AB100-engrossed,2088,177
149.10
(9) "Resident" means a person who has been legally domiciled in this
8state for a period of at least 30 days
or, with respect to an eligible individual, an
9individual who resides in this state. For purposes of this
subchapter chapter, legal
10domicile is established by living in this state and obtaining a Wisconsin motor vehicle
11operator's license, registering to vote in Wisconsin or filing a Wisconsin income tax
12return. A child is legally domiciled in this state if the child lives in this state and if
13at least one of the child's parents or the child's guardian is legally domiciled in this
14state. A person with a developmental disability or another disability which prevents
15the person from obtaining a Wisconsin motor vehicle operator's license, registering
16to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in
17this state by living in this state
for 30 days.
AB100-engrossed,2088,23
20149.11 (title) Establishment
Operation of plan. The
commissioner 21department shall promulgate rules
establishing for the operation of a plan of health
22insurance coverage for an eligible person which satisfies the requirements of this
23chapter.
AB100-engrossed,2089,5
1619.115 Rules relating to creditable coverage. The commissioner shall
2promulgate rules that specify how creditable coverage is to be aggregated for
3purposes of s. 619.10 (2t) (a) and that determine the creditable coverage to which s.
4619.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L.
5104-191.
AB100-engrossed, s. 4825f
6Section 4825f. 619.115 of the statutes, as created by 1997 Wisconsin Act ....
7(this act), is renumbered 149.115 and amended to read:
AB100-engrossed,2089,12
8149.115 Rules relating to creditable coverage. The commissioner
, in
9consultation with the department, shall promulgate rules that specify how
10creditable coverage is to be aggregated for purposes of s.
619.10 149.10 (2t) (a) and
11that determine the creditable coverage to which s.
619.10 149.10 (2t) (b) and (d)
12applies. The rules shall comply with section 2701 (c) of P.L.
104-191.
AB100-engrossed, s. 4827
14Section
4827. 619.12 (1) of the statutes is renumbered 149.12 (1), and 149.12
15(1) (intro.), as renumbered, is amended to read:
AB100-engrossed,2089,2316
149.12
(1) (intro.) Except as provided in subs. (1m) and (2), the board or
17administering carrier plan administrator shall certify as eligible a person who is
18covered by medicare because he or she is disabled under
42 USC 423, a person who
19submits evidence that he or she has tested positive for the presence of HIV, antigen
20or nonantigenic products of HIV or an antibody to HIV,
a person who is an eligible
21individual, and any person who receives and submits any of the following based
22wholly or partially on medical underwriting considerations within 9 months prior to
23making application for coverage by the plan:
AB100-engrossed, s. 4828
24Section
4828. 619.12 (1m) (intro) and (a) of the statutes are consolidated,
25renumbered 149.12 (1m) and amended to read:
AB100-engrossed,2090,4
1149.12
(1m) The board or
administering carrier plan administrator may not
2certify a person as eligible under circumstances requiring notice under sub. (1) (a)
3to (d) if the required notices were issued by
one of the following: (a) An an insurance
4intermediary who is not acting as an administrator, as defined in s. 633.01.
AB100-engrossed,2090,118
149.12
(2) (b) 1. Except as provided in subd. 2., no person who is covered under
9the plan and
who voluntarily terminates the coverage under the plan
, is again
10eligible for coverage unless 12 months have elapsed since the person's latest
11voluntary termination of coverage under the plan.
AB100-engrossed,2090,1412
2. Subdivision 1. does not apply
to any person who is an eligible individual or 13to any person who terminates coverage under the plan because he or she
is receiving, 14or is eligible to receive
, medical assistance benefits.
AB100-engrossed, s. 4830c
15Section 4830c. 619.12 (2) (c) of the statutes is renumbered 149.12 (2) (c) and
16amended to read:
AB100-engrossed,2090,1817
149.12
(2) (c) No person on whose behalf the plan has paid out
$500,000 18$1,000,000 or more is eligible for coverage under the plan.
AB100-engrossed, s. 4830d
19Section 4830d. 619.12 (2) (d) of the statutes is renumbered 149.12 (2) (d) and
20amended to read:
AB100-engrossed,2090,2221
149.12
(2) (d)
No Except for a person who is an eligible individual, no person
22who is 65 years of age or older is eligible for coverage under the plan.
AB100-engrossed, s. 4830ec
23Section 4830ec. 619.12 (2) (e) of the statutes, as affected by 1997 Wisconsin
24Act .... (this act), is renumbered 149.12 (2) (e) and amended to read:
AB100-engrossed,2091,4
1149.12
(2) (e) No person who is eligible for
health care benefits creditable
2coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that
are
3is provided by an employer on a self-insured basis or through health insurance is
4eligible for coverage under the plan.
