AB500: Bill Text

1995 - 1996 LEGISLATURE

1995 Assembly BILL 500

August 7, 1995 - Introduced by Representatives Wood, Underheim, Grobschmidt, Huber, Klusman, Krusick, Springer, F. Lasee, Albers, Ziegelbauer, Goetsch, Ladwig, Musser, Baldus, Boyle, Reynolds, Hasenohrl, Kreuser, Hahn, Otte and Olsen, cosponsored by Senators Weeden, Huelsman and Andrea. Referred to Committee on Health.

AB500,2,2 An Act to repeal 49.47 (6) (a) 1. and 49.47 (6) (a) 6m.; to renumber 632.72 (1) and 632.755 (2); to renumber and amend 49.002 (2), 49.01 (5m), 49.043, 49.06 (3), 49.47 (6) (a) (intro.), 49.47 (6) (a) 6., 49.47 (6) (a) 7. and 635.01; to consolidate, renumber and amend 49.035 (1) (intro.) and (d) and 49.046 (3) (b) 1. to 3.; to amend 20.435 (4) (eb), 40.51 (8), 40.51 (9), 40.51 (15m), 46.275 (6), 46.278 (8), 49.015 (3), 49.032 (4r), 49.035 (2) (b) 7. and 8., 49.035 (2) (cm) (intro.), 49.035 (4e) (a) and (b), 49.035 (6) (am) and (b), 49.43 (8), 49.43 (10), 49.45 (8m) (intro.), 49.45 (24m) (a), 49.45 (37) (intro.), 49.46 (2) (a) (intro.), 49.46 (2) (b) (intro.), 49.475 (1) (a), 613.03 (3), 625.12 (2), 625.15 (1), 625.22 (1), 628.34 (3), 628.36 (2) (b) 5. and 632.70; and to create 20.145 (9), 40.51 (17), 46.27 (11) (e), 49.002 (2) (b), 49.01 (5m) (b), 49.02 (5m), 49.02 (20), 49.035 (4e) (d), 49.043 (2), 49.046 (3) (b) 2., 49.046 (4) (bm), 49.06 (3) (b), 49.44, 49.45 (50), 49.46 (2) (bm), 49.465 (10), 49.47 (6) (ag) 7., 49.47 (6) (as), 49.47 (15), 49.49 (7), 632.72 (1c), 632.755 (2) (a), 635.01 (2) and chapter 637 of the statutes; relating to: creating a basic health insurance plan, establishing a subsidy program for premiums under that plan, seeking a federal waiver or federal legislation regarding medical assistance, medical assistance benefits and providers, medical benefits under the general relief and relief of needy Indian persons programs, granting rule-making authority and making appropriations.

Analysis by the Legislative Reference Bureau

This bill requires the department of health and social services (DHSS) to request a waiver, developed in consultation with and approved by the commissioner of insurance (commissioner), from the secretary of the federal department of health and human services to allow the state to receive federal funding to provide health care coverage under a basic health insurance plan (basic plan), to be designed by rule and administered by the commissioner, to certain persons who are eligible for medical assistance for reasons related to aid to families with dependent children eligibility (covered persons). If the waiver request is denied, DHSS is required to seek federal legislation instead of a waiver. Any waiver or legislation must seek to obtain an amount of federal funding, expressed as a percentage of total program costs, including both administrative and benefit costs, to cover eligible persons under the basic plan that either exceeds or is substantially equivalent to the amount of federal funding, expressed as a percentage of total program costs, including both administrative and benefit costs, available to provide medical assistance to covered persons. If DHSS determines that a waiver is approved, or legislation is enacted, that meets the maintenance of federal effort requirement and if DHSS determines that state legislation has been enacted making appropriations specifically for the purpose of providing health care coverage under the basic plan to covered persons and specifically for the purpose of funding premium subsidies, DHSS is required to certify its determination to the commissioner on the first day of the first month beginning after the waiver is approved or the legislation is enacted. The commissioner is required to implement that basic plan coverage no later than the first day of the 12th month beginning after the certification is made.

