SB77: Bill Text

SB77, s. 4814 Section 4814. 619.10 (intro.) of the statutes is renumbered 149.10 (intro.) and amended to read:

SB77,1805,9 149.10 Definitions. (intro.) In this subchapter chapter:

SB77, s. 4815 Section 4815. 619.10 (1) of the statutes is repealed.

SB77, s. 4816 Section 4816. 619.10 (1m) of the statutes is repealed.

SB77, s. 4817 Section 4817. 619.10 (2) of the statutes is renumbered 149.10 (2) and amended to read:

SB77,1805,15 149.10 (2) "Board" means the board of governors established under s. 619.15 149.15.

SB77, s. 4818 Section 4818. 619.10 (3) of the statutes is renumbered 149.10 (3) and amended to read:

SB77,1805,20 149.10 (3) "Eligible person" means a resident of this state who qualifies under s. 619.12 149.12 whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.

SB77, s. 4819 Section 4819. 619.10 (3m) and (4) of the statutes are renumbered 149.10 (3m) and (4).

SB77, s. 4820 Section 4820. 619.10 (4m) of the statutes is renumbered 149.10 (4m).

SB77, s. 4821 Section 4821. 619.10 (5) of the statutes is renumbered 149.10 (5) and amended to read:

SB77,1806,12 149.10 (5) "Insurer" means any person or association of persons, including a health maintenance organization, limited service health organization or preferred provider plan offering or insuring health services on a prepaid basis, including, but not limited to, policies of health insurance issued by a currently licensed insurer, as defined in s. 600.03 (27), nonprofit hospital or medical service plans under ch. 613, cooperative medical service plans under s. 185.981, or other entity whose primary function is to provide diagnostic, therapeutic or preventive services to a defined population in return for a premium paid on a periodic basis. "Insurer" includes any person providing health services coverage for individuals on a self-insurance basis without the intervention of other entities, as well as any person providing health insurance coverage under a medical reimbursement plan to persons. "Insurer" does not include a plan under ch. 613 which offers only dental care.

SB77, s. 4822 Section 4822. 619.10 (6) and (7) of the statutes are renumbered 149.10 (6) and (7).

SB77, s. 4823 Section 4823. 619.10 (8) of the statutes is renumbered 149.10 (8) and amended to read:

SB77,1806,18 149.10 (8) "Plan" means the health care insurance plan established and administered under this subchapter chapter.

SB77, s. 4824 Section 4824. 619.10 (9) of the statutes is renumbered 149.10 (9) and amended to read:

SB77,1807,5 149.10 (9) "Resident" means a person who has been is legally domiciled in this state for a period of at least 30 days. For purposes of this subchapter chapter, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin or filing a Wisconsin income tax return. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state. A person with a developmental disability or another disability which prevents the person from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in this state by living in this state for 30 days.

SB77, s. 4825 Section 4825. 619.11 of the statutes is renumbered 149.11 and amended to read:

SB77,1807,11 149.11 (title) Establishment Operation of plan. The commissioner department shall promulgate rules establishing for the operation of a plan of health insurance coverage for an eligible person which satisfies the requirements of this chapter.

SB77, s. 4826 Section 4826. 619.12 (title) of the statutes is renumbered 149.12 (title).

SB77, s. 4827 Section 4827. 619.12 (1) of the statutes is renumbered 149.12 (1), and 149.12 (1) (intro.), as renumbered, is amended to read:

SB77,1807,21 149.12 (1) (intro.) Except as provided in subs. (1m) and (2), the board or administering carrier plan administrator shall certify as eligible a person who is covered by medicare because he or she is disabled under 42 USC 423, a person who submits evidence that he or she has tested positive for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV, and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:

SB77, s. 4828 Section 4828. 619.12 (1m) (intro) and (a) of the statutes are consolidated, renumbered 149.12 (1m) and amended to read:

SB77,1808,2 149.12 (1m) The board or administering carrier plan administrator may not certify a person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required notices were issued by one of the following: (a) An an insurance intermediary who is not acting as an administrator, as defined in s. 633.01.

SB77, s. 4829 Section 4829. 619.12 (1m) (b) of the statutes is repealed.

SB77, s. 4830 Section 4830. 619.12 (2) of the statutes is renumbered 149.12 (2), and 149.12 (2) (b) 1. and (e) 2. c., as renumbered, are amended to read:

SB77,1808,9 149.12 (2) (b) 1. Except as provided in subd. 2., no person who is covered under the plan and who voluntarily terminates the coverage under the plan, is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan.