AB100-engrossed,2091,107
619.12
(2) (e)
Except as provided in subd. 2., no No person who is eligible for
8health care benefits
, other than those benefits specified in s. 632.745 (11) (b) 1. to 12.,
9that are provided by an employer on a self-insured basis or through health insurance
10is eligible for coverage under the plan.
AB100-engrossed, s. 4831
13Section
4831. 619.12 (3) of the statutes, as affected by 1997 Wisconsin Act ....
14(this act), is renumbered 149.12 (3), and 149.12 (3) (c), as renumbered, is amended
15to read:
AB100-engrossed,2091,1916
149.12
(3) (c) The
commissioner, in consultation with the board, department 17may promulgate rules specifying other deductible or coinsurance amounts that, if
18paid or reimbursed for persons, will not make the persons ineligible for coverage
19under the plan.
AB100-engrossed,2092,221
619.12
(3) (a) Except as provided in pars. (b)
and to (c), no person is eligible for
22coverage under the plan for whom a premium, deductible or coinsurance amount is
23paid or reimbursed by a federal, state, county or municipal government or agency as
24of the first day of any term for which a premium amount is paid or reimbursed and
1as of the day after the last day of any term during which a deductible or coinsurance
2amount is paid or reimbursed.
AB100-engrossed,2092,64
619.12
(3) (bm) Persons for whom premium costs for health insurance coverage
5are subsidized under s. 252.16 are not ineligible for coverage under the plan by
6reason of such payments.
AB100-engrossed,2092,12
10149.125 Health insurance risk-sharing plan fund. There is created a
11health insurance risk-sharing plan fund, under the management of the
board 12department, to fund administrative expenses.
AB100-engrossed,2092,2016
149.13
(1) Every insurer shall participate in the cost of administering the plan,
17except the commissioner may by rule exempt as a class those insurers whose share
18as determined under
par. (b) sub. (2) would be so minimal as to not exceed the
19estimated cost of levying the assessment.
The commissioner shall advise the
20department of the insurers participating in the cost of administering the plan.
AB100-engrossed,2093,323
149.13
(2) Except as provided by a rule promulgated under s. 619.145 (4), every 24Every participating insurer shall share in the operating, administrative and subsidy
25expenses of the plan in proportion to the ratio of the insurer's total health care
1coverage revenue for residents of this state during the preceding calendar year to the
2aggregate health care coverage revenue of all participating insurers for residents of
3this state during the preceding calendar year, as determined by the commissioner.
AB100-engrossed,2093,117
149.13
(3) (a) Each insurer's proportion of participation under
par. (b) sub. (2) 8shall be determined annually by the commissioner based on annual statements and
9other reports filed by the insurer with the commissioner.
The commissioner shall
10assess an insurer for the insurer's proportion of participation based on the total
11assessments estimated by the department under s. 149.143 (2) (a) 3.
AB100-engrossed,2093,1812
(b) If the
department or the commissioner finds that the commissioner's
13authority to require insurers to report under chs. 600 to 646 and 655 is not adequate
14to permit the
department, the commissioner or the board to carry out the
15department's, commissioner's or
the board's responsibilities under this
subchapter 16chapter, the commissioner
may shall promulgate rules requiring insurers to report
17the information necessary for the
department, commissioner and
the board to make
18the determinations required under this
subchapter
chapter.
AB100-engrossed, s. 4840c
20Section 4840c. 619.135 (title) of the statutes is renumbered 149.144 (title) and
21amended to read:
AB100-engrossed,2093,23
22149.144 (title)
Insurer Adjustments to insurer assessments and
23provider payment rates for premium and deductible reductions.
AB100-engrossed,2094,15
3149.144 If the moneys under s.
20.145 (7) (a) and (g) 20.435 (5) (ah) are
4insufficient to reimburse the plan for premium reductions under s.
619.165 149.165 5and deductible reductions under s.
619.14 149.14 (5) (a), or the
commissioner 6department determines that the moneys under s.
20.145 (7) (a) and (g) 20.435 (5) (ah) 7will be insufficient to reimburse the plan for premium reductions under s.
619.165 8149.165 and deductible reductions under s.
619.14 149.14 (5) (a), the
commissioner 9department shall, by rule,
increase
adjust in equal proportions the amount of the
10assessment
under sub. (1) (a) or levy an assessment against every insurer, or a
11combination of both, set under s. 149.143 (2) (a) 3. and the provider payment rate set
12under s. 149.143 (2) (a) 4., subject to s. 149.143 (1) (b) 1., sufficient to reimburse the
13plan for premium reductions under s.
619.165 149.165 and deductible reductions
14under s.
619.14 149.14 (5) (a).
The department shall notify the commissioner so that
15the commissioner may levy any increase in insurer assessments.
AB100-engrossed, s. 4848
18Section
4848. 619.14 (1) of the statutes is renumbered 149.14 (1), and 149.14
19(1) (b), as renumbered, is amended to read:
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.