The basic plan is to be designed to provide basic coverage of hospital, surgical and medical services and items. It must provide both single and family coverage; it must require a copayment of at least $2 for every service or item covered; it may be exempted by the commissioner from any health insurance mandate; and it may not provide abortion coverage except in a case of sexual assault or incest or if the abortion is medically necessary to save the life of the woman or to prevent grave, long-lasting physical health damage to the woman due to a medical condition existing prior to the abortion. Any employer, including the state and its political subdivisions, and any individual who is a resident of this state and who does not have coverage under the basic plan through an employer, except for an individual who has coverage under the health insurance risk sharing plan (HIRSP), is eligible to purchase coverage under the basic plan. Such an employer or individual who voluntarily terminates coverage under the basic plan is not eligible again for coverage under the basic plan for 12 months.

The commissioner may, but is not required to, divide the state into regions for the purpose of pooling individuals and employes with coverage under the basic plan. The commissioner must select insurers to provide coverage under the basic plan by using a competitive sealed proposal process.

An insurer that is selected by the commissioner to provide coverage must provide coverage under the basic plan, without regard to health condition or claims experience, to any employer that agrees to pay the premium and comply with all other plan provisions and to any of the employer's employes and their dependents; to any individual who is eligible for coverage and who agrees to pay the premium and comply with all other plan provisions and to such an individual's dependents; and to any individual who is entitled to coverage and to such an individual's dependents. Coverage under the basic plan must be community rated. The community rates, however, may be modified according to the insured's age, gender, geographic area and tobacco use and by whether the insured's coverage is single or family. The commissioner must by rule prescribe rate bands for the modifications and may also by rule prescribe rate restrictions that provide for a transition to the modified community rates.

The basic plan may not deny, exclude or limit benefits on account of a preexisting condition for more than 12 months after the commencement of coverage (and may not deny, exclude or limit benefits on account of a preexisting condition for any amount of time for a person who has coverage because he or she is eligible for medical assistance) and may not define a preexisting condition more restrictively than a condition for which the insured sought or should have sought medical care during the 12 months immediately preceding coverage or more restrictively than a pregnancy existing on the effective date of coverage, except that coverage may not be excluded for covered expenses for such a pregnancy that exceed $5,000. An individual who has been a resident for at least 6 months or an employe may obtain coverage without any preexisting condition exclusion or limitation if he or she applies for coverage during a biennial 30-day open enrollment period specified by the commissioner by rule. Additionally, the basic plan must waive any period applicable to a preexisting condition exclusion or limitation that was satisfied under another health care plan, including medical assistance but excluding HIRSP, under which the insured had coverage that terminated 60 days or fewer before the effective date of coverage under the basic plan. These preexisting condition exclusion or limitation and portability provisions are very similar to those required under current law for a group health benefit plan issued to a small employer (one that employs between 2 and 25 employes with a normal work week of 30 or more hours). Under current law, a group health benefit plan issued to a small employer may not exclude or limit benefits on account of a preexisting condition for more than 12 months after the commencement of coverage and may not define a preexisting condition more restrictively than a pregnancy existing on the effective date of coverage or a condition for which the insured sought or should have sought medical care during the 6 months immediately preceding coverage. Additionally, such a plan must waive any period applicable to a preexisting-condition exclusion or limitation that was satisfied under another plan, including medical assistance, under which the insured had coverage to a date not less than 30 days before the effective date of coverage under the new plan.

The bill requires the commissioner to establish and administer a program to subsidize premiums for coverage under the basic plan. An individual or an employe, other than one eligible for medical assistance, would be eligible for a premium subsidy if he or she had a family income in the preceding year that was less than 200% of the poverty line for a family the size of his or her family. For an individual or an employe with a family income that did not exceed 100% of the poverty line, the amount of the premium subsidy would be 100% of the premium cost. For an individual or an employe with a family income of between 100% and 200% of the poverty line, the amount of the premium subsidy would be reduced from 100% of the premium cost by one percentage point for every percentage point that the individual's or employe's family income exceeded 100% of the poverty line.

Upon implementation of the basic plan, medical benefits will no longer be available under the general relief or relief of needy Indian persons programs, although agencies administering these programs are required to assist recipients under these programs in obtaining coverage and a premium subsidy under the basic plan. In addition, medical assistance benefits for covered persons will be limited to coverage under the basic plan or, in some cases, payment of medicare premiums, copayments and deductibles.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB500, s. 1 Section 1. 20.145 (9) of the statutes is created to read:

AB500,4,3 20.145 (9) Basic health plan. (c) Premium subsidies. A sum sufficient for the premium subsidies under s. 637.27.

