Amendment SSA3-AB365

AB365-SSA3,33,4 (2) Any agent, employee, or director of the authority, plan, or board.

AB365-SSA3,33,5 (3) Any participating insurer.

AB365-SSA3,33,6 (4) The commissioner.

AB365-SSA3,33,7 (5) Any of the commissioner's agents, employees, or representatives.

AB365-SSA3,33,10 SUBCHAPTER II health insurance risk-sharing plan provisions

AB365-SSA3,33,13 656.10 Administration of plan. (1) Authority. The authority shall be responsible for the operation of the plan and, subject to ss. 656.43 (3) and 656.47, may enter into contracts for the plan's administration.

AB365-SSA3,33,16 (2) Fund. (a) The authority shall pay the operating administrative expenses of the plan from the fund, which shall be outside the state treasury and which shall consist of all of the following:

AB365-SSA3,33,17 1. Insurer assessments paid under s. 656.15.

AB365-SSA3,33,18 2. Premiums paid by eligible persons.

AB365-SSA3,33,19 3. Moneys received from the federal government as grants for high-risk pools.

AB365-SSA3,33,20 4. The earnings resulting from investments under par. (b).

AB365-SSA3,33,21 5. Any other moneys received by the authority.

AB365-SSA3,33,23 (b) The authority controls assets of the fund, including investment of assets of the fund.

AB365-SSA3,33,25 (c) Moneys in the fund may be expended only for the purposes specified in par. (a).

AB365-SSA3,34,5 656.11 Rules relating to creditable coverage. The commissioner shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 656.12 (1) (c) 1. and that determine the creditable coverage to which s. 656.12 (1) (c) 2. and 4. applies. The rules shall comply with any applicable federal law regarding creditable coverage.

AB365-SSA3,34,8 656.12 Eligibility determination. (1) Eligible persons. Except as provided in sub. (3) and subject to subs. (2) and (4), the authority shall certify as eligible a person who is a resident of this state and is any of the following:

AB365-SSA3,34,10 (a) A person who is covered by the Medicare program under 42 USC 1395 et seq. because he or she is disabled under 42 USC 423.

AB365-SSA3,34,12 (b) A person who submits evidence that he or she has a positive, validated HIV test result, as defined in s. 252.01 (8).

AB365-SSA3,34,13 (c) A person for whom all of the following apply:

AB365-SSA3,34,15 1. The aggregate of the individual's periods of creditable coverage is 18 months or more.

AB365-SSA3,34,18 2. The individual's most recent period of creditable coverage was under a group health plan, governmental plan, federal governmental plan, church plan, or under any health insurance offered in connection with any of those plans.

AB365-SSA3,34,22 3. The individual does not have creditable coverage and is not eligible for coverage under a group health plan; part A, B, or D of the Medicare program under 42 USC 1395 et seq.; or a state plan under the Medicaid program under 42 USC 1396 et seq.

AB365-SSA3,34,25 4. The individual's most recent period of creditable coverage was not terminated for any reason related to fraud or intentional misrepresentation of material fact or a failure to pay premiums.

AB365-SSA3,35,3 5. If the individual was offered the option of continuation coverage under a federal continuation provision or similar state program, the individual elected the continuation coverage.

AB365-SSA3,35,4 6. The individual has exhausted any continuation coverage under subd. 5.

AB365-SSA3,35,8 (d) A person who receives and submits any of the following notices based wholly or partially on medical underwriting considerations within 9 months before making an application for coverage by the plan and issued by a person acting as an administrator, as defined in s. 633.01 (1):

AB365-SSA3,35,9 1. A notice of rejection of coverage from one or more insurers.

AB365-SSA3,35,10 2. A notice of cancellation of coverage from one or more insurers.

AB365-SSA3,35,14 3. A notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.

AB365-SSA3,35,17 4. A notice of increase in premium exceeding the premium then in effect for the insured person by 50 percent or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.

AB365-SSA3,35,20 5. A notice of premium for a policy not yet in effect from 2 or more insurers which exceeds the premium applicable to a person considered a standard risk by 50 percent or more for the types of coverage provided by the plan.

AB365-SSA3,35,25 (e) A person not otherwise eligible under this subsection who meets eligibility criteria set by the authority. The authority shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.

AB365-SSA3,36,6 (2) Resident status. (a) For purposes of eligibility under sub. (1) (a), (b), (d), and (e), a resident is a person who has been legally domiciled in this state for a period of at least 3 months. Except for any of the following circumstances, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return:

AB365-SSA3,36,9 1. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state.

AB365-SSA3,36,13 2. A person with a developmental disability or another disability that prevents him or her from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return is legally domiciled in this state by living in this state.

AB365-SSA3,36,15 (b) For purposes of eligibility under sub. (1) (c), a resident is a person who legally resides in this state.

AB365-SSA3,36,21 (3) Exceptions to eligibility. (a) No person who is covered under the plan and who voluntarily terminates the coverage under the plan is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan. This paragraph does not apply to a person who is eligible under sub. (1) (c) or who terminates coverage under the plan because he or she is eligible to receive benefits under the Medical Assistance program.

