AB100-engrossed,2094,2420
149.14
(1) (b) If an individual terminates medical assistance coverage and
21applies for coverage under the plan within 45 days after the termination and is
22subsequently found to be eligible under s.
619.12
149.12, the effective date of
23coverage for the eligible person under the plan shall be the date of termination of
24medical assistance coverage.
AB100-engrossed, s. 4849
1Section
4849. 619.14 (2) of the statutes is renumbered 149.14 (2), and 149.14
2(2) (a), as renumbered, is amended to read:
AB100-engrossed,2095,93
149.14
(2) (a) The plan shall provide every eligible person who is not eligible
4for medicare with major medical expense coverage. Major medical expense coverage
5offered under the plan
under this section shall pay an eligible person's covered
6expenses, subject to sub. (3) and deductible and coinsurance payments authorized
7under sub. (5), up to a lifetime limit of
$500,000
$1,000,000 per covered individual.
8The maximum limit under this paragraph shall not be altered by the board, and no
9actuarially equivalent benefit may be substituted by the board.
AB100-engrossed, s. 4850
10Section
4850. 619.14 (3) of the statutes is renumbered 149.14 (3), and 149.14
11(3) (intro.) and (c) 3., as renumbered, are amended to read:
AB100-engrossed,2095,2412
149.14
(3) Covered expenses. (intro.) Except as restricted by cost containment
13provisions under s.
619.17 149.17 (4) and except as reduced by the board under s.
14619.15 149.15 (3) (e)
or by the department under s. 149.143 or 149.144, covered
15expenses
for the coverage under this section shall be the usual and customary
16charges for the services provided by persons licensed under ch. 446
and certified
17under s. 49.45 (2) (a) 11. Except as restricted by cost containment provisions under
18s.
619.17 149.17 (4) and except as reduced by the board under s.
619.15 149.15 (3) (e)
19or by the department under s. 149.143 or 149.144, covered expenses
for the coverage
20under this section shall also be the usual and customary charges for the following
21services and articles
when if the service or article is prescribed by a physician
who
22is licensed under ch. 448 or in another state
and who is certified under s. 49.45 (2)
23(a) 11. and if the service or article is provided by a provider certified under s. 49.45
24(2) (a) 11.:
AB100-engrossed,2096,3
1 (c) 3. Subject to the limits under subd. 2. and to rules promulgated by the
2commissioner department, services for the chronically mentally ill in community
3support programs operated under s. 51.421.
AB100-engrossed, s. 4851
4Section
4851. 619.14 (4) of the statutes is renumbered 149.14 (4), and 149.14
5(4) (intro.), (a) and (m), as renumbered, are amended to read:
AB100-engrossed,2096,76
149.14
(4) Exclusions. (intro.) Covered expenses
for the coverage under this
7section shall not include the following:
AB100-engrossed,2096,108
(a) Any charge for treatment for cosmetic purposes other than surgery for the
9repair or treatment of an injury or a congenital bodily defect.
Breast reconstruction
10incident to a mastectomy shall not be considered treatment for cosmetic purposes.
AB100-engrossed,2096,1211
(m) Experimental treatment, as determined by the
board or its designee 12department.
AB100-engrossed, s. 4852c
13Section 4852c. 619.14 (5) (title) of the statutes is renumbered 149.14 (5) (title)
14and amended to read:
AB100-engrossed,2096,1515
149.14
(5) (title)
Premiums, deductibles Deductibles and coinsurance.
AB100-engrossed, s. 4853
16Section
4853. 619.14 (5) (a) of the statutes is renumbered 149.14 (5) (a) and
17amended to read:
AB100-engrossed,2097,918
149.14
(5) (a) The plan shall offer a deductible in combination with appropriate
19premiums determined under this
subchapter chapter for major medical expense
20coverage required under this section. For coverage offered to those persons eligible
21for medicare, the plan shall offer a deductible equal to the deductible charged by part
22A of title XVIII of the federal social security act, as amended. The deductible
23amounts for all other eligible persons shall be dependent upon household income as
24determined under s.
619.165 149.165. For eligible persons under s.
619.165 (1) (b)
251. 149.165 (2) (a), the deductible shall be $500. For eligible persons under s.
619.165
1(1) (b) 2. 149.165 (2) (b), the deductible shall be $600. For eligible persons under s.
2619.165 (1) (b) 3. 149.165 (2) (c), the deductible shall be $700. For eligible persons
3under s.
