AB365-SSA3,40,17 14(4) Covered services; payment rates. The commissioner shall establish a list,
15by rule, of acute and primary care services and prescription drugs that are required
16to be covered by the plan. The authority shall establish criteria for service providers
17under the plan and payment rates for those providers.
AB365-SSA3,40,19 18(5) Plan design. (a) Subject to subs. (1) to (4), (7), and (8), the authority shall
19do all of the following:
AB365-SSA3,40,2220 1. Establish the plan design, after taking into consideration the levels of health
21insurance coverage provided in the state and medical economic factors, as
22appropriate.
AB365-SSA3,41,223 2. Provide benefit levels, deductibles, copayment and coinsurance
24requirements, exclusions, and limitations under the plan that the authority

1determines generally reflect and are commensurate with comprehensive health
2insurance coverage offered in the private individual market in the state.
AB365-SSA3,41,43 (b) The authority may develop additional benefit designs that are responsive
4to market conditions.
AB365-SSA3,41,7 5(6) Deductible and copayment subsidies. (a) The authority shall establish and
6provide subsidies for deductibles paid by eligible persons with household incomes
7specified in s. 656.30 (2).
AB365-SSA3,41,98 (b) The authority may provide subsidies for prescription drug copayment
9amounts paid by eligible persons specified in par. (a).
AB365-SSA3,41,12 10(7) Preexisting conditions. (a) The plan may not subject an eligible person
11who obtains coverage as an enrollee under the plan to any preexisting condition
12exclusion.
AB365-SSA3,41,1513 (b) Upon initial application of an eligible person in the plan before enrollment,
14the plan shall cover any preexisting condition of the eligible person but the coverage
15may last no longer than 12 months.
AB365-SSA3,41,23 16(8) Coordination of benefits. (a) Covered expenses under the plan may not
17include any charge for care for injury or disease for which benefits are payable
18without regard to fault under coverage that is statutorily required to be contained
19in any motor vehicle or other liability insurance policy or equivalent self-insurance,
20for which benefits are payable under a worker's compensation or similar law, or for
21which benefits are payable under another policy of health care insurance, the
22Medicare program, the Medical Assistance program, or any other governmental
23program, except as otherwise provided by law.
AB365-SSA3,42,224 (b) The authority has a cause of action against an eligible person participating
25in the plan for the recovery of the amount of benefits paid that are not for covered

1expenses under the plan. Benefits under the plan may be reduced or refused as a
2setoff against any amount recoverable under this paragraph.
AB365-SSA3,42,53 (c) The authority is subrogated to the rights of an eligible person to recover
4special damages for illness or injury to the person caused by the act of a 3rd person
5to the extent that benefits are provided under the plan.
AB365-SSA3,42,8 6656.23 Premiums. (1) Percentage of costs. Except as provided in sub. (2),
7the authority shall set premium rates for coverage under the plan at a level that is
8sufficient to cover 60 percent of plan costs, as provided in s. 656.27 (1).
AB365-SSA3,42,10 9(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
10applicable to individual standard risks.
AB365-SSA3,42,12 11(3) State funds. Any state funds received for premium support shall be used
12to offset premium costs for persons covered under the plan.
AB365-SSA3,42,18 13656.25 Provider payment rates. (1) Establishment of rates. The authority
14shall establish provider payment rates for covered expenses that consist of the usual
15and customary payment rates, as determined by the authority, for the services and
16articles provided plus an adjustment determined by the authority. The adjustments
17to the usual and customary rates shall be sufficient to cover the portion of plan costs
18specified in s. 656.27 (1) (c) and (2) (b).
AB365-SSA3,42,24 19(2) Payment is payment in full. Except for copayments, coinsurance, or
20deductibles required or authorized under the plan, a provider of a covered service or
21article shall accept as payment in full for the covered service or article the payment
22rate determined under sub. (1) and may not bill an eligible person who receives the
23service or article for any amount by which the charge for the service or article is
24reduced under sub. (1).