AB365-SSA3,36,23 (b) No person on whose behalf the plan has paid out the lifetime limit under s. 656.20 (2) (a) or more is eligible for coverage under the plan.

AB365-SSA3,37,3 (c) No person who is 65 years of age or older is eligible for coverage under the plan unless the person is eligible under sub. (1) (c) or the person has coverage under the plan on the date on which he or she attains the age of 65 years.

AB365-SSA3,37,9 (d) No person who is eligible for creditable coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12. that are provided by an employer on a self-insured basis or through health insurance, is eligible for coverage under the plan. The board may specify, subject to approval of the commissioner, other types of coverage provided by an employer that do not render a person ineligible for coverage under the plan.

AB365-SSA3,37,12 (e) No person who is eligible for a Medical Assistance program under 42 USC 1396 et seq. is eligible for coverage under the plan, except for a person who is eligible only for any of the following:

AB365-SSA3,37,13 1. Family planning services under s. 49.45 (24s).

AB365-SSA3,37,15 2. Care and services for the treatment of an emergency medical condition under s. 49.45 (27).

AB365-SSA3,37,16 3. Medical Assistance under s. 49.46 (1) (a) 15.

AB365-SSA3,37,17 4. Ambulatory prenatal care under s. 49.465.

AB365-SSA3,37,19 5. Medicare premium, coinsurance, or deductible payments under s. 49.46 (2) (c) 2. or 3. or (cm), 49.468 (1) (b) or (c), (1m), or (2), or 49.47 (6) (a) 6. b. or c. or 6m.

AB365-SSA3,37,25 (f) No person is eligible for coverage under the plan for whom a premium, deductible, or coinsurance amount is paid or reimbursed by a federal, state, county, or municipal government or agency during any period in which the person has coverage for which the premium, deductible, or coinsurance amount is paid. A person is not ineligible for coverage if the premium, deductible, or coinsurance amounts are any of the following:

AB365-SSA3,38,2 1. Deductible or coinsurance amounts paid or reimbursed under ch. 47 or s. 49.68, 49.685 (8), 49.683, 49.686, or 253.05.

AB365-SSA3,38,3 2. Premium costs for health insurance subsidized under s. 252.16.

AB365-SSA3,38,5 (4) Eligibility verification. The authority shall establish policies for determining and verifying continued eligibility of an eligible person.

AB365-SSA3,38,8 (5) Open enrollment. The plan shall provide an open enrollment period once per year. Coverage under the plan begins on January 1 of the year immediately following the year of the open enrollment period.

AB365-SSA3,38,14 656.15 Participation of insurers. (1) Participation required. Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the authority of the insurers participating in the cost of administering the plan.

AB365-SSA3,38,21 (2) Participation share; determination. (a) Every participating insurer shall share in the operating, administrative, and subsidy expenses of the plan in proportion to the ratio of the insurer's total health care coverage revenue for residents of this state, as determined under s. 656.12 (2), during the preceding calendar year to the aggregate health care coverage revenue of all participating insurers for residents of this state during the preceding calendar year, as determined by the commissioner.

AB365-SSA3,39,2 (b) Each insurer's proportion of participation under this subsection shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the authority. The insurer shall pay the amount of the assessment directly to the authority.

AB365-SSA3,39,8 (c) If the authority or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600 to 646 and 655 is not adequate to permit the commissioner or the authority to carry out the commissioner's or authority's responsibilities under this subchapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the commissioner and authority to make the determinations required under this subchapter.

AB365-SSA3,39,10 656.20 Coverage. (1) Coverage offered. (a) The plan shall offer coverage for each eligible person in an annually renewable policy.

AB365-SSA3,39,13 (b) If an eligible person is also eligible for Medicare program coverage under 42 USC 1395 et seq., the plan may not pay or reimburse any person for expenses paid for by the Medicare program.

AB365-SSA3,39,16 (c) If an eligible person is eligible for coverage described under s. 656.12 (2) (e) 1. to 5., the plan may not pay or reimburse the person for expenses paid for by the Medical Assistance program.

AB365-SSA3,39,20 (2) Timing of coverage. The effective date of coverage for a person who terminates coverage under the Medical Assistance program, applies within 45 days of the date of termination for coverage under the plan, and is determined to be eligible under s. 656.12 (1) is the date of termination of Medical Assistance coverage.

AB365-SSA3,40,3 (3) Major medical expense coverage. (a) The plan shall provide every eligible person who is not eligible for the Medicare program under 42 USC 1395 et seq. major medical expense coverage that pays an eligible person's covered expenses, subject to deductible, copayment, and coinsurance payments, up to a lifetime limit per covered individual of $1,000,000 or a higher amount, as determined by the authority. The plan shall provide an alternative policy that reduces the benefits payable under this paragraph by the amounts paid under the Medicare program for those persons eligible for the Medicare program.

