AB500: Bill Text

AB500,25,17 (7) "Poverty line" means the poverty line as defined and revised annually under 42 USC 9902 (2).

AB500,25,19 (8) "Qualifying coverage" means benefits or coverage provided under any of the following:

AB500,25,20 (a) Medicare or medicaid.

AB500,25,22 (b) An employer-based health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under the basic plan.

AB500,26,2 (c) Except for a policy under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619, an individual health insurance policy that provides benefits similar to or exceeding benefits provided under the basic plan if the policy has been in effect for at least one year.

AB500,26,8 637.05 Basic plan. (1) The commissioner shall by rule design a health care plan that provides basic coverage of hospital, surgical and medical services and items. The basic plan shall provide both single and family coverage. The commissioner shall require a copayment of at least $2 for every service or item covered under the basic plan. The commissioner may by rule exempt the basic plan from any health insurance mandate, as defined in s. 601.423 (1).

AB500,26,12 (2) The commissioner shall administer the basic plan under this chapter and may promulgate rules relating to the operation and administration of the basic plan, including rules that are designed to reduce adverse selection, or the effects of adverse selection, in relation to the basic plan.

AB500,26,16 (3) The commissioner shall ensure that individuals and employers may obtain, and that medical assistance recipients shall receive, coverage under the basic plan no later than the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5).

AB500,27,2 637.10 Designating regions; selecting insurers. (1) The commissioner may divide the state into regions for the purpose of pooling individuals and employes with coverage under the basic plan if the commissioner determines that regional pools will result in more efficient and cost-effective delivery of health care coverage or services. The commissioner shall select insurers to provide coverage under the basic plan using a competitive sealed proposal process. Any insurer authorized to do a health insurance business in this state may submit a proposal to provide coverage under a basic health insurance plan that complies with this chapter, any rules promulgated under this chapter and the terms of any waiver under s. 49.44 (2) or any legislation under s. 49.44 (3).

AB500,27,5 (2) An insurer selected by the commissioner shall comply with any requirements imposed by the commissioner related to the insurer's provision of coverage under the basic plan.

AB500,27,10 637.15 Coverage eligibility and entitlement. (1) Beginning on the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5), persons eligible for medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or 49.47 (4) (a) 1. or 2. shall receive coverage, under s. 49.44 (6), under the basic plan.

AB500,27,14 (2) Beginning on the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5), all of the following are eligible to purchase coverage under the basic plan, subject to sub. (4):

AB500,27,15 (a) Any employer.

AB500,27,17 (b) Except as provided in sub. (3), any individual who is a resident of this state and who is not employed by an employer that offers coverage under the basic plan.

AB500,27,22 (3) An individual who, on the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5), has coverage under the health insurance risk-sharing plan under subch. II of ch. 619 or an alternative plan under s. 619.145 is not eligible for coverage under the basic plan.

AB500,28,2 (4) An employer or individual under sub. (2) who is covered under the basic plan and who voluntarily terminates that coverage is not again eligible for coverage under the basic plan until 12 months have elapsed since the employer or individual last voluntarily terminated coverage under the basic plan.

AB500,28,5 637.20 Guaranteed issue. Subject to s. 637.15 (3) and (4), an insurer that is selected by the commissioner under s. 637.10 shall provide coverage, regardless of health condition or claims experience, to all of the following:

AB500,28,7 (1) To an employer and to any of the employer's employes and their dependents, if all of the following apply:

AB500,28,9 (a) The employer agrees to pay the premium required for coverage under the basic plan, less any subsidy for which an employe may be eligible under s. 637.27.

AB500,28,12 (b) The employer agrees to comply with all other provisions of the basic plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

AB500,28,16 (2) To any employe, and to the dependents of the employe, for whom an employer with coverage under the basic plan desires to provide coverage after the commencement of the employer's coverage, if the employer agrees to pay the required premium less any subsidy for which the employe may be eligible under s. 637.27.

AB500,28,18 (3) To an individual under s. 637.15 (2) (b) and his or her dependents, if all of the following apply:

AB500,28,20 (a) The individual agrees to pay the premium required for coverage under the basic plan, less any subsidy for which the individual may be eligible under s. 637.27.

