6 years.

SB40-SSA1-SA1,245,25 (i) Accept bids from health care networks in accordance with the criteria set out in s. 260.30, or make payments to fee-for-service providers in accordance with s. 260.30. The board shall consult with the department of employee trust funds in determining the most effective and efficient way of purchasing health care benefits.

SB40-SSA1-SA1,246,2 (j) Audit health care networks and providers to determine if their services meet the plan objectives and criteria under this chapter.

SB40-SSA1-SA1,246,5 (5) Powers. The board shall have all the powers necessary or convenient to carry out the purposes and provisions of this chapter. In addition to all other powers granted the board under this chapter, the board may:

SB40-SSA1-SA1,246,7 (a) Adopt, amend, and repeal bylaws and policies and procedures for the regulation of its affairs and the conduct of its business.

SB40-SSA1-SA1,246,8 (b) Have a seal and alter the seal at pleasure.

SB40-SSA1-SA1,246,9 (c) Maintain an office.

SB40-SSA1-SA1,246,10 (d) Sue and be sued.

SB40-SSA1-SA1,246,12 (e) Accept gifts, grants, loans, or other contributions from private or public sources.

SB40-SSA1-SA1,246,14 (f) Establish the authority's annual budget and monitor the fiscal management of the authority.

SB40-SSA1-SA1,246,16 (g) Execute contracts and other instruments, including contracts for any professional services required for the authority.

SB40-SSA1-SA1,246,18 (h) Employ any officers, agents, and employees that it may require and determine their qualifications and compensation.

SB40-SSA1-SA1,246,19 (i) Procure liability insurance.

SB40-SSA1-SA1,246,21 (j) Contract for studies on issues, as identified by the board or by the advisory committee under s. 260.49, that relate to the plan.

SB40-SSA1-SA1,246,23 (k) Borrow money, as necessary on a short-term basis, to address cash flow issues.

SB40-SSA1-SA1,246,25 (L) Compel witnesses to attend meetings and to testify upon any necessary matter concerning the plan.

SB40-SSA1-SA1,247,3 260.10 Eligibility. (1) Covered persons. Except as provided in subs. (2) to (5) and subject to sub. (6), a person is eligible to participate in the plan if the person satisfies all of the following criteria:

SB40-SSA1-SA1,247,5 (a) The person has maintained his or her place of permanent abode, as defined by the board, in this state for at least 12 months.

SB40-SSA1-SA1,247,7 (b) The person maintains a substantial presence in this state, as defined by the board.

SB40-SSA1-SA1,247,8 (c) The person is under 65 years of age.

SB40-SSA1-SA1,247,12 (d) The person is not eligible for health care coverage from the federal government or a foreign government, is not an inmate of a penal facility, as defined in s. 19.32 (1e), and is not placed or confined in, or committed to, an institution for the mentally ill or developmentally disabled.

SB40-SSA1-SA1,247,15 (e) Unless a waiver requested under sub. (6) (b) has been granted and is in effect, the person is not eligible for Medical Assistance under subch. IV of ch. 49 or for health care coverage under the Badger Care health care program under s. 49.665.

SB40-SSA1-SA1,247,20 (2) Gainfully employed. If a person and the members of the person's immediate family do not meet the criteria under sub. (1) (a) and (b), but do meet the criteria under sub. (1) (c) to (e) and the person is gainfully employed in this state, as defined by the board, the person and the members of the person's immediate family are eligible to participate in the plan.

SB40-SSA1-SA1,247,24 (3) Dependent children. If a child under age 18 resides with his or her parent in this state but the parent does not yet meet the residency requirement under sub. (1) (a), the child is eligible to participate in the plan regardless of the length of time the child has resided in this state.

SB40-SSA1-SA1,248,4 (4) Pregnant women. A pregnant woman who resides in this state who does not yet meet the residency requirement under sub. (1) (a) is eligible to participate in the plan regardless of the length of time the pregnant woman has resided in this state.

SB40-SSA1-SA1,248,10 (5) Collective bargaining agreement. A person who is eligible to participate in the plan under sub. (1), (2), (3), or (4) and who receives health care coverage under a collective bargaining agreement that is in effect on January 1, 2009, is not eligible to participate in the plan until the day on which the collective bargaining agreement expires or the day on which the collective bargaining agreement is extended, modified, or renewed.

SB40-SSA1-SA1,248,12 (6) Waiver request. (a) In this subsection, "department" means the department of health and family services.

SB40-SSA1-SA1,248,20 (b) 1. The department shall develop a request for a waiver from the secretary of the federal department of health and human services to provide coverage under the plan to individuals who are eligible for Medical Assistance under subch. IV of ch. 49 in the low-income families category, as determined by the department, and to individuals who are eligible for health care coverage under the Badger Care health care program under s. 49.665. The waiver request shall be written so as to allow the use of federal financial participation to fund, to the maximum extent possible, health care coverage under the plan for the individuals specified in this subdivision.

SB40-SSA1-SA1,249,2 2. The department shall, not later than July 1, 2008, submit the waiver request developed under subd. 1. to a special legislative committee that shall be comprised of the members of the joint committee on finance and the members of the standing committees of the senate and the assembly with subject matter jurisdiction over health issues. The special legislative committee shall have 60 days to review and comment to the department on the waiver request.