AB365-SSA3,40,9 (b) In addition to coverage under par. (a), the plan shall offer to all eligible persons who are not eligible for the Medicare program under 42 USC 1395 et seq. a choice of coverage that includes at least one form of coverage that is comparable to comprehensive health insurance coverage offered in the individual market in this state or that is comparable to a standard option of coverage available under the group or individual health insurance laws of this state.

AB365-SSA3,40,13 (c) An eligible person who is not eligible for the Medicare program under 42 USC 1395 et seq. may elect once each year, at the time and according to the procedures established by the authority, among the coverages offered under pars. (a) and (b).

AB365-SSA3,40,17 (4) Covered services; payment rates. The commissioner shall establish a list, by rule, of acute and primary care services and prescription drugs that are required to be covered by the plan. The authority shall establish criteria for service providers under the plan and payment rates for those providers.

AB365-SSA3,40,19 (5) Plan design. (a) Subject to subs. (1) to (4), (7), and (8), the authority shall do all of the following:

AB365-SSA3,40,22 1. Establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate.

AB365-SSA3,41,2 2. Provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state.

AB365-SSA3,41,4 (b) The authority may develop additional benefit designs that are responsive to market conditions.

AB365-SSA3,41,7 (6) Deductible and copayment subsidies. (a) The authority shall establish and provide subsidies for deductibles paid by eligible persons with household incomes specified in s. 656.30 (2).

AB365-SSA3,41,9 (b) The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in par. (a).

AB365-SSA3,41,12 (7) Preexisting conditions. (a) The plan may not subject an eligible person who obtains coverage as an enrollee under the plan to any preexisting condition exclusion.

AB365-SSA3,41,15 (b) Upon initial application of an eligible person in the plan before enrollment, the plan shall cover any preexisting condition of the eligible person but the coverage may last no longer than 12 months.

AB365-SSA3,41,23 (8) Coordination of benefits. (a) Covered expenses under the plan may not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage that is statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care insurance, the Medicare program, the Medical Assistance program, or any other governmental program, except as otherwise provided by law.

AB365-SSA3,42,2 (b) The authority has a cause of action against an eligible person participating in the plan for the recovery of the amount of benefits paid that are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.

AB365-SSA3,42,5 (c) The authority is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan.

AB365-SSA3,42,8 656.23 Premiums. (1) Percentage of costs. Except as provided in sub. (2), the authority shall set premium rates for coverage under the plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s. 656.27 (1).

AB365-SSA3,42,10 (2) Limitation. In no event may plan premium rates exceed 200 percent of rates applicable to individual standard risks.

AB365-SSA3,42,12 (3) State funds. Any state funds received for premium support shall be used to offset premium costs for persons covered under the plan.

AB365-SSA3,42,18 656.25 Provider payment rates. (1) Establishment of rates. The authority shall establish provider payment rates for covered expenses that consist of the usual and customary payment rates, as determined by the authority, for the services and articles provided plus an adjustment determined by the authority. The adjustments to the usual and customary rates shall be sufficient to cover the portion of plan costs specified in s. 656.27 (1) (c) and (2) (b).

AB365-SSA3,42,24 (2) Payment is payment in full. Except for copayments, coinsurance, or deductibles required or authorized under the plan, a provider of a covered service or article shall accept as payment in full for the covered service or article the payment rate determined under sub. (1) and may not bill an eligible person who receives the service or article for any amount by which the charge for the service or article is reduced under sub. (1).

AB365-SSA3,43,6 656.27 Payment of plan costs. (1) Costs excluding subsidies. The authority shall pay plan costs, excluding any premium, deductible, and copayment subsidies, first from any federal funds under s. 656.10 (2) (a) 3. that exceed premium, deductible, and copayment subsidy costs in a policy year. The remainder of the plan costs, excluding premium, deductible, and copayment subsidy costs, shall be paid as follows:

AB365-SSA3,43,7 (a) Sixty percent from premiums paid by eligible persons.

AB365-SSA3,43,8 (b) Twenty percent from insurer assessments under s. 656.15.

AB365-SSA3,43,10 (c) Twenty percent from adjustments to provider payment rates under s. 656.25.

AB365-SSA3,43,14 (2) Subsidy costs. The authority shall pay for premium, deductible, and copayment subsidies in a policy year first from any federal funds under s. 656.10 (2) (a) 3. received in that year. The remainder of the subsidy costs shall be paid as follows:

AB365-SSA3,43,15 (a) Fifty percent from insurer assessments under s. 656.15.

AB365-SSA3,43,16 (b) Fifty percent from adjustments to provider payment rates under s. 656.25.

AB365-SSA3,43,19 656.30 Reductions in premiums for low-income eligible persons. (1) Definition. In this section, “household income” means household income, as defined in s. 71.52 (5), and as determined under sub. (3).

AB365-SSA3,43,21 (2) Premium reduction. Subject to sub. (3), the authority shall reduce the premiums established under s. 656.23 for eligible persons by the following amounts.

AB365-SSA3,43,23 1. If the household income is $0 or more but less than $10,000, by at least 30 percent.