AB876,9,14 14(2) Insurer assessments established under s. 635.30 (3) (a) 2.
AB876,9,15 15(3) Provider assessments established under s. 635.30 (3) (a) 3.
AB876,9,16 16(4) Premiums established under s. 635.30 (3) (a) 4.
AB876, s. 9 17Section 9. 40.51 (6) of the statutes is renumbered 40.51 (6) (a) and amended
18to read:
AB876,9,2419 40.51 (6) (a) This Except as provided in par. (b), the state shall offer to all of
20its employees at least 2 insured or uninsured health care coverage plans providing
21substantially equivalent hospital and medical benefits, including a health
22maintenance organization or a preferred provider plan, if those health care plans are
23determined by the group insurance board to be available in the area of the place of
24employment and are approved by the group insurance board.
AB876, s. 10 25Section 10. 40.51 (6) (b) of the statutes is created to read:
AB876,10,7
140.51 (6) (b) Notwithstanding s. 40.03 (6) (c), in addition to the health care
2coverage plans offered under par. (a), the state shall also offer to all of its employees
3a defined contribution plan that permits employees to choose the level of premiums,
4deductibles, and co-payments and to select the hospital and medical benefits offered
5under the plan, but only if the group insurance board determines that such a defined
6contribution plan is available in the area of the place of employment and approves
7the plan.
AB876, s. 11 8Section 11. 40.98 (2) (h) of the statutes is created to read:
AB876,10,149 40.98 (2) (h) The department may seek funding from any person for the
10payment of costs of designing, marketing, and contracting for or providing
11administrative services under the health care coverage program and for lapsing to
12the general fund any amount required under sub. (6m). Any moneys received by the
13department under this paragraph shall be credited to the appropriation account
14under s. 20.515 (2) (g).
AB876, s. 12 15Section 12. 40.98 (6m) of the statutes is created to read:
AB876,10,2416 40.98 (6m) The secretary of administration shall lapse from the appropriation
17under s. 20.515 (2) (g) to the general fund the amounts necessary to repay the loan
18under s. 601.34 when the secretary of administration, after consulting with the
19board, determines that funds in the appropriation under s. 20.515 (2) (g) are
20sufficient to make the lapse. The amounts that are required to be lapsed under s.
2120.515 (2) (g) shall equal the amount necessary to pay all principal and interest costs
22on the loan, less any amount that is lapsed to the general fund under s. 20.515 (2)
23(a) at the end of the 2001-03 fiscal biennium. The secretary of administration may
24lapse the amounts under s. 20.515 (2) (g) in installments.
AB876, s. 13 25Section 13. 149.12 (1) (intro.) of the statutes is amended to read:
AB876,11,8
1149.12 (1) (intro.) Except as provided in subs. (1m) and, (2), and (4), the board
2or plan administrator shall certify as eligible a person who is covered by medicare
3because he or she is disabled under 42 USC 423, a person who submits evidence that
4he or she has tested positive for the presence of HIV, antigen or nonantigenic
5products of HIV, or an antibody to HIV, a person who is an eligible individual, and
6any person who receives and submits any of the following based wholly or partially
7on medical underwriting considerations within 9 months prior to making application
8for coverage by the plan:
AB876, s. 14 9Section 14. 149.12 (4) of the statutes is created to read:
AB876,11,1710 149.12 (4) Notwithstanding subs. (1) to (3), the board may, in its discretion,
11certify as eligible for coverage under the plan a person who applies for coverage after
12his or her enrollment in the program under s. 635.30 is terminated under s. 635.30
13(4) (b), regardless of whether the person satisfies the eligibility requirements under
14subs. (1) to (3). The board shall determine whether a person who obtains coverage
15under the plan under this subsection and who does not satisfy the eligibility
16requirements under subs. (1) to (3) may remain covered under the plan after the
17program under s. 635.30 is no longer in operation.
AB876, s. 15 18Section 15. 149.14 (6) (a) of the statutes is amended to read:
AB876,11,2319 149.14 (6) (a) Except as provided in par. pars. (b) and (c), no person who obtains
20coverage under the plan may be covered for any preexisting condition during the first
216 months of coverage under the plan if the person was diagnosed or treated for that
22condition during the 6 months immediately preceding the filing of an application
23with the plan.