SB77,1808,14 (e) 2. c. The board finds that the person is eligible for coverage under the plan after a review process, determined by the commissioner department by rule under s. 619.123 149.123, that evaluates and approves the certification by the physician that the person has a severe and chronic or long-lasting physical or mental illness or disability.

SB77, s. 4831 Section 4831. 619.12 (3) of the statutes is renumbered 149.12 (3), and 149.12 (3) (c), as renumbered, is amended to read:

SB77,1808,20 149.12 (3) (c) The commissioner, in consultation with the board, department may promulgate rules specifying other deductible or coinsurance amounts that, if paid or reimbursed for persons, will not make the persons ineligible for coverage under the plan.

SB77, s. 4832 Section 4832. 619.123 of the statutes is renumbered 149.123 and amended to read:

SB77,1809,2 149.123 Rules for review of physician certification. The commissioner department shall promulgate rules that establish the procedure to be used by the board under s. 619.12 149.12 (2) (e) 2. c. The rules shall provide for an insurer that would be affected by the decision of the board to participate in the review process to contest or support the physician's certification.

SB77, s. 4833 Section 4833. 619.125 of the statutes is renumbered 149.125 and amended to read:

SB77,1809,7 149.125 Health insurance risk-sharing plan fund. There is created a health insurance risk-sharing plan fund, under the management of the board department, to fund administrative expenses.

SB77, s. 4834 Section 4834. 619.13 (title) of the statutes is renumbered 149.13 (title).

SB77, s. 4835 Section 4835. 619.13 (1) (a) of the statutes is renumbered 149.13 (1) (a) and amended to read:

SB77,1809,15 149.13 (1) (a) Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under par. (b) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department of the insurers participating in the cost of administering the plan.

SB77, s. 4836 Section 4836. 619.13 (1) (b) of the statutes is renumbered 149.13 (1) (b) and amended to read:

SB77,1809,24 149.13 (1) (b) Except as provided by a rule promulgated under s. 619.145 (4), every Every participating insurer shall share in the operating, administrative and subsidy expenses of the plan in proportion to the ratio of the insurer's total health care coverage revenue for residents of this state during the preceding calendar year to the aggregate health care coverage revenue of all participating insurers for residents of this state during the preceding calendar year, as determined by the commissioner.

SB77, s. 4837 Section 4837. 619.13 (1) (c) of the statutes is repealed.

SB77, s. 4838 Section 4838. 619.13 (1) (d) of the statutes is renumbered 149.13 (1) (d), and 149.13 (1) (d) 2., as renumbered, is amended to read:

SB77,1810,9 149.13 (1) (d) 2. If the department or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600 to 646 and 655 is not adequate to permit the department, the commissioner or the board to carry out the department's, commissioner's or the board's responsibilities under this subchapter chapter, the commissioner may shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and the board to make the determinations required under this subchapter chapter.

SB77, s. 4839 Section 4839. 619.13 (2) of the statutes is renumbered 149.13 (2).

SB77, s. 4840 Section 4840. 619.135 (title) of the statutes is renumbered 149.135 (title).

SB77, s. 4841 Section 4841. 619.135 (1) (a) of the statutes is renumbered 149.135 (1) (a) and amended to read:

SB77,1810,21 149.135 (1) (a) Whenever a person becomes eligible for and obtains coverage under the plan as a result of receiving a notice under s. 619.12 149.12 (1) (am), (b) or (c), the commissioner shall levy an assessment of $1,750 against the insurer that issued the notice, except that the commissioner may not levy an assessment if the notice of cancellation under s. 619.12 149.12 (1) (am) was issued on one of the permissible grounds under s. 631.36 (2) (a). The commissioner shall notify the department if an assessment is not levied under this paragraph because a notice of cancellation was issued on permissible grounds.

SB77, s. 4842 Section 4842. 619.135 (1) (b) of the statutes is renumbered 149.135 (1) (b).

SB77, s. 4843 Section 4843. 619.135 (1) (c) of the statutes is renumbered 149.135 (1) (c) and amended to read:

SB77,1811,4 149.135 (1) (c) If an assessment levied under par. (a) is not paid within the time prescribed, the commissioner shall impose a penalty against the insurer in an amount established by the commissioner by rule, in consultation with the department.

SB77, s. 4844 Section 4844. 619.135 (1) (d) of the statutes is renumbered 149.135 (1) (d) and amended to read:

SB77,1811,8 149.135 (1) (d) All assessments and penalties collected under this subsection shall be credited to the appropriation under s. 20.145 (7) (g) 20.435 (5) (hp).