AB365-SSA3,43,6
1656.27 Payment of plan costs. (1) Costs excluding subsidies. The authority
2shall pay plan costs, excluding any premium, deductible, and copayment subsidies,
3first from any federal funds under s. 656.10 (2) (a) 3. that exceed premium,
4deductible, and copayment subsidy costs in a policy year. The remainder of the plan
5costs, excluding premium, deductible, and copayment subsidy costs, shall be paid as
6follows:
AB365-SSA3,43,77 (a) Sixty percent from premiums paid by eligible persons.
AB365-SSA3,43,88 (b) Twenty percent from insurer assessments under s. 656.15.
AB365-SSA3,43,109 (c) Twenty percent from adjustments to provider payment rates under s.
10656.25.
AB365-SSA3,43,14 11(2) Subsidy costs. The authority shall pay for premium, deductible, and
12copayment subsidies in a policy year first from any federal funds under s. 656.10 (2)
13(a) 3. received in that year. The remainder of the subsidy costs shall be paid as
14follows:
AB365-SSA3,43,1515 (a) Fifty percent from insurer assessments under s. 656.15.
AB365-SSA3,43,1616 (b) Fifty percent from adjustments to provider payment rates under s. 656.25.
AB365-SSA3,43,19 17656.30 Reductions in premiums for low-income eligible persons. (1)
18Definition.
In this section, “household income” means household income, as defined
19in s. 71.52 (5), and as determined under sub. (3).
AB365-SSA3,43,21 20(2) Premium reduction. Subject to sub. (3), the authority shall reduce the
21premiums established under s. 656.23 for eligible persons by the following amounts.
AB365-SSA3,43,2322 1. If the household income is $0 or more but less than $10,000, by at least 30
23percent.
AB365-SSA3,43,2524 2. If the household income is $10,000 or more but less than $14,000, by at least
2525 percent.
AB365-SSA3,44,2
13. If the household income is $14,000 or more but less than $17,000, by at least
220 percent.
AB365-SSA3,44,43 4. If the household income is $17,000 or more but less than $20,000, by at least
415 percent.
AB365-SSA3,44,65 5. If the household income is $20,000 or more but less than $34,000, by at least
610 percent.
AB365-SSA3,44,9 7(3) Determining household income. (a) Subject to par. (b), the authority shall
8establish and implement the method for determining the household income of an
9eligible person.
AB365-SSA3,44,1210 (b) In determining the household income of an eligible person, the authority
11shall consider information submitted by an eligible person on a completed federal
12profit or loss from farming form, schedule F, if all of the following apply:
AB365-SSA3,44,1313 1. The person is a farmer, as defined in s. 102.04 (3).
AB365-SSA3,44,1514 2. The person was not eligible to claim the homestead credit under subch. VIII
15of ch. 71 in the preceding taxable year.
AB365-SSA3,44,1816 (c) The authority may approve adjustment of the household income dollar
17amounts listed in sub. (2) to reflect changes in the consumer price index for all urban
18consumers, U.S. city average, as determined by the U.S. department of labor.
AB365-SSA3,44,19 19656.32 Contents of plan. The plan shall include all of the following:
AB365-SSA3,44,21 20(1) Subject to s. 656.27, a rating plan calculated in accordance with generally
21accepted actuarial principles.
AB365-SSA3,44,23 22(2) Procedures for applicants and participants to have grievances reviewed by
23an impartial body.
AB365-SSA3,45,3
1656.35 Chapters 600 to 645 applicable. Except as explicitly provided in this
2subchapter, the plan shall comply and be administered in compliance with chs. 600
3to 645.
AB365-SSA3,45,64 suBchapter III
5 health insurance risk-sharing
6 plan authority
AB365-SSA3,45,12 7656.41 Creation and organization of authority. (1) Creation; board.
8There is created a public body corporate and polity to be known as the “Health
9Insurance Risk-Sharing Plan Authority.” The board of directors of the authority
10shall consist of the commissioner of insurance, or his or her designee, as a nonvoting
11member, and all of the following members, who shall be nominated by the governor,
12and with the advice and consent of the senate appointed:
AB365-SSA3,45,1313 (a) Four members who represent insurers participating in the plan.