SB40-SSA1-SA1,249,5 (c) Except as required under par. (b), the department may develop waiver requests to the appropriate federal agencies to permit funds from federal health care services programs to be used for health care coverage for persons under the plan.

SB40-SSA1-SA1,249,7 (7) Definitions of terms. For purposes of this chapter, the board shall define all of the following terms:

SB40-SSA1-SA1,249,8 (a) Place of permanent abode.

SB40-SSA1-SA1,249,19 (b) Substantial presence this state. In defining "substantial presence in this state," the board shall consider such factors as the amount of time per year that an individual is actually present in the state and the amount of taxes that an individual pays in this state, except that, if the individual attends school outside of this state and is under 23 years of age, the factors shall include the amount of time that the individual's parent or guardian is actually present in the state and the amount of taxes that the individual's parent or guardian pays in this state, and if the individual is in active service with the U.S. armed forces outside of this state, the factors shall include the amount of time that the individual's parent, guardian, or spouse is actually present in the state and the amount of taxes that the individual's parent, guardian, or spouse pays in this state.

SB40-SSA1-SA1,249,20 (c) Immediate family.

SB40-SSA1-SA1,249,22 (d) Gainfully employed. The definition shall include employment by persons who are self-employed and persons who work on farms.

SB40-SSA1-SA1,250,6 260.12 Office of outreach, enrollment, and advocacy. (1) Establishment. The board shall establish an office of outreach, enrollment, and advocacy. The office shall contract with nonprofit organizations to perform the outreach, enrollment, and advocacy functions specified in this section, and to review the health care payment and services records of persons who are participating, or who are eligible to participate, in the plan and who have provided the office with informed consent for the review. The office may not contract with any organization under this subsection that provides services under the plan or that has any other conflict of interest, as described in sub. (3).

SB40-SSA1-SA1,250,8 (2) Duties. The office of outreach, enrollment, and advocacy shall do all of the following:

SB40-SSA1-SA1,250,10 (a) Engage in aggressive outreach to enroll eligible persons and participants in their choice of health care coverage under the plan.

SB40-SSA1-SA1,250,13 (b) Assist eligible persons in choosing health care coverage by examining cost, quality, and geographic coverage information regarding their choice of available networks or providers.

SB40-SSA1-SA1,250,18 (c) Inform plan participants of the role they can play in holding down health care costs by taking advantage of preventive care, enrolling in chronic disease management programs if appropriate, responsibly utilizing medical services, and engaging in healthy lifestyles. The office shall inform participants of networks or workplaces where healthy lifestyle incentives are in place.

SB40-SSA1-SA1,250,20 (d) At the direction of the board, establish a process for resolving disputes with providers.

SB40-SSA1-SA1,250,25 (e) Act as an advocate for plan participants having questions, difficulties, or complaints about their health care services or coverage, including investigating and attempting to resolve the complaint. Investigation should include, when appropriate, consulting with the health care advisory committee under s. 260.49 regarding best practice guidelines.

SB40-SSA1-SA1,251,4 (f) If a participant's complaint cannot be successfully resolved, inform the participant of any legal or other means of recourse for his or her complaint. If the complaint involves a dispute over eligibility or other determinations made by the board, the participant shall be directed to the appeals process for board decisions.

SB40-SSA1-SA1,251,8 (g) Provide information to the public, agencies, legislators, and others regarding problems and concerns of plan participants and, in consultation with the health care advisory committee under s. 260.49, make recommendations for resolving those problems and concerns.

SB40-SSA1-SA1,251,10 (h) Ensure that plan participants have timely access to the services provided by the office.

SB40-SSA1-SA1,251,15 (3) Conflict of interest limitation. The office and its employees and contractors shall not have any conflict of interest relating to the performance of their duties. There is a conflict of interest if, with respect to the office's director, employees, or contractors, or a person affiliated with the office's director, employees, or contractors, any of the following exists:

SB40-SSA1-SA1,251,17 (a) Direct involvement in the licensing, certification, or accreditation of a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,251,19 (b) Direct ownership interest or investment interest in a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,251,21 (c) Employment by, or participation in, the management of a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,251,24 (d) Receipt of, or having the right to receive, directly or indirectly, remuneration under a compensation arrangement with a health care facility, health insurer, or health care provider.

SB40-SSA1-SA1,252,7 260.15 Benefits. (1) Generally. The board shall establish a health care plan that will take effect on January 1, 2009. The plan shall provide the same benefits as those that were in effect as of January 1, 2007, under the state employee health plan under s. 40.51 (6). The board may adjust the plan benefits to provide additional cost-effective treatment options if there is evidence-based research that the options are likely to reduce health care costs, avoid health risks, or result in better health outcomes.

SB40-SSA1-SA1,252,11 (2) Additional benefits. In addition to the benefit requirements under sub. (1), the plan shall provide coverage for mental health services and alcohol or other drug abuse treatment to the same extent as the plan covers treatment for physical conditions and coverage for preventive dental care for children up to 18 years of age.

SB40-SSA1-SA1,252,13 260.20 Cost sharing. (1) No cost sharing. The plan shall cover the following preventive services without any cost-sharing requirement:

SB40-SSA1-SA1,252,14 (a) Prenatal care for pregnant women.

SB40-SSA1-SA1,252,15 (b) Well-baby care.