AB500,28,23 (b) The individual agrees to comply with all other provisions of the basic plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

AB500,28,25 (4) To a person who is eligible for medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or 49.47 (4) (a) 1. or 2.

AB500,29,5 637.23 Preexisting conditions and portability. (1) The basic plan may not deny, exclude or limit benefits for a covered individual for losses incurred more than 12 months after the effective date of the individual's coverage due to a preexisting condition. The basic plan may not define a preexisting condition more restrictively than any of the following:

AB500,29,9 (a) A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 12 months immediately preceding the effective date of coverage and for which the individual did not seek medical advice, diagnosis, care or treatment.

AB500,29,12 (b) A condition for which medical advice, diagnosis, care or treatment was recommended or received during the 12 months immediately preceding the effective date of coverage.

AB500,29,16 (c) A pregnancy existing on the effective date of coverage, except that coverage may not be excluded for covered expenses related to such a pregnancy that exceed $5,000. Coverage not excluded may be subject to any deductibles or copayments that apply generally under the policy.

AB500,29,20 (2) Notwithstanding sub. (1), the basic plan may not deny, exclude or limit benefits for a covered individual or his or her dependents for losses incurred due to a preexisting condition if the individual is a person who receives coverage under the basic plan under s. 637.15 (1).

AB500,30,2 (3) (a) Notwithstanding sub. (1), the basic plan may not deny, exclude or limit benefits for a covered individual or his or her dependents for losses due to a preexisting condition if the individual applies for coverage during a 30-day enrollment period specified by the commissioner by rule under par. (b), provided that an individual who is eligible for coverage under s. 637.15 (2) (b) has been a resident of this state for at least 6 months on the effective date of the individual's coverage.

AB500,30,6 (b) The commissioner shall by rule specify a biennial 30-day enrollment period during which individuals and their dependents may obtain coverage under the basic plan without any preexisting condition exclusion or limitation, as provided in par. (a).

AB500,30,11 (4) (a) The basic plan shall waive any period applicable to a preexisting condition exclusion or limitation period with respect to particular services for the period that an individual was previously covered by qualifying coverage that provided benefits with respect to such services, if the qualifying coverage terminated not more than 60 days before the effective date of the new coverage.

AB500,30,17 (b) Paragraph (a) does not prohibit the application of a waiting period to all new enrollees under the basic plan issued to an employer; however, a waiting period may not be counted when determining whether the qualifying coverage terminated not more than 60 days before the effective date of the new coverage. For the purpose of par. (a), the new coverage shall be considered effective as of the date that it would be effective but for the waiting period.

AB500,30,20 637.25 Premiums; community rates. (1) Except as provided in subs. (2) and (4), an insurer that provides coverage under the basic plan shall charge a community rate for such coverage.

AB500,30,23 (2) Subject to rate bands prescribed by the commissioner by rule, an insurer may modify the community rate under sub. (1) by taking into account the following factors:

AB500,30,24 (a) The insured's age.

AB500,30,25 (b) The insured's gender.

AB500,31,1 (c) The insured's geographic area.

AB500,31,2 (d) The insured's tobacco use.

AB500,31,4 (e) Whether the insured's coverage is single coverage or a type of family coverage.

AB500,31,7 (3) For each of the following factors, the rate bands prescribed by the commissioner by rule may not restrict the ratio of the highest variance to the lowest variance to a ratio that is less than the ratio shown after each factor:

AB500,31,8 (a) For age, a ratio of 2.5.

AB500,31,9 (b) For gender, a ratio of 1.2.

AB500,31,10 (c) For geographic area, a ratio of 1.2.

AB500,31,17 (4) Notwithstanding subs. (1) and (2), the commissioner may promulgate rules that permit an insurer to vary from the community rate required under sub. (1) and modified under sub. (2) within restrictions provided in the rules. The restrictions provided in the rules shall be reasonably designed to provide for an orderly transition to the community rates required under sub. (1) and modified under sub. (2) by no later than the first day of the 24th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5).

AB500,31,20 (5) An employer may pay any portion or all of the premium, or the premium less a subsidy under s. 637.27, on behalf of an employe who is not a medical assistance recipient.