619.165 (1) (b) 4. 149.165 (2) (d), the deductible shall be $800. For all other
4eligible persons who are not eligible for medicare, the deductible shall be $1,000.
5With respect to all eligible persons, expenses used to satisfy the deductible during
6the last 90 days of a calendar year shall also be applied to satisfy the deductible for
7the following calendar year.
The schedule of premiums shall be promulgated by rule
8by the commissioner. The commissioner shall set rates at 60% of the operating and
9administrative costs of the plan.
AB100-engrossed, s. 4856
12Section
4856. 619.14 (5) (d) of the statutes is renumbered 149.14 (5) (d) and
13amended to read:
AB100-engrossed,2097,1914
149.14
(5) (d) Notwithstanding pars. (a) to (c), the
board department may
15establish different deductible amounts, a different coinsurance percentage and
16different covered costs and deductible aggregate amounts from those specified in
17pars. (a) to (c) in accordance with cost containment provisions established by the
18commissioner department under s.
619.17 (4) (a) and for individuals who enroll in
19an alternative plan under s. 619.145 149.17 (4).
AB100-engrossed,2098,221
619.14
(5) (e) Using the procedure under s. 227.24, the commissioner may
22promulgate rules under par. (a)
or s. 619.146 (2) (b) for the schedule of premiums for
23the period before the effective date of any permanent rules promulgated under par.
24(a)
or s. 619.146 (2) (b) for the schedule of premiums, but not to exceed the period
1authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the
2commissioner is not required to make a finding of emergency.
AB100-engrossed, s. 4857c
3Section 4857c. 619.14 (5) (e) of the statutes, as affected by 1997 Wisconsin Act
4.... (this act), is repealed.
AB100-engrossed,2098,107
619.14
(6) (a)
No Except as provided in par. (b), no person who obtains coverage
8under the plan may be covered for any preexisting condition during the first 6 months
9of coverage under the plan if the person was diagnosed or treated for that condition
10during the 6 months immediately preceding the filing of an application with the plan.
AB100-engrossed, s. 4858c
11Section 4858c. 619.14 (6) of the statutes, as affected by 1997 Wisconsin Act
12.... (this act), is renumbered 149.14 (6).
AB100-engrossed,2098,1914
619.14
(6) (b) An eligible individual who obtains coverage under the plan on
15or after the effective date of this paragraph .... [revisor inserts date], may not be
16subject to any preexisting condition exclusion under the plan. An eligible individual
17who is covered under the plan on the effective date of this paragraph .... [revisor
18inserts date], may not be subject to any preexisting condition exclusion on or after
19the effective date of this paragraph .... [revisor inserts date].
AB100-engrossed, s. 4859
20Section
4859. 619.14 (7) of the statutes is renumbered 149.14 (7), and 149.14
21(7) (b) and (c), as renumbered, are amended to read:
AB100-engrossed,2098,2522
149.14
(7) (b) The
board department has a cause of action against an eligible
23participant for the recovery of the amount of benefits paid which are not for covered
24expenses under the plan. Benefits under the plan may be reduced or refused as a
25setoff against any amount recoverable under this paragraph.
AB100-engrossed,2099,4
1(c) The
board department is subrogated to the rights of an eligible person to
2recover special damages for illness or injury to the person caused by the act of a 3rd
3person to the extent that benefits are provided under the plan.
Section 814.03 (3)
4applies to the department under this paragraph.
AB100-engrossed,2099,10
7619.146 Choice of coverage. (1) (a) Beginning on January 1, 1998, in
8addition to the coverage required under s. 619.14, the plan shall offer to all eligible
9persons a choice of coverage, as described in section 2744 (a) (1) (
C) of P.L.
104-191.
10Any such choice of coverage shall be major medical expense coverage.
AB100-engrossed,2099,1911
(b) An eligible person may elect once each year, at the time and according to
12procedures established by the board, among the coverages offered under this section
13and s. 619.14. If an eligible person elects new coverage, any preexisting condition
14exclusion imposed under the new coverage is met to the extent that the eligible
15person has been previously and continuously covered under this subchapter. No
16preexisting condition exclusion may be imposed on an eligible person who elects new
17coverage if the person was an eligible individual when first covered under this
18subchapter and the person remained continuously covered under this subchapter up
19to the time of electing new coverage.