AB876, s. 16 24Section 16. 149.14 (6) (c) of the statutes is created to read:
AB876,12,5
1149.14 (6) (c) A person who obtains coverage under the plan under s. 149.12
2(4) and whose application for coverage was received within 63 after his or her
3enrollment in the program under s. 635.30 was terminated under s. 635.30 (4) (b),
4may not be subject to any preexisting condition exclusion under the plan, as provided
5in s. 635.30 (4) (b).
AB876, s. 17 6Section 17. 601.34 of the statutes is created to read:
AB876,12,21 7601.34 Loan to general fund. No later than the first day of the 2nd month
8after the effective date of this section .... [revisor inserts date], an amount equal to
9$850,000 shall be lapsed from the appropriation account under s. 20.145 (1) (g) to the
10general fund. The amount lapsed from the appropriation account shall be considered
11a loan to the general fund and interest shall accrue on the amount lapsed at the
12average rate earned by the state on its deposits in the state investment fund during
13the period of the loan. The general fund shall repay the loan from moneys lapsed to
14the general fund from the appropriation under s. 20.515 (2) (a) at the end of the
152001-03 fiscal biennium, if any, and from moneys lapsed to the general fund from the
16appropriation under s. 20.515 (2) (g) in the amounts specified in s. 40.98 (6m). If the
17secretary of administration determines that the moneys lapsed from these
18appropriations will not be sufficient to repay the loan within a reasonable period of
19time, as determined by the secretary and the commissioner, the secretary shall credit
20the appropriation account under s. 20.145 (1) (g) from moneys in the general fund an
21amount sufficient to repay the loan.
AB876, s. 18 22Section 18. 632.835 (2) (b) of the statutes, as created by 1999 Wisconsin Act
23155
, is amended to read:
AB876,13,624 632.835 (2) (b) Whenever If an adverse determination or an experimental
25treatment determination is made, the insurer involved in the determination shall

1provide notice to the insured of the insured's right to obtain the independent review
2required under this section, how to request the review, and the time within which the
3review must be requested. The notice shall include a current listing of independent
4review organizations certified under sub. (4). An independent review under this
5section may be conducted only by an independent review organization certified
6under sub. (4) and selected by the insured.
AB876, s. 19 7Section 19. 632.835 (2) (bg) of the statutes is created to read:
AB876,13,118 632.835 (2) (bg) Notwithstanding par. (b), an insurer is not required to provide
9the notice under par. (b) to an insured who uses the internal grievance procedure
10under s. 632.83 until the insurer sends it notice of the disposition of the internal
11grievance if all of the following apply:
AB876,13,1612 1. The health benefit plan issued by the insurer contains a description of the
13independent review procedure under this section, including an explanation of the
14insured's rights under par. (d), how to request the review, the time within which the
15review must be requested, and how to obtain a current listing of independent review
16organizations certified under sub. (4).
AB876,13,1917 2. The insurer includes on its explanation of benefits form a reference to the
18section of the policy or certificate that contains the description of the independent
19review procedure.
AB876, s. 20 20Section 20. 635.25 of the statutes is created to read:
AB876,13,22 21635.25 Catastrophic risk. (1) Definition. In this section, "board" means the
22small employer catastrophic reinsurance board.
AB876,14,2 23(2) Thresholds for covered benefits. (a) By December 1, 2002, and every 2
24years thereafter until December 1, 2006, every small employer insurer shall select,

1and submit a report to the commissioner that specifies, the small employer insurer's
2threshold level of covered benefits, which may be any of the following:
AB876,14,33 1. Fifty thousand dollars in a calendar year.
AB876,14,44 2. One hundred thousand dollars in a calendar year.
AB876,14,55 3. One hundred fifty thousand dollars in a calendar year.
AB876,14,66 4. Two hundred fifty thousand dollars in a calendar year.
AB876,14,97 (b) The threshold level of benefits specified in a report under par. (a) shall apply
8to each insured under every group health benefit plan issued to a small employer in
9this state by the small employer insurer submitting the report.