AB500,4,6 (i) Recovery of premium subsidies. All moneys received from the recovery, under s. 637.30 (2), of premium subsidies, for the payment of premium subsidies under s. 637.27.

AB500, s. 2 Section 2. 20.435 (4) (eb) of the statutes is amended to read:

AB500,4,10 20.435 (4) (eb) General relief aid. The amounts in the schedule for state aid to counties for eligible general relief costs as determined under s. 49.035 (4e) (a) and (b).

AB500, s. 3 Section 3. 40.51 (8) of the statutes is amended to read:

AB500,5,4 40.51 (8) Every Except as provided in sub. (17), every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 632.72 (2), 632.87 (3) to (5), 632.895 (5m) and (8) to (10) and 632.896.

AB500, s. 4 Section 4. 40.51 (9) of the statutes is amended to read:

AB500,5,8 40.51 (9) Every Except as provided in sub. (17), every health maintenance organization and preferred provider plan offered by the state under sub. (6) shall comply with s. 632.87 (2m).

AB500, s. 5 Section 5. 40.51 (15m) of the statutes is amended to read:

AB500,5,12 40.51 (15m) Every Except as provided in sub. (17), every health care plan, except a health maintenance organization or a preferred provider plan, offered by the state under sub. (6) shall comply with s. 632.86.

AB500, s. 6 Section 6. 40.51 (17) of the statutes is created to read:

AB500,5,17 40.51 (17) If one of the plans offered by the state under sub. (6) is the basic plan under ch. 637, that plan is required to comply with only those health insurance mandates, as defined in s. 601.423 (1), that the commissioner of insurance determines by rule under s. 637.05 (1) apply to the basic plan under ch. 637.

AB500, s. 7 Section 7. 46.27 (11) (e) of the statutes is created to read:

AB500,5,23 46.27 (11) (e) Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), the department may not provide home and community-based services under this subsection to 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.

AB500, s. 8 Section 8. 46.275 (6) of the statutes is amended to read:

AB500,6,10 46.275 (6) Effective period. This section takes effect on the date approved by the secretary of the U.S. federal department of health and human services as the beginning date of the period of waiver received under sub. (2). This section remains in effect for 3 years following that date and, if the secretary of the U.S. federal department of health and human services approves a waiver extension, shall continue an additional 3 years, except that, beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), the department may not provide services under this section to 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.

AB500, s. 9 Section 9. 46.278 (8) of the statutes is amended to read:

AB500,6,21 46.278 (8) Effective period. Except as provided under sub. (2), this section takes effect on the date approved by the secretary of the federal department of health and human services as the beginning date of the period of waiver received under sub. (3). This section remains in effect for 3 years following that date and, if the secretary of the federal department of health and human services approves a waiver extension, shall continue an additional 3 years, except that, beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), the department may not provide services under this section to 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.

AB500, s. 10 Section 10. 49.002 (2) of the statutes is renumbered 49.002 (2) (a) and amended to read:

AB500,7,7 49.002 (2) (a) It Before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), it is the declared legislative policy that general relief is the payer of last resort in all cases, except those cases involving crime victim awards under s. 949.06, where a dispute may arise over payment for costs associated with maintaining the health and welfare of recipients of general relief, including disputes concerning health care costs with private or public payees of health care costs, other governmental welfare programs, rehabilitation programs and programs requiring institutionalization or long-term medical and psychiatric treatment.

AB500, s. 11 Section 11. 49.002 (2) (b) of the statutes is created to read:

AB500,7,14 49.002 (2) (b) Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), it is the declared legislative policy that general relief is the payer of last resort in all cases, except those cases involving crime victim awards under s. 949.06, where a dispute may arise over payment for costs associated with maintaining the welfare of recipients of general relief.

