Amendment SSA3-AB365

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.

AB365-SSA3,43,25 2. If the household income is $10,000 or more but less than $14,000, by at least 25 percent.

AB365-SSA3,44,2 3. If the household income is $14,000 or more but less than $17,000, by at least 20 percent.

AB365-SSA3,44,4 4. If the household income is $17,000 or more but less than $20,000, by at least 15 percent.

AB365-SSA3,44,6 5. If the household income is $20,000 or more but less than $34,000, by at least 10 percent.

AB365-SSA3,44,9 (3) Determining household income. (a) Subject to par. (b), the authority shall establish and implement the method for determining the household income of an eligible person.

AB365-SSA3,44,12 (b) In determining the household income of an eligible person, the authority shall consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:

AB365-SSA3,44,13 1. The person is a farmer, as defined in s. 102.04 (3).

AB365-SSA3,44,15 2. The person was not eligible to claim the homestead credit under subch. VIII of ch. 71 in the preceding taxable year.

AB365-SSA3,44,18 (c) The authority may approve adjustment of the household income dollar amounts listed in sub. (2) to reflect changes in the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.

AB365-SSA3,44,19 656.32 Contents of plan. The plan shall include all of the following:

AB365-SSA3,44,21 (1) Subject to s. 656.27, a rating plan calculated in accordance with generally accepted actuarial principles.

AB365-SSA3,44,23 (2) Procedures for applicants and participants to have grievances reviewed by an impartial body.

AB365-SSA3,45,3 656.35 Chapters 600 to 645 applicable. Except as explicitly provided in this subchapter, the plan shall comply and be administered in compliance with chs. 600 to 645.

AB365-SSA3,45,6 suBchapter III health insurance risk-sharing plan authority

AB365-SSA3,45,12 656.41 Creation and organization of authority. (1) Creation; board. There is created a public body corporate and polity to be known as the “Health Insurance Risk-Sharing Plan Authority.” The board of directors of the authority shall consist of the commissioner of insurance, or his or her designee, as a nonvoting member, and all of the following members, who shall be nominated by the governor, and with the advice and consent of the senate appointed:

AB365-SSA3,45,13 (a) Four members who represent insurers participating in the plan.

AB365-SSA3,45,15 (b) Four members who represent health care providers, including all of the following:

AB365-SSA3,45,16 1. One representative of the Wisconsin Medical Society.

AB365-SSA3,45,17 2. One representative of the Wisconsin Hospital Association.

AB365-SSA3,45,18 3. One representative of the Pharmacy Society of Wisconsin.

AB365-SSA3,45,20 4. One representative of health care providers that provide services to persons with coverage under the plan.

AB365-SSA3,45,21 (c) Five other members, including all of the following:

AB365-SSA3,45,23 1. At least one member who represents small businesses that purchase private health insurance.

AB365-SSA3,45,25 2. At least one member who is a professional consumer advocate who is familiar with the plan.

AB365-SSA3,46,1 3. At least two members who are persons with coverage under the plan.

AB365-SSA3,46,3 (2) Vacancy. 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.

AB365-SSA3,46,6 (3) Compensation. A member of the board may not be compensated for his or her services but shall be reimbursed for actual and necessary expenses, including travel expenses, incurred in the performance of his or her duties.

AB365-SSA3,46,9 (4) Chairperson; board action. (a) Annually, the governor shall appoint one member other than the commissioner as chairperson, and the members of the board may elect other officers as they consider appropriate.

AB365-SSA3,46,12 (b) Seven voting members of the board constitute a quorum for the purpose of conducting the business and exercising the powers of the authority, notwithstanding the existence of any vacancy.

AB365-SSA3,46,14 (c) The board may take action upon a vote of a majority of the members, present, unless the bylaws of the authority require a larger number.

AB365-SSA3,46,25 (5) Executive director. The board may appoint an executive director who may not be a member of the board and who shall serve at the pleasure of the board. The authority may delegate by resolution to one or more of its members or its executive director any powers and duties that it considers proper. The executive director shall receive such compensation as may be determined by the board. The executive director or other person designated by resolution of the board shall keep a record of the proceedings of the authority, and its official seal. The executive director or other person may cause copies to be made of all minutes and other records and documents of the authority and may give certificates under the official seal of the authority to the effect that such copies are true copies, and all persons dealing with the authority may rely upon such certificates.

AB365-SSA3,47,2 656.43 Duties of the authority. In addition to all other duties imposed under this chapter, the authority shall do all of the following:

AB365-SSA3,47,3 (1) Adopt policies for the administration of this chapter.

AB365-SSA3,47,5 (2) Establish the authority's annual budget and monitor the fiscal management of the authority.

AB365-SSA3,47,6 (3) Do, or contract with another person to do, all of the following:

AB365-SSA3,47,8 (a) Perform all eligibility and administrative claims payment functions relating to the plan.

AB365-SSA3,47,11 (b) Establish a premium billing procedure for collection of premiums from covered persons. Billings shall be made on a periodic basis as determined by the authority.

AB365-SSA3,47,13 (c) Perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including all of the following:

AB365-SSA3,47,16 1. Making available information relating to the proper manner of submitting a claim for benefits under the plan and distributing forms upon which submissions shall be made.

AB365-SSA3,47,17 2. Evaluating the eligibility of each claim for payment under the plan.

AB365-SSA3,47,19 3. Notifying each claimant within 30 days after receiving a properly completed and executed proof of loss whether the claim is accepted, rejected, or compromised.

AB365-SSA3,47,21 (4) Seek to qualify or maintain the plan as a state pharmacy assistance program, as defined in 42 CFR 423.464.

AB365-SSA3,47,23 (5) Annually submit a report to the legislature under s. 13.172 (2) and to the governor on the operation of the plan.