AB876,14,1910 (c) For each of the 2 calendar years after the year in which a small employer
11insurer submits a report under par. (a), if the amount of covered benefits paid in a
12calendar year, beginning with 2004 and ending with 2008, by the small employer
13insurer on behalf of any insured under any group health benefit plan to which this
14section applies exceeds the threshold level of covered benefits specified in the report,
15the commissioner, at the direction of the board, shall reimburse the small employer
16insurer from the appropriation under s. 20.145 (1) (j), in accordance with the
17procedures established by rule under sub. (5) (e), for 80% of the amount paid by the
18small employer insurer in that calendar year in excess of the threshold level specified
19in the report.
AB876,14,23 20(3) Premiums for reimbursements. (a) For every group health benefit plan
21issued or renewed to a small employer in this state on or between the dates specified
22by rule under sub. (5) (b), a small employer insurer shall charge a total premium that
23includes the premium amount established by rule under sub. (5) (a).
AB876,15,324 (b) By the date specified by rule under sub. (5) (c), a small employer insurer
25shall forward to the board the premiums established by rule under sub. (5) (a), in the

1manner required by rule under sub. (5) (d). The board shall credit all premium
2amounts received under this paragraph to the appropriation account under s. 20.145
3(1) (j).
AB876,15,74 (c) In addition to the disclosures required under s. 635.11, before the issuance
5or renewal of a group health benefit plan to a small employer in this state on or
6between the dates specified by rule under sub. (5) (b), a small employer insurer shall
7disclose to the small employer all of the following:
AB876,15,98 1. The small employer insurer's current threshold level of covered benefits
9under sub. (2) (a) and the calendar years to which it applies.
AB876,15,1210 2. The amount of the total premium that is attributable to coverage for the
11small employer insurer's threshold level of covered benefits and 20% of covered
12benefits in excess of that threshold level.
AB876,15,1413 3. The amount of the total premium that is the premium amount established
14by rule under sub. (5) (a).
AB876,15,21 15(4) Provider discounts. (a) The commissioner by rule shall establish provider
16discount rates for charges for covered services provided to insureds under group
17health benefit plans that are issued or renewed to small employers in this state on
18or between the dates specified by rule under sub. (5) (b). The commissioner may
19establish higher provider discount rates for covered benefits under group health
20benefit plans that are issued by small employer insurers that specify higher
21threshold levels under sub. (2) (a).
AB876,16,222 (b) Except for copayments, coinsurance, or deductibles required or authorized
23under a group health benefit plan, a provider of a covered service, drug, or device
24shall accept as payment in full for the covered service, drug, or device the discounted
25payment rate under par. (a) and may not bill the insured under the group health

1benefit plan who receives the service, drug, or device for any amount by which the
2charge is reduced under par. (a).
AB876,16,4 3(5) Rules. The commissioner shall promulgate rules developed by the board
4for the operation of this section, including rules that do all of the following:
AB876,16,95 (a) Establish and periodically adjust the premium amounts that must be
6charged to small employers under sub. (3) (c) 3. The premium amounts under sub.
7(3) (c) 3. shall be based on an actuarily sound charge per covered individual that is
8calculated to generate sufficient moneys, in conjunction with provider discounts
9under sub. (4), to cover the reimbursements required under sub. (2) (c).
AB876,16,1110 (b) Specify the dates that apply in sub. (3) (a), subject to the dates specified in
11par. (c) and sub. (2) (c).
AB876,16,1412 (c) Specify the dates by which a small employer insurer must forward to the
13board the premiums established under par. (a). The first date by which the
14premiums must be forwarded to the board may not be later than July 1, 2003.
AB876,16,1715 (d) Specify the procedures that small employer insurers must use for collecting,
16segregating, holding in trust, and forwarding to the board the premiums established
17under par. (a).
AB876,16,2118 (e) Specify the procedures that small employer insurers must use for obtaining
19reimbursement under sub. (2) (c), including requirements for documenting the
20payment of covered benefits for determining whether a small employer insurer has
21paid its threshold level of covered benefits.
AB876, s. 21 22Section 21. 635.30 of the statutes is created to read:
AB876,16,23 23635.30 Pilot catastrophic care program. (1) In this section:
AB876,16,2424 (a) "Board" means the small employer catastrophic care board.
AB876,17,2
1(b) "Fiscal year" means the period beginning on July 1 and ending on the
2following June 30.
AB876,17,33 (c) "Fund" means the small employer catastrophic care program fund.
AB876,17,44 (d) "Health care coverage revenue" has the meaning given in s. 149.10 (3m).