AB500, s. 12 Section 12. 49.01 (5m) of the statutes is renumbered 49.01 (5m) (a) and amended to read:

AB500,8,4 49.01 (5m) (a) "General Before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), "general relief" means such services, commodities or money moneys as are reasonable and necessary under the circumstances to provide food, housing, clothing, fuel, light, water, medicine, medical, dental, and surgical treatment (including hospital care), optometrical services, nursing, transportation, and funeral expenses, and include includes wages for work relief. The food furnished shall be of a kind and quantity sufficient to provide a nourishing diet. The housing provided shall be adequate for health and decency. Where there are children of school age the general relief furnished shall include necessities for which no other provision is made by law. The general relief furnished, whether by money or otherwise, shall be at such times and in such amounts, as will in the discretion of the general relief official or agency meet the needs of the recipient and protect the public.

AB500, s. 13 Section 13. 49.01 (5m) (b) of the statutes is created to read:

AB500,8,16 49.01 (5m) (b) Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), "general relief" means such services, commodities or moneys as are reasonable and necessary under the circumstances to provide food, housing, clothing, fuel, light, water, transportation, and funeral expenses, and includes wages for work relief. The food furnished shall be of a kind and quantity sufficient to provide a nourishing diet. The housing provided shall be adequate for health and decency. Where there are children of school age the general relief furnished shall include necessities for which no other provision is made by law. The general relief furnished, whether by money or otherwise, shall be at such times and in such amounts, as will in the discretion of the general relief official or agency meet the needs of the recipient and protect the public.

AB500, s. 14 Section 14. 49.015 (3) of the statutes is amended to read:

AB500,8,25 49.015 (3) After December 31, 1986, a A general relief agency may waive the requirement under sub. (1) (b) or (2) (a) in a medical emergency or in case of unusual misfortune or hardship. Before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), a general relief agency may also waive the requirement under sub. (1) (b) or (2) (a) in a medical emergency. Each waiver shall be reported to the department. The department may deny reimbursement under s. 49.035 for any case in which a waiver is inappropriately granted.

AB500, s. 15 Section 15. 49.02 (5m) of the statutes is created to read:

AB500,9,6 49.02 (5m) Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), the general relief agency shall assist general relief recipients in applying for health care coverage under the basic plan under s. 637.05 and in applying for a premium subsidy under s. 637.27.

AB500, s. 16 Section 16. 49.02 (20) of the statutes is created to read:

AB500,9,10 49.02 (20) Subsections (5), (6c), (6g), (6r), (8), (9) and (10) do not apply beginning on 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. 17 Section 17. 49.032 (4r) of the statutes is amended to read:

AB500,9,16 49.032 (4r) If a general relief agency provides a monthly general relief benefit to an eligible dependent person which exceeds the monthly benefit amount required under sub. (1) (c), the department shall reimburse the general relief agency at the rate set forth under s. 49.035 (1) (d), from the appropriation under s. 20.435 (4) (eb), for the amount paid to the eligible dependent person.

AB500, s. 18 Section 18. 49.035 (1) (intro.) and (d) of the statutes are consolidated, renumbered 49.035 (1) and amended to read:

AB500,9,21 49.035 (1) As provided in sub. (4e), the department shall reimburse, except for medical costs: (d) A, a county for up to 37.5% of the eligible costs paid by the general relief agency for general relief provided under s. 49.02.

AB500, s. 19 Section 19. 49.035 (2) (b) 7. and 8. of the statutes are amended to read:

AB500,9,24 49.035 (2) (b) 7. Up to 40% of eligible medical costs that are incurred by the county before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), that are incurred on behalf of an individual client and that are not more than $10,000 per claim period.

AB500,10,6 8. Up to 70% of eligible medical costs that are incurred by the county before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), that are incurred on behalf of an individual client and that exceed $10,000 per claim period.

AB500, s. 20 Section 20. 49.035 (2) (cm) (intro.) of the statutes is amended to read:

AB500,10,12 49.035 (2) (cm) (intro.) A county for up to 60% of the eligible medical costs that are incurred before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5) for individual clients who are enrolled in a prepaid health care system with a uniform fee per person, if the following requirements are met:

AB500, s. 21 Section 21. 49.035 (4e) (a) and (b) of the statutes are amended to read:

AB500,10,21 49.035 (4e) (a) If claims for reimbursement of eligible general relief costs at the maximum rates under subs. (1) and (2) do not exceed the total of the funds available under s. 20.435 (4) (eb) and the payments to county hospitals and county mental health complexes under par. (c) for that fiscal year, the department shall determine the amount of a county's reimbursement from the appropriation under s. 20.435 (4) (eb) by applying the maximum rates under subs. (1) and (2) to the county's eligible costs and subtracting the amount paid to county hospitals and county mental health complexes in the county under par. (c).