AB100-engrossed,2099,23
20(2) (a) Except as specified by the board, the terms of coverage under s. 619.14,
21including deductible reductions under s. 619.14 (5) (a), do not apply to the coverage
22offered under this section. Premium reductions under s. 619.165 do not apply to the
23coverage offered under this section.
AB100-engrossed,2100,224
(b) The schedule of premiums for coverage under this section shall be
25promulgated by rule by the commissioner. The rates for coverage under this section
1shall be set such that they differ from the rates for coverage under s. 619.14 by the
2same percentage as the percentage difference between the following:
AB100-engrossed,2100,53
1. The rate that a standard risk would be charged under an individual policy
4providing substantially the same coverage and deductibles as provided under s.
5619.14.
AB100-engrossed,2100,86
2. The rate that a standard risk would be charged under an individual policy
7providing substantially the same coverage and deductibles as the coverage offered
8under this section.
AB100-engrossed, s. 4860d
9Section 4860d. 619.146 of the statutes, as created by 1997 Wisconsin Act ....
10(this act), is renumbered 149.146, and 149.146 (1) (a) and (b) and (2) (a) and (b)
11(intro.) and 1., as renumbered, are amended to read:
AB100-engrossed,2100,1512
149.146
(1) (a) Beginning on January 1, 1998, in addition to the coverage
13required under s.
619.14 149.14, the plan shall offer to all eligible persons a choice
14of coverage, as described in section 2744 (a) (1) (
C), P.L.
104-191. Any such choice
15of coverage shall be major medical expense coverage.
AB100-engrossed,2100,2416
(b) An eligible person may elect once each year, at the time and according to
17procedures established by the
board department, among the coverages offered under
18this section and s.
619.14 149.14. If an eligible person elects new coverage, any
19preexisting condition exclusion imposed under the new coverage is met to the extent
20that the eligible person has been previously and continuously covered under this
21subchapter chapter. No preexisting condition exclusion may be imposed on an
22eligible person who elects new coverage if the person was an eligible individual when
23first covered under this
subchapter chapter and the person remained continuously
24covered under this
subchapter chapter up to the time of electing the new coverage.
AB100-engrossed,2101,4
1(2) (a) Except as specified by the
board department, the terms of coverage
2under s.
619.14 149.14, including deductible reductions under s.
619.14 149.14 (5)
3(a), do not apply to the coverage offered under this section. Premium reductions
4under s.
619.165 149.165 do not apply to the coverage offered under this section.
AB100-engrossed,2101,95
(b) (intro.) The schedule of premiums for coverage under this section shall be
6promulgated by rule by the
commissioner department, as provided in s. 149.143. The
7rates for coverage under this section shall be set such that they differ from the rates
8for coverage under s.
619.14 149.14 by the same percentage as the percentage
9difference between the following:
AB100-engrossed,2101,1210
1. The rate that a standard risk would be charged under an individual policy
11providing substantially the same coverage and deductibles as provided under s.
12619.14 149.14.
AB100-engrossed,2102,816
149.15
(1) The plan shall
operate subject to the supervision and approval of a
17have a board
of governors consisting of representatives of 2 participating insurers
18which are nonprofit corporations,
representatives of 2 other participating insurers,
193 health care provider representatives, including one representative of the State
20Medical Society of Wisconsin, one representative of the Wisconsin Health and
21Hospital Association and one representative of an integrated multidisciplinary
22health system, and 3 public members,
including one representative of small
23businesses in the state, appointed by the
commissioner secretary for staggered
243-year terms. In addition, the commissioner
, or a designated representative from
25the office of the commissioner
, and the secretary, or a designated representative from
1the department, shall be
a member members of the board. The public members shall
2not be professionally affiliated with the practice of medicine, a hospital or an insurer.
3At least 2 of the public members shall be individuals reasonably expected to qualify
4for coverage under the plan or the parent or spouse of such an individual. The
5commissioner secretary or the
commissioner's secretary's representative shall be the
6chairperson of the board. Board members, except the commissioner or the
7commissioner's representative
and the secretary or the secretary's representative,
8shall be compensated at the rate of $50 per diem plus actual and necessary expenses.
AB100-engrossed,2102,1611
149.15
(2) Annually, the board shall make a report to the
members of the plan
12and to the chief clerk of each house of the legislature, for distribution to the 13appropriate standing committees under s. 13.172 (3)
,
and to the members of the plan 14summarizing the activities of the plan in the preceding calendar year. The annual
15report shall define the cost burden imposed by the plan on all policyholders in this
16state.