AB365-SSA3,45,1514 (b) Four members who represent health care providers, including all of the
15following:
AB365-SSA3,45,1616 1. One representative of the Wisconsin Medical Society.
AB365-SSA3,45,1717 2. One representative of the Wisconsin Hospital Association.
AB365-SSA3,45,1818 3. One representative of the Pharmacy Society of Wisconsin.
AB365-SSA3,45,2019 4. One representative of health care providers that provide services to persons
20with coverage under the plan.
AB365-SSA3,45,2121 (c) Five other members, including all of the following:
AB365-SSA3,45,2322 1. At least one member who represents small businesses that purchase private
23health insurance.
AB365-SSA3,45,2524 2. At least one member who is a professional consumer advocate who is familiar
25with the plan.
AB365-SSA3,46,1
13. At least two members who are persons with coverage under the plan.
AB365-SSA3,46,3 2(2) Vacancy. A vacancy on the board shall be filled in the same manner as the
3original appointment to the board for the remainder of the unexpired term, if any.
AB365-SSA3,46,6 4(3) Compensation. A member of the board may not be compensated for his or
5her services but shall be reimbursed for actual and necessary expenses, including
6travel expenses, incurred in the performance of his or her duties.
AB365-SSA3,46,9 7(4) Chairperson; board action. (a) Annually, the governor shall appoint one
8member other than the commissioner as chairperson, and the members of the board
9may elect other officers as they consider appropriate.
AB365-SSA3,46,1210 (b) Seven voting members of the board constitute a quorum for the purpose of
11conducting the business and exercising the powers of the authority, notwithstanding
12the existence of any vacancy.
AB365-SSA3,46,1413 (c) The board may take action upon a vote of a majority of the members, present,
14unless the bylaws of the authority require a larger number.
AB365-SSA3,46,25 15(5) Executive director. The board may appoint an executive director who may
16not be a member of the board and who shall serve at the pleasure of the board. The
17authority may delegate by resolution to one or more of its members or its executive
18director any powers and duties that it considers proper. The executive director shall
19receive such compensation as may be determined by the board. The executive
20director or other person designated by resolution of the board shall keep a record of
21the proceedings of the authority, and its official seal. The executive director or other
22person may cause copies to be made of all minutes and other records and documents
23of the authority and may give certificates under the official seal of the authority to
24the effect that such copies are true copies, and all persons dealing with the authority
25may rely upon such certificates.
AB365-SSA3,47,2
1656.43 Duties of the authority. In addition to all other duties imposed under
2this chapter, the authority shall do all of the following:
AB365-SSA3,47,3 3(1) Adopt policies for the administration of this chapter.
AB365-SSA3,47,5 4(2) Establish the authority's annual budget and monitor the fiscal
5management of the authority.
AB365-SSA3,47,6 6(3) Do, or contract with another person to do, all of the following:
AB365-SSA3,47,87 (a) Perform all eligibility and administrative claims payment functions
8relating to the plan.
AB365-SSA3,47,119 (b) Establish a premium billing procedure for collection of premiums from
10covered persons. Billings shall be made on a periodic basis as determined by the
11authority.
AB365-SSA3,47,1312 (c) Perform all necessary functions to assure timely payment of benefits to
13covered persons under the plan, including all of the following:
AB365-SSA3,47,1614 1. Making available information relating to the proper manner of submitting
15a claim for benefits under the plan and distributing forms upon which submissions
16shall be made.
AB365-SSA3,47,1717 2. Evaluating the eligibility of each claim for payment under the plan.
AB365-SSA3,47,1918 3. Notifying each claimant within 30 days after receiving a properly completed
19and executed proof of loss whether the claim is accepted, rejected, or compromised.
AB365-SSA3,47,21 20(4) Seek to qualify or maintain the plan as a state pharmacy assistance
21program, as defined in 42 CFR 423.464.