AB500,11,5 (b) If claims for reimbursement of eligible general relief costs at the maximum rates under subs. (1) and (2) do exceed the total of the funds available under s. 20.435 (4) (eb) and the payments to county hospitals and county mental health complexes under par. (c) for that fiscal year, the department shall prorate the funds available under s. 20.435 (4) (eb) among the counties. Under this paragraph, the department shall determine the amount of a county's reimbursement from the appropriation under s. 20.435 (4) (eb) by subtracting the amount paid to county hospitals and county mental health complexes in the county under par. (c) from its prorated share of the funds available under s. 20.435 (4) (eb).

AB500, s. 22 Section 22. 49.035 (4e) (d) of the statutes is created to read:

AB500,11,10 49.035 (4e) (d) This subsection does not apply with respect to claims for reimbursement of eligible general relief costs that were incurred on or after 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. 23 Section 23. 49.035 (6) (am) and (b) of the statutes are amended to read:

AB500,11,15 49.035 (6) (am) Requires Before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), requires prior authorization or health care provider certification for a specified period of time by the general relief agency for all nonemergency medical care that is provided.

AB500,11,23 (b) Develops Before the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), develops and files with the department on or before October 1 of each year a medical cost containment plan for the subsequent calendar year. The plan shall include provisions limiting the inappropriate use of emergency room care and controlling payments to providers and may include provisions on supplying case management services. The department shall approve or disapprove the plan within a reasonable period of time after the plan is timely filed.

AB500, s. 24 Section 24. 49.043 of the statutes is renumbered 49.043 (1) and amended to read:

AB500,12,4 49.043 (1) Any Except as provided in sub. (2), any municipality or county may purchase health or dental insurance for unemployed persons residing in the municipality or county who are not eligible for medical assistance under s. 49.46, 49.468 or 49.47.

AB500, s. 25 Section 25. 49.043 (2) of the statutes is created to read:

AB500,12,8 49.043 (2) This section does not apply on or after 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. 26 Section 26. 49.046 (3) (b) 1. to 3. of the statutes are consolidated, renumbered 49.046 (3) (b) 1 and amended to read:

AB500,12,14 49.046 (3) (b) 1. Payments Except as provided in subd. 2., payments for medical care may be made for any benefit authorized under s. 49.46 (2). 2. Payments and shall be equal to the rates established under s. 49.45. 3. Recipients of aid for medical care are subject to the copayment provisions established under s. 49.45 (18).

AB500, s. 27 Section 27. 49.046 (3) (b) 2. of the statutes is created to read:

AB500,12,18 49.046 (3) (b) 2. This paragraph does not apply with respect to payments for medical care incurred on or after 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. 28 Section 28. 49.046 (4) (bm) of the statutes is created to read:

AB500,12,24 49.046 (4) (bm) Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), the administering agency shall assist recipients of aid under this section in applying for health care coverage under the basic plan under s. 637.05 and in applying for a premium subsidy under s. 637.27.

AB500, s. 29 Section 29. 49.06 (3) of the statutes is renumbered 49.06 (3) (a) and amended to read:

AB500,13,7 49.06 (3) (a) A Except as provided in par. (b), a general relief agency may adopt written criteria to deny eligibility for general relief medical benefits to a person who, in contemplation of becoming eligible to receive general relief benefits, disposes of his or her assets for significantly less than full value during the 90 days immediately before the person applies for general relief medical benefits.

AB500, s. 30 Section 30. 49.06 (3) (b) of the statutes is created to read:

AB500,13,11 49.06 (3) (b) This subsection does not apply after 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. 31 Section 31. 49.43 (8) of the statutes is amended to read:

AB500,13,19 49.43 (8) "Medical assistance" means any services or items under ss. 49.45 to 49.47 and 49.49 to 49.497, or any payment or reimbursement made for such services or items, and, beginning on the first day of the 12th month beginning after the date on which the department makes a determination under s. 49.44 (5), coverage under the basic plan under s. 637.05 provided to 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.