AB500,25,17 16(7) "Poverty line" means the poverty line as defined and revised annually under
1742 USC 9902 (2).
AB500,25,19 18(8) "Qualifying coverage" means benefits or coverage provided under any of the
19following:
AB500,25,2020 (a) Medicare or medicaid.
AB500,25,2221 (b) An employer-based health insurance or health benefit arrangement that
22provides benefits similar to or exceeding benefits provided under the basic plan.
AB500,26,223 (c) Except for a policy under the health insurance risk-sharing plan or an
24alternative plan under subch. II of ch. 619, an individual health insurance policy that

1provides benefits similar to or exceeding benefits provided under the basic plan if the
2policy has been in effect for at least one year.
AB500,26,8 3637.05 Basic plan. (1) The commissioner shall by rule design a health care
4plan that provides basic coverage of hospital, surgical and medical services and
5items. The basic plan shall provide both single and family coverage. The
6commissioner shall require a copayment of at least $2 for every service or item
7covered under the basic plan. The commissioner may by rule exempt the basic plan
8from any health insurance mandate, as defined in s. 601.423 (1).
AB500,26,12 9(2) The commissioner shall administer the basic plan under this chapter and
10may promulgate rules relating to the operation and administration of the basic plan,
11including rules that are designed to reduce adverse selection, or the effects of adverse
12selection, in relation to the basic plan.
AB500,26,16 13(3) The commissioner shall ensure that individuals and employers may obtain,
14and that medical assistance recipients shall receive, coverage under the basic plan
15no later than the first day of the 12th month beginning after the date on which the
16department of health and social services makes a certification under s. 49.44 (5).
AB500,27,2 17637.10 Designating regions; selecting insurers. (1) The commissioner
18may divide the state into regions for the purpose of pooling individuals and employes
19with coverage under the basic plan if the commissioner determines that regional
20pools will result in more efficient and cost-effective delivery of health care coverage
21or services. The commissioner shall select insurers to provide coverage under the
22basic plan using a competitive sealed proposal process. Any insurer authorized to
23do a health insurance business in this state may submit a proposal to provide
24coverage under a basic health insurance plan that complies with this chapter, any

1rules promulgated under this chapter and the terms of any waiver under s. 49.44 (2)
2or any legislation under s. 49.44 (3).
AB500,27,5 3(2) An insurer selected by the commissioner shall comply with any
4requirements imposed by the commissioner related to the insurer's provision of
5coverage under the basic plan.
AB500,27,10 6637.15 Coverage eligibility and entitlement. (1) Beginning on the first
7day of the 12th month beginning after the date on which the department of health
8and social services makes a certification under s. 49.44 (5), persons eligible for
9medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or
1049.47 (4) (a) 1. or 2. shall receive coverage, under s. 49.44 (6), under the basic plan.
AB500,27,14 11(2) Beginning on the first day of the 12th month beginning after the date on
12which the department of health and social services makes a certification under s.
1349.44 (5), all of the following are eligible to purchase coverage under the basic plan,
14subject to sub. (4):
AB500,27,1515 (a) Any employer.
AB500,27,1716 (b) Except as provided in sub. (3), any individual who is a resident of this state
17and who is not employed by an employer that offers coverage under the basic plan.
AB500,27,22 18(3) An individual who, on the first day of the 12th month beginning after the
19date on which the department of health and social services makes a certification
20under s. 49.44 (5), has coverage under the health insurance risk-sharing plan under
21subch. II of ch. 619 or an alternative plan under s. 619.145 is not eligible for coverage
22under the basic plan.
AB500,28,2 23(4) An employer or individual under sub. (2) who is covered under the basic
24plan and who voluntarily terminates that coverage is not again eligible for coverage