AB500,31,22 637.26 Abortion coverage. The basic plan may provide coverage for services related to the performance of an abortion only if any of the following applies:

AB500,32,5 (1) The abortion is directly and medically necessary to save the life of the woman or in a case of sexual assault or incest, provided that prior thereto the physician signs a certification which so states, and provided that, in the case of sexual assault or incest the crime has been reported to the law enforcement authorities. The certification shall be affixed to the claim form or invoice when submitted to an insurer for payment, and shall specify and attest to the direct medical necessity of such abortion upon the best clinical judgment of the physician or attest to his or her belief that sexual assault or incest has occurred.

AB500,32,12 (2) The physician performing the abortion determines that, due to a medical condition existing prior to the abortion, the abortion is directly and medically necessary to prevent grave, long-lasting physical health damage to the woman, provided that prior thereto the physician signs a certification which so states. The certification shall be affixed to the claim form or invoice when submitted to an insurer for payment, and shall specify and attest to the direct medical necessity of such abortion upon the best clinical judgment of the physician.

AB500,32,19 637.27 Premium subsidies. (1) The commissioner shall establish and administer a program to subsidize, from the appropriations under s. 20.145 (9) (c) and (i), the premium cost for coverage under the basic plan for an individual other than a medical assistance recipient or for an employe whose employer provides coverage for the employe under the basic plan, if the individual or employe had a family income in the preceding year that was less than 200% of the poverty line for a family the size of the individual's or employe's family.

AB500,33,4 (2) Except as provided in rules promulgated under sub. (3) (d) to (f), for an individual or employe who is eligible for a subsidy under sub. (1) and whose family income in the preceding year did not exceed 100% of the poverty line for a family the size of the individual's or employe's family, the subsidy amount shall be 100% of the cost of coverage under the basic plan. Except as provided in rules promulgated under sub. (3) (d) to (f), for all other individuals or employes who are eligible for a subsidy under sub. (1), the subsidy amount shall be reduced from 100% of the cost of coverage by one percentage point for every percentage point that the individual's or employe's family income in the preceding year exceeded 100% of the poverty line for a family the size of the individual's or employe's family.

AB500,33,5 (3) The commissioner shall promulgate rules that do all of the following:

AB500,33,6 (a) Define family income for purposes of this section.

AB500,33,9 (b) Specify how an individual, employe or employer may provide satisfactory evidence of family income to the insurer providing coverage under the basic plan for the individual or employe.

AB500,33,12 (c) Establish procedures for paying subsidies to insurers for the cost of coverage under the basic plan for individuals or employes eligible for a subsidy under this section.

AB500,33,14 (d) Establish asset-based eligibility criteria for premium subsidies under this section.

AB500,33,17 (e) Limit an individual's eligibility for premium subsidies under this section for specified periods, if the individual transfers assets or income for less than fair market within a specified period prior to applying for a premium subsidy under this section.

AB500,33,19 (f) Provide for reducing or eliminating premium subsidies under this section for violations of this chapter or of rules promulgated under this chapter.

AB500,33,22 (g) Provide for the recovery of premium subsidies paid under this section, if the family income of a recipient of a premium subsidy increases above the level at which the recipient is eligible for a premium subsidy under this section.

AB500,33,23 637.30 Commissioner duties. The commissioner shall do all of the following:

AB500,33,25 (1) Enter into contracts with insurers selected under s. 637.10 to provide coverage under the basic plan.

AB500,34,6 (2) After reasonable notice and opportunity for hearing, recover premium subsidies paid under s. 637.27 that are improperly or erroneously paid, by offsetting or adjusting amounts owed to the insurer under this chapter, by crediting against an insurer's future claims for premium subsidies or by requiring the insurer to make direct payment to the commissioner. Any moneys received under this subsection shall be credited to the appropriation under s. 20.145 (9) (i).

AB500,34,13 (3) Review the statutory provisions governing the provision of coverage under the basic plan to medical assistance recipients and, if the commissioner determines that remedial legislation is required, submit proposed remedial legislation to the appropriate standing committees of the legislature under s. 13.172 (3), no later than the first day of the first floorperiod ending before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5).

AB500, s. 66 Section 66. Initial applicability.

AB500,34,19 (1)  Basic plan premium subsidies. The treatment of sections 20.145 (9) (c) and (i) and 637.27 of the statutes first applies to subsidies for premiums for coverage under the basic plan that commences on the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under section 49.44 (5) of the statutes, as created by this act.

AB500,34,20 (End)