AB876,17,55 (e) "Insurer" has the meaning given in s. 632.745 (15).
AB876,17,76 (f) "Program" means the pilot program established and administered under
7this section.
AB876,17,108 (g) "Provider" means a health care professional, as defined in s. 180.1901 (1m),
9a health care facility, as defined in s. 146.997 (1) (c), or a health care service or
10organization.
AB876,17,16 11(2) Establishment and administration of program. (a) There is established
12a pilot catastrophic care program for employees who are eligible for coverage under
13group health benefit plans issued to small employers. The program shall operate for
145 years, beginning on January 1, 2003, in a region of the state that includes
15Winnebago County and that shall be determined and described by the commissioner
16by rule.
AB876,17,1817 (b) The board shall oversee the operations of the program, and shall do all of
18the following:
AB876,17,2019 1. Annually, by no later than April 30, establish a budget for the program for
20the next fiscal year.
AB876,17,2321 2. Subject to sub. (3) (a) 4., establish the methodology for determining the
22premium to be charged a small employer for providing coverage under the program
23for an employee of the small employer.
AB876,18,3
13. Establish procedures for collecting and depositing in the fund the insurer
2assessments under sub. (3) (a) 2., the provider assessments under sub. (3) (a) 3., and
3the premiums under sub. (3) (a) 4.
AB876,18,74 4. Establish procedures for paying the costs of covered benefits for employees
5enrolled in the program, including procedures that small employer insurers must
6use for documenting and obtaining reimbursement of claims costs under sub. (6) (c),
7and for paying all other operating and administrative costs of the program.
AB876,18,228 5. Annually, by no later than April 30, based on data from the previous calendar
9year, perform a reconciliation with respect to program costs, the transfer to the fund
10under s. 20.145 (1) (g), insurer assessments under sub. (3) (a) 2., provider
11assessments under sub. (3) (a) 3., provider payment rate discounts under sub. (3) (b),
12and premiums under sub. (3) (a) 4. If the board determines that in the preceding
13calendar year the insurer assessments under sub. (3) (a) 2., or the provider
14assessments under sub. (3) (a) 3. in conjunction with the provider payment rate
15discounts under sub. (3) (b), were not equal to the transfer to the fund under s. 20.145
16(1) (g), as required in sub. (3) (a) 2. and 3., the board shall make any necessary
17adjustments for the fiscal year beginning on the first July 1 after the reconciliation,
18by increasing or decreasing the insurer assessments under sub. (3) (a) 2., the
19provider assessments under sub. (3) (a) 3., or the provider payment rate discounts
20under sub. (3) (b) to reflect the amount by which the insurer assessments or provider
21assessments in conjunction with the provider payment rate discounts did not equal
22the amount of the transfer.
AB876,18,2523 6. Provide for the procurement, in a competitive process, of a contract for the
24services of a qualified administrator to administer the program and to assist the
25board in its oversight of the program.
AB876,19,5
1(3) Program funding. (a) In establishing the annual budget under sub. (2) (b)
21., the board shall determine and approve the amount of funding needed for the fiscal
3year to pay the anticipated costs of covered benefits for employees enrolled in the
4program and all other operating and administrative costs of the program. Funding
5for the program shall consist of all of the following:
AB876,19,76 1. The transfer to the fund from the appropriation account under s. 20.145 (1)
7(g).
AB876,19,188 2. Assessments paid by insurers that are established by the board and
9promulgated by the commissioner by rule and that annually equal the amount of the
10annual transfer under subd. 1. Each insurer's share of the assessment under this
11subdivision shall be determined annually by the commissioner based on annual
12statements and other reports filed by the insurer with the commissioner, and shall
13be in the same ratio as the insurer's total health care coverage revenue for residents
14of this state during the preceding calendar year bears to the aggregate health care
15coverage revenue of all insurers for residents of this state, as determined by the
16commissioner. The commissioner may by rule exempt as a class those insurers whose
17share would be so minimal as not to exceed the estimated cost of levying the
18assessment.
AB876,19,2519 3. Assessments paid by providers that are established by the board and
20promulgated by the commissioner by rule and that, in conjunction with the provider
21discounts established under par. (b), annually equal the amount of the annual
22transfer under subd. 1. Each provider's share of the assessment under this
23subdivision shall be determined as provided in the rule under this subdivision. The
24commissioner may by rule exempt as a class those providers whose share would be
25so minimal as not to exceed the estimated cost of levying the assessment.