1under the basic plan until 12 months have elapsed since the employer or individual
2last voluntarily terminated coverage under the basic plan.
AB500,28,5 3637.20 Guaranteed issue. Subject to s. 637.15 (3) and (4), an insurer that is
4selected by the commissioner under s. 637.10 shall provide coverage, regardless of
5health condition or claims experience, to all of the following:
AB500,28,7 6(1) To an employer and to any of the employer's employes and their dependents,
7if all of the following apply:
AB500,28,98 (a) The employer agrees to pay the premium required for coverage under the
9basic plan, less any subsidy for which an employe may be eligible under s. 637.27.
AB500,28,1210 (b) The employer agrees to comply with all other provisions of the basic plan
11that apply generally to a policyholder or an insured without regard to health
12condition or claims experience.
AB500,28,16 13(2) To any employe, and to the dependents of the employe, for whom an
14employer with coverage under the basic plan desires to provide coverage after the
15commencement of the employer's coverage, if the employer agrees to pay the required
16premium less any subsidy for which the employe may be eligible under s. 637.27.
AB500,28,18 17(3) To an individual under s. 637.15 (2) (b) and his or her dependents, if all of
18the following apply:
AB500,28,2019 (a) The individual agrees to pay the premium required for coverage under the
20basic plan, less any subsidy for which the individual may be eligible under s. 637.27.
AB500,28,2321 (b) The individual agrees to comply with all other provisions of the basic plan
22that apply generally to a policyholder or an insured without regard to health
23condition or claims experience.
AB500,28,25 24(4) To a person who is eligible for medical assistance under s. 49.46 (1) (a) 1.,
251m., 6. or 12., (c), (cg), (co), (cr) or (cs) or 49.47 (4) (a) 1. or 2.
AB500,29,5
1637.23 Preexisting conditions and portability. (1) The basic plan may not
2deny, exclude or limit benefits for a covered individual for losses incurred more than
312 months after the effective date of the individual's coverage due to a preexisting
4condition. The basic plan may not define a preexisting condition more restrictively
5than any of the following:
AB500,29,96 (a) A condition that would have caused an ordinarily prudent person to seek
7medical advice, diagnosis, care or treatment during the 12 months immediately
8preceding the effective date of coverage and for which the individual did not seek
9medical advice, diagnosis, care or treatment.
AB500,29,1210 (b) A condition for which medical advice, diagnosis, care or treatment was
11recommended or received during the 12 months immediately preceding the effective
12date of coverage.
AB500,29,1613 (c) A pregnancy existing on the effective date of coverage, except that coverage
14may not be excluded for covered expenses related to such a pregnancy that exceed
15$5,000. Coverage not excluded may be subject to any deductibles or copayments that
16apply generally under the policy.
AB500,29,20 17(2) Notwithstanding sub. (1), the basic plan may not deny, exclude or limit
18benefits for a covered individual or his or her dependents for losses incurred due to
19a preexisting condition if the individual is a person who receives coverage under the
20basic plan under s. 637.15 (1).
AB500,30,2 21(3) (a) Notwithstanding sub. (1), the basic plan may not deny, exclude or limit
22benefits for a covered individual or his or her dependents for losses due to a
23preexisting condition if the individual applies for coverage during a 30-day
24enrollment period specified by the commissioner by rule under par. (b), provided that

1an individual who is eligible for coverage under s. 637.15 (2) (b) has been a resident
2of this state for at least 6 months on the effective date of the individual's coverage.
AB500,30,63 (b) The commissioner shall by rule specify a biennial 30-day enrollment period
4during which individuals and their dependents may obtain coverage under the basic
5plan without any preexisting condition exclusion or limitation, as provided in par.
6(a).
AB500,30,11 7(4) (a) The basic plan shall waive any period applicable to a preexisting
8condition exclusion or limitation period with respect to particular services for the
9period that an individual was previously covered by qualifying coverage that
10provided benefits with respect to such services, if the qualifying coverage terminated
11not more than 60 days before the effective date of the new coverage.
AB500,30,1712 (b) Paragraph (a) does not prohibit the application of a waiting period to all new
13enrollees under the basic plan issued to an employer; however, a waiting period may
14not be counted when determining whether the qualifying coverage terminated not
15more than 60 days before the effective date of the new coverage. For the purpose of
16par. (a), the new coverage shall be considered effective as of the date that it would
17be effective but for the waiting period.
AB500,30,20 18637.25 Premiums; community rates. (1) Except as provided in subs. (2) and
19(4), an insurer that provides coverage under the basic plan shall charge a community
20rate for such coverage.
AB500,30,23 21(2) Subject to rate bands prescribed by the commissioner by rule, an insurer
22may modify the community rate under sub. (1) by taking into account the following
23factors:
AB500,30,2424 (a) The insured's age.
AB500,30,2525 (b) The insured's gender.
AB500,31,1
1(c) The insured's geographic area.
AB500,31,22 (d) The insured's tobacco use.
AB500,31,43 (e) Whether the insured's coverage is single coverage or a type of family
4coverage.
AB500,31,7 5(3) For each of the following factors, the rate bands prescribed by the
6commissioner by rule may not restrict the ratio of the highest variance to the lowest
7variance to a ratio that is less than the ratio shown after each factor:
AB500,31,88 (a) For age, a ratio of 2.5.
AB500,31,99 (b) For gender, a ratio of 1.2.
AB500,31,1010 (c) For geographic area, a ratio of 1.2.
AB500,31,17 11(4) Notwithstanding subs. (1) and (2), the commissioner may promulgate rules
12that permit an insurer to vary from the community rate required under sub. (1) and
13modified under sub. (2) within restrictions provided in the rules. The restrictions
14provided in the rules shall be reasonably designed to provide for an orderly transition
15to the community rates required under sub. (1) and modified under sub. (2) by no
16later than the first day of the 24th month beginning after the date on which the
17department of health and social services makes a certification under s. 49.44 (5).
AB500,31,20 18(5) An employer may pay any portion or all of the premium, or the premium
19less a subsidy under s. 637.27, on behalf of an employe who is not a medical
20assistance recipient.
AB500,31,22 21637.26 Abortion coverage. The basic plan may provide coverage for services
22related to the performance of an abortion only if any of the following applies:
AB500,32,5 23(1) The abortion is directly and medically necessary to save the life of the
24woman or in a case of sexual assault or incest, provided that prior thereto the
25physician signs a certification which so states, and provided that, in the case of