AB100-engrossed, s. 4864
17Section
4864. 619.15 (3) (intro.) of the statutes is renumbered 149.15 (3)
18(intro.) and amended to read:
AB100-engrossed,2102,1919
149.15
(3) (intro.) The board shall
do all of the following:
AB100-engrossed, s. 4867c
22Section 4867c. 619.15 (3) (c) of the statutes is renumbered 149.15 (3) (c) and
23amended to read:
AB100-engrossed,2103,524
149.15
(3) (c) Collect assessments from all insurers to provide for claims paid
25under the plan and for administrative expenses incurred or estimated to be incurred
1during the period for which the assessment is made. The level of payments shall be
2established
by the board as provided under s. 149.143. Assessment of the insurers
3shall occur at the end of each calendar year or other fiscal year end established by
4the board. Assessments are due and payable within 30 days of receipt by the insurer
5of the assessment notice.
AB100-engrossed,2103,149
149.15
(3) (e) Establish for payment of covered expenses, a payment rate that
10is 10% less than the charges approved by the
administering carrier plan
11administrator for reimbursement of covered expenses under s.
619.14 149.14 (3).
A
12provider of a covered service or article may not bill an eligible person who receives
13the service or article for any amount by which the charge is reduced under this
14paragraph.
AB100-engrossed,2103,1716
619.15
(3) (f) In consultation with the office and the department of health and
17family services, establish a choice of coverage under s. 619.146.
AB100-engrossed, s. 4869m
18Section 4869m. 619.15 (3) (f) of the statutes, as created by 1997 Wisconsin Act
19.... (this act), is repealed.
AB100-engrossed, s. 4870
20Section
4870. 619.15 (4) (intro.) of the statutes is renumbered 149.15 (4)
21(intro.) and amended to read:
AB100-engrossed,2103,2222
149.15
(4) (intro.) The board may
do any of the following:
AB100-engrossed,2104,65
149.15
(5) The
commissioner department may, by rule, establish additional
6powers and duties of the board.
AB100-engrossed,2104,109
149.15
(6) If any provision of this
subchapter chapter conflicts with s. 625.11
10or 625.12, this
subchapter chapter prevails.
AB100-engrossed, s. 4882
15Section
4882. 619.16 (3) (a) of the statutes is renumbered 149.16 (3) (a) and
16amended to read:
AB100-engrossed,2104,1817
149.16
(3) (a) The
administering carrier plan administrator shall perform all
18eligibility and administrative claims payment functions relating to the plan.
AB100-engrossed, s. 4883
19Section
4883. 619.16 (3) (b) of the statutes is renumbered 149.16 (3) (b) and
20amended to read:
AB100-engrossed,2104,2321
149.16
(3) (b) The
administering carrier plan administrator shall establish a
22premium billing procedure for collection of premiums from insured persons. Billings
23shall be made on a periodic basis as determined by the
board department.
AB100-engrossed, s. 4884c
24Section 4884c. 619.16 (3) (c) of the statutes is renumbered 149.16 (3) (c), and
25149.16 (3) (c) (intro.), as renumbered, is amended to read:
AB100-engrossed,2105,3
1149.16
(3) (c) (intro.) The
administering carrier plan administrator shall
2perform all necessary functions to assure timely payment of benefits to covered
3persons under the plan, including:
AB100-engrossed, s. 4886
5Section
4886. 619.16 (3) (e) of the statutes is renumbered 149.16 (3) (e) and
6amended to read:
AB100-engrossed,2105,147
149.16
(3) (e) The
administering carrier plan administrator, under the
8direction of the department, shall pay claims expenses from the premium payments
9received from or on behalf of covered persons under the plan. If the
administering
10carrier's plan administrator's payments for claims expenses exceed
the portion of
11premiums allocated by the board for payment of claims expenses
premium
12payments, the board
shall forward to the department, and the department shall
13provide to the
carrier plan administrator, additional funds for payment of claims
14expenses.
AB100-engrossed, s. 4890
18Section
4890. 619.165 (1) (a) of the statutes is renumbered 149.165 (1) and
19amended to read:
AB100-engrossed,2105,2320
149.165
(1) The board Except as provided in s. 149.146 (2) (a), the department 21shall reduce the premiums established
by the commissioner under s.
619.11 149.11 22in conformity with ss.
619.14 (5) 149.143 and
619.17 149.17, for the eligible persons
23and in the manner set forth in
pars. (b) to (d) subs. (2) and (3).