AB876,20,5
14. The premiums described in sub. (5) (c) 2., which shall be established by the
2board and promulgated by the commissioner by rule, and which shall be calculated
3on the basis of the amount by which the sum of the amounts under subds. 1. to 3. is
4not sufficient to pay the anticipated costs of covered benefits for employees enrolled
5in the program and all other operating and administrative costs of the program.
AB876,20,86 (b) 1. Subject to par. (a) 3., the commissioner by rule shall establish provider
7discount rates for charges for covered services provided to employees enrolled in the
8program.
AB876,20,149 2. Except for copayments, coinsurance, or deductibles required or authorized
10under the group health benefit plan for which the employee is eligible under sub. (4)
11(a) 1., a provider of a covered service, drug, or device shall accept as payment in full
12for the covered service, drug, or device the discounted payment rate under subd. 1.
13and may not bill the employee who receives the service, drug, or device for any
14amount by which the charge is reduced under subd 1.
AB876,20,16 15(4) Employee eligibility. (a) An employee may be enrolled in the program if
16all of the following apply:
AB876,20,1917 1. The employee is eligible for coverage under a group health benefit plan that
18is issued or renewed by a small employer insurer to a small employer on or between
19the dates specified by rule under sub. (7) (c).
AB876,20,2120 2. The small employer is located in the region determined by rule under sub.
21(2) (a).
AB876,20,2522 3. When the small employer insurer applies health status underwriting factors
23under s. 635.05 for determining premiums under the group health benefit plan under
24subd. 1., the small employer insurer determines that the employee is eligible to enroll
25in the program by using the guidelines established by rule under sub. (7) (a).
AB876,21,1
14. The small employer agrees to enroll the employee in the program.
AB876,21,32 5. The small employer pays the additional premium described in sub. (5) (c) 2.
3for the enrolled employee's coverage under the program.
AB876,21,94 (b) If an employee who is enrolled in the program becomes ineligible under par.
5(a), the employee may apply for coverage under the health insurance risk-sharing
6plan under ch. 149. If the employee applies for and obtains coverage under that plan
7and his or her application for coverage was received within 63 days after his or her
8enrollment under the program was terminated under this paragraph, the employee
9may not be subject to any preexisting condition exclusion under that plan.
AB876,21,14 10(5) Premiums. (a) For every group health benefit plan issued or renewed to a
11small employer that agrees to enroll in the program an employee who is eligible
12under sub. (4) (a), the small employer insurer shall charge a total premium that
13includes an amount established by rule under sub. (3) (a) 4. for the employee's
14coverage under the program.
AB876,21,1715 (b) The small employer insurer shall forward to the board, in the manner and
16time required by rule under sub. (7) (d), the premium amounts that are charged for
17coverage under the program.
AB876,21,2118 (c) In addition to the disclosures required under s. 635.11, upon the issuance
19or renewal of a group health benefit plan to a small employer that agrees to enroll
20an employee in the program, the small employer insurer shall disclose to the small
21employer all of the following:
AB876,21,2422 1. The amount of the total premium that is attributable to coverage under the
23group health benefit plan for the small employer's employees who are not enrolled
24in the program.
AB876,22,2
12. The amount of the total premium that is attributable to an employee's
2coverage under the program and that is established by rule under sub. (3) (a) 4.
AB876,22,73 (d) If a small employer does not agree to enroll in the program an employee who
4is otherwise eligible for enrollment under sub. (4) (a), the small employer insurer
5issuing or renewing the group health benefit plan to the small employer may apply
6health status underwriting factors and determine premiums for the group health
7benefit plan without regard to the requirements established under s. 635.05.
AB876,22,10 8(6) Covered benefits; reimbursements. (a) Covered benefits for an employee
9who is enrolled in the program are the same as the covered benefits under the group
10health benefit plan for which the employee is eligible under sub. (4) (a) 1.
AB876,22,1411 (b) All claims for covered benefits for an employee enrolled in the program shall
12be processed for payment or denial by the small employer insurer issuing or
13renewing the group health benefit plan for which the employee is eligible under sub.
14(4) (a) 1.
Loading...
Loading...