SB77, s. 4845 Section 4845. 619.135 (2) of the statutes is renumbered 149.135 (2) and amended to read:

SB77,1811,21 149.135 (2) If the moneys under s. 20.145 (7) (a) and (g) 20.435 (5) (ah), (g) and (hp) are insufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a), or the commissioner department determines that the moneys under s. 20.145 (7) (a) and (g) 20.435 (5) (ah), (g) and (hp) will be insufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a), the department shall notify the commissioner. In consultation with the department, the commissioner shall, by rule, increase the amount of the assessment under sub. (1) (a) or levy an assessment against every insurer, or a combination of both, sufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a).

SB77, s. 4846 Section 4846. 619.135 (3) of the statutes is renumbered 149.135 (3) and amended to read:

SB77,1812,5 149.135 (3) In addition to the assessments under subs. (1) (a) and (2), in consultation with the department the commissioner may, by rule, establish an assessment to be levied against each insurer that issues a notice of rejection under s. 619.12 149.12 (1) (a) to a person who becomes eligible for and obtains coverage under the plan as a result of receiving the notice. Any assessments levied and collected under this subsection shall be credited to the appropriation under s. 20.145 (7) (g) 20.435 (5) (hp).

SB77, s. 4847 Section 4847. 619.14 (title) of the statutes is renumbered 149.14 (title).

SB77, s. 4848 Section 4848. 619.14 (1) of the statutes is renumbered 149.14 (1), and 149.14 (1) (b), as renumbered, is amended to read:

SB77,1812,13 149.14 (1) (b) If an individual terminates medical assistance coverage and applies for coverage under the plan within 45 days after the termination and is subsequently found to be eligible under s. 619.12 149.12, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.

SB77, s. 4849 Section 4849. 619.14 (2) of the statutes is renumbered 149.14 (2).

SB77, s. 4850 Section 4850. 619.14 (3) of the statutes is renumbered 149.14 (3), and 149.14 (3) (intro.) and (c) 1. and 3., as renumbered, are amended to read:

SB77,1813,3 149.14 (3) Covered expenses. (intro.) Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 (3) (e), covered expenses shall be the usual and customary allowable charges paid under the medical assistance program under ss. 49.45 to 49.47 for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 (3) (e), covered expenses shall also be the usual and customary allowable charges paid under the medical assistance program under ss. 49.45 to 49.47 for the following services and articles when if the service or article is prescribed by a physician who is licensed under ch. 448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45 (2) (a) 11.:

SB77,1813,7 (c) 1. Inpatient treatment in a hospital as defined in s. 632.89 (1) (c) or in a medical facility in another state approved by the board, licensed under s. 50.35 for up to 30 days' confinement per calendar year due to alcoholism or drug abuse and up to 60 days' confinement per calendar year for nervous and mental disorders.

SB77,1813,10 3. Subject to the limits under subd. 2. and to rules promulgated by the commissioner department, services for the chronically mentally ill in community support programs operated under s. 51.421.

SB77, s. 4851 Section 4851. 619.14 (4) of the statutes is renumbered 149.14 (4), and 149.14 (4) (d) and (m), as renumbered, are amended to read:

SB77,1813,17 149.14 (4) (d) That part of any charge for services or articles rendered or prescribed by a physician, dentist or other health care personnel which exceeds the prevailing charge in the locality where the service is provided allowable charge paid under the medical assistance program under ss. 49.45 to 49.47 or any charge not medically necessary.

SB77,1813,19 (m) Experimental treatment, as determined by the board or its designee department.

SB77, s. 4852 Section 4852. 619.14 (5) (title) of the statutes is renumbered 149.14 (5) (title).

SB77, s. 4853 Section 4853. 619.14 (5) (a) of the statutes is renumbered 149.14 (5) (a) and amended to read:

SB77,1814,17 149.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter chapter for major medical expense coverage required under this section. For coverage offered to those persons eligible for medicare, the plan shall offer a deductible equal to the deductible charged by part A of title XVIII of the federal social security act, as amended. The deductible amounts for all other eligible persons shall be dependent upon household income as determined under s. 619.165 149.165. For eligible persons under s. 619.165 (1) (b) 1. 149.165 (2) (a), the deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2. 149.165 (2) (b), the deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3. 149.165 (2) (c), the deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4. 149.165 (2) (d), the deductible shall be $800. For all other eligible persons who are not eligible for medicare, the deductible shall be $1,000. With respect to all eligible persons, expenses used to satisfy the deductible during the last 90 days of a calendar year shall also be applied to satisfy the deductible for the following calendar year. The schedule of premiums shall be promulgated by rule by the commissioner department. The commissioner department shall set rates at 60% of the operating and administrative costs of the plan, except that a rate may not exceed 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan.