1sexual assault or incest the crime has been reported to the law enforcement
2authorities. The certification shall be affixed to the claim form or invoice when
3submitted to an insurer for payment, and shall specify and attest to the direct
4medical necessity of such abortion upon the best clinical judgment of the physician
5or attest to his or her belief that sexual assault or incest has occurred.
AB500,32,12 6(2) The physician performing the abortion determines that, due to a medical
7condition existing prior to the abortion, the abortion is directly and medically
8necessary to prevent grave, long-lasting physical health damage to the woman,
9provided that prior thereto the physician signs a certification which so states. The
10certification shall be affixed to the claim form or invoice when submitted to an
11insurer for payment, and shall specify and attest to the direct medical necessity of
12such abortion upon the best clinical judgment of the physician.
AB500,32,19 13637.27 Premium subsidies. (1) The commissioner shall establish and
14administer a program to subsidize, from the appropriations under s. 20.145 (9) (c)
15and (i), the premium cost for coverage under the basic plan for an individual other
16than a medical assistance recipient or for an employe whose employer provides
17coverage for the employe under the basic plan, if the individual or employe had a
18family income in the preceding year that was less than 200% of the poverty line for
19a family the size of the individual's or employe's family.
AB500,33,4 20(2) Except as provided in rules promulgated under sub. (3) (d) to (f), for an
21individual or employe who is eligible for a subsidy under sub. (1) and whose family
22income in the preceding year did not exceed 100% of the poverty line for a family the
23size of the individual's or employe's family, the subsidy amount shall be 100% of the
24cost of coverage under the basic plan. Except as provided in rules promulgated under
25sub. (3) (d) to (f), for all other individuals or employes who are eligible for a subsidy

1under sub. (1), the subsidy amount shall be reduced from 100% of the cost of coverage
2by one percentage point for every percentage point that the individual's or employe's
3family income in the preceding year exceeded 100% of the poverty line for a family
4the size of the individual's or employe's family.
AB500,33,5 5(3) The commissioner shall promulgate rules that do all of the following:
AB500,33,66 (a) Define family income for purposes of this section.
AB500,33,97 (b) Specify how an individual, employe or employer may provide satisfactory
8evidence of family income to the insurer providing coverage under the basic plan for
9the individual or employe.
AB500,33,1210 (c) Establish procedures for paying subsidies to insurers for the cost of coverage
11under the basic plan for individuals or employes eligible for a subsidy under this
12section.
AB500,33,1413 (d) Establish asset-based eligibility criteria for premium subsidies under this
14section.
AB500,33,1715 (e) Limit an individual's eligibility for premium subsidies under this section for
16specified periods, if the individual transfers assets or income for less than fair market
17within a specified period prior to applying for a premium subsidy under this section.
AB500,33,1918 (f) Provide for reducing or eliminating premium subsidies under this section
19for violations of this chapter or of rules promulgated under this chapter.
AB500,33,2220 (g) Provide for the recovery of premium subsidies paid under this section, if the
21family income of a recipient of a premium subsidy increases above the level at which
22the recipient is eligible for a premium subsidy under this section.
AB500,33,23 23637.30 Commissioner duties. The commissioner shall do all of the following:
AB500,33,25 24(1) Enter into contracts with insurers selected under s. 637.10 to provide
25coverage under the basic plan.
AB500,34,6
1(2) After reasonable notice and opportunity for hearing, recover premium
2subsidies paid under s. 637.27 that are improperly or erroneously paid, by offsetting
3or adjusting amounts owed to the insurer under this chapter, by crediting against an
4insurer's future claims for premium subsidies or by requiring the insurer to make
5direct payment to the commissioner. Any moneys received under this subsection
6shall be credited to the appropriation under s. 20.145 (9) (i).
AB500,34,13 7(3) Review the statutory provisions governing the provision of coverage under
8the basic plan to medical assistance recipients and, if the commissioner determines
9that remedial legislation is required, submit proposed remedial legislation to the
10appropriate standing committees of the legislature under s. 13.172 (3), no later than
11the first day of the first floorperiod ending before the first day of the 12th month
12beginning after the date on which the department makes a certification under s.
1349.44 (5).
AB500, s. 66 14Section 66. Initial applicability.
AB500,34,19 15(1)  Basic plan premium subsidies. The treatment of sections 20.145 (9) (c) and
16(i) and 637.27 of the statutes first applies to subsidies for premiums for coverage
17under the basic plan that commences on the first day of the 12th month beginning
18after the date on which the department of health and social services makes a
19certification under section 49.44 (5) of the statutes, as created by this act.
AB500,34,2020 (End)
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