AB365-SSA3,47,23 22(5) Annually submit a report to the legislature under s. 13.172 (2) and to the
23governor on the operation of the plan.
AB365-SSA3,48,2 24656.45 Powers of authority. (1) Except as provided under sub. (2), the
25authority shall have all the powers necessary or convenient to carry out the purposes

1and provisions of this chapter. In addition to all other powers granted by this chapter,
2the authority may:
AB365-SSA3,48,43 (a) Adopt bylaws and policies and procedures for the regulation of its affairs
4and the conduct of its business.
AB365-SSA3,48,65 (b) Have a seal and alter the seal at pleasure; have perpetual existence; and
6maintain an office.
AB365-SSA3,48,77 (c) Hire employees, define their duties, and fix their rate of compensation.
AB365-SSA3,48,88 (d) Incur debt, except as provided under sub. (2).
AB365-SSA3,48,109 (e) Contract for any professional services required for the authority, subject to
10ss. 656.43 (3) and 656.47.
AB365-SSA3,48,1411 (f) Appoint any technical or professional advisory committee that the authority
12finds necessary to assist the authority in exercising its duties and powers. The
13authority shall define the duties of the committee and provide reimbursement for the
14expenses of the committee.
AB365-SSA3,48,1515 (g) Execute contracts and other instruments.
AB365-SSA3,48,1716 (h) Accept gifts, grants, loans, or other contributions from private or public
17sources.
AB365-SSA3,48,1818 (i) Procure liability insurance.
AB365-SSA3,48,19 19(2) The authority may not issue bonds.
AB365-SSA3,48,24 20656.47 Contracting for professional services. (1) Contracting.
21Whenever contracting for professional services, the authority shall solicit
22competitive sealed bids or competitive sealed proposals, whichever is appropriate.
23Each request for competitive sealed proposals shall state the relative importance of
24price and other evaluation factors.
AB365-SSA3,49,8
1(2) Solicitation procedures. (a) When the estimated cost exceeds $25,000, the
2authority may invite competitive sealed bids or proposals by publishing a class 2
3notice under ch. 985 or by posting notice on the Internet at a site determined or
4approved by the authority. The notice shall describe the contractual services to be
5purchased, the intent to make the procurement by solicitation of bids or proposals,
6any requirement for surety, and the date the bids or proposals will be opened, which
7shall be at least 7 days after the date of the last insertion of the notice or at least 7
8days after the date of posting on the Internet.
AB365-SSA3,49,119 (b) When the estimated costs is $25,000 or less, the authority may award the
10contract in accordance with simplified procedures established by the authority for
11such transactions.
AB365-SSA3,49,1512 (c) For purposes of clarification, the authority may discuss the requirements
13of the proposed contract with any person who submits a bid or proposal and shall
14permit any offerer to revise his or her bid or proposal to ensure its responsiveness to
15those requirements.
AB365-SSA3,49,23 16(3) Negotiation. (a) The authority shall determine which bids or proposals are
17reasonably likely to be awarded the contract and shall provide each offerer of such
18bid or proposal a fair and equal opportunity to discuss the bid or proposal. The
19authority may negotiate with each offerer in order to obtain terms that are
20advantageous to the authority. Prior to the award of the contract, any offerer may
21revise his or her bid proposal. The authority shall keep a written record of all
22meetings, conferences, oral presentations, discussions, negotiations, and
23evaluations of bids or proposals under this section.
AB365-SSA3,50,3
1(b) In opening, discussing, and negotiating bids or proposals, the authority may
2not disclose any information that would reveal the terms of a competing bid or
3proposal.
AB365-SSA3,50,9 4(4) Awarding of contract. (a) After receiving each offerer's best and final offer,
5the authority shall determine which proposal is most advantageous and shall award
6the contract to the person who offered it. The authority's determination shall be
7based only on price and the other evaluation factors specified in the request for bids
8or proposals. The authority shall state in writing the reason for the award and shall
9place the statement in the contract file.
AB365-SSA3,50,1110 (b) Following the award of the contract, the authority shall prepare a register
11of all bids or proposals.
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