SB77, s. 4854 Section 4854. 619.14 (5) (b) of the statutes is renumbered 149.14 (5) (b) and amended to read:

SB77,1814,24 149.14 (5) (b) Except as provided in par. (c), if the covered costs incurred by the eligible person exceed the deductible for major medical expense coverage in a calendar year, the plan shall pay at least 80% of the allowable charges paid under the medical assistance program under ss. 49.45 to 49.47 for any additional covered costs incurred by the person during the calendar year.

SB77, s. 4855 Section 4855. 619.14 (5) (c) of the statutes is renumbered 149.14 (5) (c) and amended to read:

SB77,1815,9 149.14 (5) (c) If the aggregate of the covered costs not paid by the plan under par. (b) and the deductible exceeds $500 for an eligible person receiving medicare, $2,000 for any other eligible person during a calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100% of the allowable charges paid under the medical assistance program under ss. 49.45 to 49.47 for all covered costs incurred by the eligible person during the calendar year after the payment ceilings under this paragraph are exceeded.

SB77, s. 4856 Section 4856. 619.14 (5) (d) of the statutes is renumbered 149.14 (5) (d) and amended to read:

SB77,1815,17 149.14 (5) (d) Notwithstanding pars. (a) to (c), the board department may establish different deductible amounts, a different coinsurance percentage and different covered costs and deductible aggregate amounts from those specified in pars. (a) to (c) in accordance with cost containment provisions established by the commissioner department under s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under s. 619.145 149.17 (4).

SB77, s. 4857 Section 4857. 619.14 (5) (e) of the statutes is renumbered 149.14 (5) (e) and amended to read:

SB77,1815,25 149.14 (5) (e) Using the procedure under s. 227.24, the commissioner department may promulgate rules under par. (a) for the schedule of premiums for the period before the effective date of any permanent rules promulgated under par. (a) for the schedule of premiums, but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the commissioner department is not required to make a finding of emergency.

SB77, s. 4858 Section 4858. 619.14 (6) of the statutes is repealed.

SB77, s. 4859 Section 4859. 619.14 (7) of the statutes is renumbered 149.14 (7), and 149.14 (7) (b) and (c), as renumbered, are amended to read:

SB77,1816,7 149.14 (7) (b) The board department has a cause of action against an eligible participant for the recovery of the amount of benefits paid which are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.

SB77,1816,11 (c) The board department is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan. Section 814.03 (3) applies to the department under this paragraph.

SB77, s. 4860 Section 4860. 619.145 of the statutes is repealed.

SB77, s. 4861 Section 4861. 619.15 (title) of the statutes is renumbered 149.15 (title).

SB77, s. 4862 Section 4862. 619.15 (1) of the statutes is renumbered 149.15 (1) and amended to read:

SB77,1817,4 149.15 (1) The plan shall operate subject to the supervision and approval of a have a board of governors consisting of representatives of 2 participating insurers which are nonprofit corporations, 2 other participating insurers, and 3 public members, appointed by the commissioner secretary for staggered 3-year terms. In addition, the commissioner, or a designated representative from the office of the commissioner, and the secretary, or a designated representative from the department, shall be a member members of the board. The public members shall not be professionally affiliated with the practice of medicine, a hospital or an insurer. At least 2 of the public members shall be individuals reasonably expected to qualify for coverage under the plan or the parent or spouse of such an individual. The commissioner secretary or the commissioner's secretary's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative and the secretary or the secretary's representative, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.

SB77, s. 4863 Section 4863. 619.15 (2) of the statutes is renumbered 149.15 (2) and amended to read:

SB77,1817,12 149.15 (2) Annually, the board shall make a report to the members of the plan and to the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under s. 13.172 (3), and to the members of the plan summarizing the activities of the plan in the preceding calendar year. The annual report shall define the cost burden imposed by the plan on all policyholders in this state.

SB77, s. 4864 Section 4864. 619.15 (3) (intro.) of the statutes is renumbered 149.15 (3) (intro.) and amended to read:

SB77,1817,15 149.15 (3) (intro.) The board shall do all of the following: