SB466,4,1210 149.10 (3) "Eligible person" means a resident of this state who qualifies under
11s. 149.12 whether or not the person is legally responsible for the payment of medical
12expenses incurred on the person's behalf.
SB466, s. 4 13Section 4. 149.10 (5f) of the statutes is created to read:
SB466,5,4
1149.10 (5f) "Labeler" means a person that receives prescription drugs from a
2manufacturer or wholesaler and repackages those drugs for later retail sale and that
3has a labeler code issued by the federal food and drug administration under 21 CFR
4207.20
(b).
SB466, s. 5 5Section 5. 149.10 (5r) of the statutes is created to read:
SB466,5,86 149.10 (5r) "Manufacturer" means a person engaged in the production,
7preparation, propagation, compounding, conversion, or processing of prescription
8drugs.
SB466, s. 6 9Section 6. 149.11 of the statutes is amended to read:
SB466,5,15 10149.11 Operation of plan. The department board shall promulgate rules for
11the design and operation of a plan of health insurance coverage for an eligible person
12which
persons that satisfies the requirements of this chapter. The board shall
13consult with the department as necessary in promulgating the rules under this
14section. The department shall provide the board with the support necessary for the
15board to carry out its responsibilities under this chapter.
SB466, s. 7 16Section 7. 149.115 of the statutes is amended to read:
SB466,5,21 17149.115 Rules relating to creditable coverage. The commissioner, in
18consultation with the department and the board, shall promulgate rules that specify
19how creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that
20determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The
21rules shall comply with section 2701 (c) of P.L. 104-191.
SB466, s. 8 22Section 8. 149.12 (1) (a) of the statutes is amended to read:
SB466,5,2323 149.12 (1) (a) A notice of rejection of coverage from one 2 or more insurers.
SB466, s. 9 24Section 9. 149.12 (1) (am) of the statutes is amended to read:
SB466,6,2
1149.12 (1) (am) A notice of rejection of coverage from one or more insurers and
2a notice of
cancellation of coverage from one or more insurers.
SB466, s. 10 3Section 10. 149.12 (1) (b) of the statutes is amended to read:
SB466,6,84 149.12 (1) (b) A notice of rejection of coverage from one or more insurers and
5a notice of
reduction or limitation of coverage, including restrictive riders, from an
6insurer if the effect of the reduction or limitation is to substantially reduce coverage
7substantially compared to the coverage available to a person considered a standard
8risk for the type of coverage provided by the plan.
SB466, s. 11 9Section 11. 149.12 (1) (c) of the statutes is amended to read:
SB466,6,1310 149.12 (1) (c) A notice of rejection of coverage from one or more insurers and
11a notice of
increase in premium exceeding the premium then in effect for the insured
12person by 50% 50 percent or more, unless the increase applies to substantially all of
13the insurer's health insurance policies then in effect.
SB466, s. 12 14Section 12. 149.12 (3) (c) of the statutes is amended to read:
SB466,6,1715 149.12 (3) (c) The department board may promulgate rules specifying other
16deductible or coinsurance amounts that, if paid or reimbursed for persons, will not
17make the persons ineligible for coverage under the plan.
SB466, s. 13 18Section 13. 149.125 of the statutes is created to read:
SB466,6,24 19149.125 Employment verification; maintenance of data; report. (1) In
20determining a person's initial and continued eligibility, the department shall verify,
21at the time that the person applies for coverage and periodically thereafter,
22information submitted by the person about his or her employment and whether
23creditable coverage is available to the person. The department shall use information
24obtained under s. 49.475 for verification purposes under this subsection.
SB466,7,4
1(2) The department shall maintain and regularly update a computer data base
2with information about eligible persons that includes employment status and
3economic and demographic information. The department shall submit a quarterly
4report to the board on the information contained in the data base.
SB466, s. 14 5Section 14. 149.13 (1) of the statutes is amended to read:
SB466,7,106 149.13 (1) Every insurer shall participate in the cost of administering the plan,
7except that the commissioner may by rule exempt as a class those insurers whose
8share as determined under sub. (2) would be so minimal as to not to exceed the
9estimated cost of levying the assessment. The commissioner shall advise the
10department board of the insurers participating in the cost of administering the plan.
SB466, s. 15 11Section 15. 149.13 (3) of the statutes is amended to read:
SB466,7,1612 149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be
13determined annually by the commissioner based on annual statements and other
14reports filed by the insurer with the commissioner. The commissioner shall assess
15an insurer for the insurer's proportion of participation based on the total
16assessments estimated by the department board under s. 149.143 (2) (a) 3.
SB466,7,2317 (b) If the department or the, commissioner, or board finds that the
18commissioner's authority to require insurers to report under chs. 600 to 646 and 655
19is not adequate to permit the department, the commissioner, or the board to carry out
20the department's, commissioner's, or board's responsibilities under this chapter, the
21commissioner shall promulgate rules requiring insurers to report the information
22necessary for the department, commissioner, and board to make the determinations
23required under this chapter.
SB466, s. 16 24Section 16. 149.13 (4) of the statutes is amended to read:
SB466,8,4
1149.13 (4) Notwithstanding subs. (1) to (3), the department, with the
2agreement of the commissioner and the board, may perform various administrative
3functions related to the assessment of insurers participating in the cost of
4administering the plan.
SB466, s. 17 5Section 17. 149.132 of the statutes is created to read:
SB466,8,12 6149.132 Participation of manufacturers and labelers. (1) Any
7manufacturer or labeler of prescription drugs that are sold, or otherwise provided,
8to persons in this state who receive health care coverage benefits under the Medical
9Assistance program under subch. IV of ch. 49, the Badger Care health care program
10under s. 49.665, or the prescription drug assistance for elderly persons program
11under s. 49.688 is required to sell prescription drugs for the prescribed use and
12purchase by eligible persons covered under the plan.
SB466,8,19 13(2) As a condition of coverage under the plan of the prescription drugs of a
14manufacturer or labeler, the manufacturer or labeler shall pay an assessment on the
15total claims that the plan paid, in the previous calendar year, to pharmacists and
16pharmacies for the prescription drugs of the manufacturer or labeler. The
17assessment amount per claim shall be equal to the rebate paid under the Medical
18Assistance program by the manufacturer or labeler for the prescription drug that is
19the subject of the claim.
SB466,8,24 20(3) The plan administrator shall notify each manufacturer and each labeler of
21the amount paid by the plan in claims for the prescription drugs of each
22manufacturer and labeler and shall advise the board and the department of the
23amounts. The department shall levy and collect the assessments and deposit the
24amounts collected in the health insurance risk-sharing plan fund.
SB466, s. 18
1Section 18. 149.14 (3) (intro.) of the statutes is renumbered 149.14 (3) and
2amended to read:
SB466,9,153 149.14 (3) Covered expenses. Except as provided in sub. (4), except as
4restricted by cost containment provisions under s. 149.17 (4) and except as reduced
5by the department board under ss. 149.143 and 149.144, covered expenses for the
6coverage under this section shall be the payment rates established by the
7department
under s. 149.142 for the services provided by persons licensed under ch.
8446 and certified under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as
9restricted by cost containment provisions under s. 149.17 (4) and except as reduced
10by the department board under ss. 149.143 and 149.144, covered expenses for the
11coverage under this section shall also be the payment rates established by the
12department
under s. 149.142 for the following services and articles specified by the
13board
if the service or article is prescribed by a physician who is licensed under ch.
14448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service
15or article is provided by a provider certified under s. 49.45 (2) (a) 11.:
SB466, s. 19 16Section 19. 149.14 (3) (a) to (r) of the statutes are repealed.
SB466, s. 20 17Section 20. 149.14 (4) of the statutes is repealed.
SB466, s. 21 18Section 21. 149.14 (4c) of the statutes is repealed.
SB466, s. 22 19Section 22. 149.14 (5) (d) of the statutes is amended to read:
SB466,9,2420 149.14 (5) (d) Notwithstanding pars. (a) to (c), the department board may
21establish different deductible amounts, a different coinsurance percentage, and
22different covered costs and deductible aggregate amounts from those specified in
23pars. (a) to (c) in accordance with cost containment provisions established by the
24department board under s. 149.17 (4).
SB466, s. 23
1Section 23. 149.14 (5) (e) of the statutes, as affected by 2003 Wisconsin Act 33,
2is amended to read:
SB466,10,133 149.14 (5) (e) Subject to sub. (8) (b), the department board may, by rule under
4s. 149.17 (4), establish for prescription drug coverage under sub. (3) (d) this section
5copayment amounts, coinsurance rates, and copayment and coinsurance
6out-of-pocket limits over which the plan will pay 100% 100 percent of covered costs
7under sub. (3) (d) for prescription drugs. The department board may provide
8subsidies for prescription drug copayment amounts paid by eligible persons under
9s. 149.165 (2) (a) 1. to 5. Any copayment amount, coinsurance rate, or out-of-pocket
10limit established under this paragraph is subject to the approval of the board.

11Copayments and coinsurance paid by an eligible person under this paragraph are
12separate from and do not count toward the deductible and covered costs not paid by
13the plan under pars. (a) to (c).
SB466, s. 24 14Section 24. 149.14 (5m) (c) of the statutes is amended to read:
SB466,10,1615 149.14 (5m) (c) Other economic factors that the department and the board
16consider considers relevant.
SB466, s. 25 17Section 25. 149.14 (7) (b) and (c) of the statutes are amended to read:
SB466,10,2118 149.14 (7) (b) The department board has a cause of action against an eligible
19participant person for the recovery of the amount of benefits paid which that are not
20for covered expenses under the plan. Benefits under the plan may be reduced or
21refused as a setoff against any amount recoverable under this paragraph.
SB466,10,2522 (c) The department board is subrogated to the rights of an eligible person to
23recover special damages for illness or injury to the person caused by the act of a 3rd
24person to the extent that benefits are provided under the plan. Section 814.03 (3)
25applies to the department board under this paragraph.
SB466, s. 26
1Section 26. 149.14 (8) of the statutes is amended to read:
SB466,11,72 149.14 (8) Applicability of medical assistance provisions. (a) Except as
3provided in par. (b), the department board may, by rule under s. 149.17 (4), apply to
4the plan the same utilization and cost control procedures that apply under rules
5promulgated by the department to medical assistance under subch. IV of ch. 49. The
6board shall consult with the department as necessary in the application of the
7utilization and cost control procedures specified in this paragraph
.
SB466,11,108 (b) The department board may not apply to eligible persons for covered services
9or articles the same copayments that apply to recipients of medical assistance under
10subch. IV of ch. 49
for services or articles covered under that program.
SB466, s. 27 11Section 27. 149.142 (1) of the statutes is amended to read:
SB466,11,2112 149.142 (1) (a) Except as provided in par. (b), the department board shall
13establish payment rates for covered expenses that consist of the allowable charges
14paid under s. 49.46 (2) for the services and articles provided plus an enhancement
15determined by the department board. The rates shall be based on the allowable
16charges paid under s. 49.46 (2), projected plan costs, and trend factors. Using the
17same methodology that applies to medical assistance under subch. IV of ch. 49, the
18department board shall establish hospital outpatient per visit reimbursement rates
19and hospital inpatient reimbursement rates that are specific to diagnostically
20related groups of eligible persons. The board shall consult with the department in
21establishing the payment and reimbursement rates under this paragraph.
SB466,12,222 (b) The payment rate for a prescription drug shall be the allowable charge paid
23under s. 49.46 (2) (b) 6. h. for the prescription drug. Notwithstanding s. 149.17 (4),
24the department board may not reduce the payment rate for prescription drugs below

1the rate specified in this paragraph, and the rate may not be adjusted under s.
2149.143 or 149.144.
SB466, s. 28 3Section 28. 149.142 (3) of the statutes is created to read:
SB466,12,84 149.142 (3) Whenever a claim is processed for payment, the adjustment of a
5provider's payment rate under sub. (1) and any adjustment under s. 149.143 or
6149.144 shall be calculated and applied on a per-claim basis. The adjustment shall
7be disclosed on the explanation-of-benefits form provided to the eligible person and
8to the provider.
SB466, s. 29 9Section 29. 149.143 (1) (intro.) of the statutes is amended to read:
SB466,12,1510 149.143 (1) (intro.) The department shall pay or recover the operating costs of
11the plan from the appropriation under s. 20.435 (4) (v) and administrative costs of
12the plan from the appropriation under s. 20.435 (4) (u). For purposes of determining
13premiums, insurer assessments, and provider payment rate adjustments, the
14department board shall apportion and prioritize responsibility for payment or
15recovery of plan costs from among the moneys constituting the fund as follows:
SB466, s. 30 16Section 30. 149.143 (1) (am) of the statutes, as affected by 2003 Wisconsin Act
1733
, is amended to read:
SB466,12,1918 149.143 (1) (am) A total of 60% 60 percent from the following sources,
19calculated as follows:
SB466,13,320 1. First, from premiums from eligible persons with coverage under s. 149.14 (2)
21(a) set at a rate that is 140% 140 percent to 150% 150 percent of the rate that a
22standard risk would be charged under an individual policy providing substantially
23the same coverage and deductibles cost-sharing provisions as are provided under
24the plan and from eligible persons with coverage under s. 149.14 (2) (b) set in
25accordance with s. 149.14 (5m), including amounts received for premium, deductible,

1and prescription drug copayment subsidies under s. 149.144, and from premiums
2collected from eligible persons with coverage under s. 149.146 set in accordance with
3s. 149.146 (2) (b).
SB466,13,54 2. Second, from moneys specified under sub. (2m), to the extent that the
5amounts under subd. 1. are insufficient to pay 60% 60 percent of plan costs.
SB466,13,166 3. Third, by increasing premiums from eligible persons with coverage under s.
7149.14 (2) (a) to more than the rate at which premiums were set under subd. 1. but
8not more than 200% 200 percent of the rate that a standard risk would be charged
9under an individual policy providing substantially the same coverage and
10deductibles cost-sharing provisions as are provided under the plan and from eligible
11persons with coverage under s. 149.14 (2) (b) by a comparable amount in accordance
12with s. 149.14 (5m), including amounts received for premium, deductible, and
13prescription drug copayment subsidies under s. 149.144, and by increasing
14premiums from eligible persons with coverage under s. 149.146 in accordance with
15s. 149.146 (2) (b), to the extent that the amounts under subds. 1. and 2. are
16insufficient to pay 60% 60 percent of plan costs.
SB466,13,2117 4. Fourth, notwithstanding par. (bm), by increasing insurer assessments,
18excluding assessments under s. 149.144, and adjusting provider payment rates,
19subject to s. 149.142 (1) (b) and excluding adjustments to those rates under s.
20149.144, in equal proportions and to the extent that the amounts under subds. 1. to
213. are insufficient to pay 60% 60 percent of plan costs.
SB466, s. 31 22Section 31. 149.143 (1) (bm) (intro.) of the statutes, as affected by 2003
23Wisconsin Act 33
, is amended to read:
SB466,13,2424 149.143 (1) (bm) (intro.) A total of 40% 40 percent as follows:
SB466, s. 32
1Section 32. 149.143 (1) (bm) 1. of the statutes, as affected by 2003 Wisconsin
2Act 33
, is renumbered 149.143 (1) (bm) 2m. a.
SB466, s. 33 3Section 33. 149.143 (1) (bm) 1m. of the statutes is created to read:
SB466,14,54 149.143 (1) (bm) 1m. First, from manufacturer and labeler assessments under
5s. 149.132.
SB466, s. 34 6Section 34. 149.143 (1) (bm) 2. of the statutes, as affected by 2003 Wisconsin
7Act 33
, is renumbered 149.143 (1) (bm) 2m. b.
SB466, s. 35 8Section 35. 149.143 (1) (bm) 2m. (intro.) of the statutes is created to read:
SB466,14,99 149.143 (1) (bm) 2m. (intro.) The remainder as follows:
SB466, s. 36 10Section 36. 149.143 (2) (a) (intro.) of the statutes, as affected by 2003
11Wisconsin Act 33
, is amended to read:
SB466,14,1612 149.143 (2) (a) (intro.) Prior to each plan year, the department board shall
13estimate the operating and administrative costs of the plan and the costs of the
14premium reductions under s. 149.165 (2) and (3), the deductible reductions under s.
15149.14 (5) (a), and any prescription drug copayment reductions under s. 149.14 (5)
16(e) for the new plan year and do all of the following:
SB466, s. 37 17Section 37. 149.143 (2) (a) 1. a. of the statutes, as affected by 2003 Wisconsin
18Act 33
, is amended to read:
SB466,14,2419 149.143 (2) (a) 1. a. Estimate the amount of enrollee premiums that would be
20received in the new plan year if the enrollee premiums were set at a level sufficient,
21when including amounts received for premium, deductible, and prescription drug
22copayment subsidies under s. 149.144 and from premiums collected from eligible
23persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to
24cover 60% 60 percent of the estimated plan costs for the new plan year.
SB466, s. 38
1Section 38. 149.143 (2) (a) 2. of the statutes, as affected by 2003 Wisconsin Act
233
, is amended to read:
SB466,15,93 149.143 (2) (a) 2. After making the determinations under subd. 1., by rule set
4premium rates for the new plan year, including the rates under s. 149.146 (2) (b), in
5the manner specified in sub. (1) (am) 1. and 3. and such that a rate for coverage under
6s. 149.14 (2) (a) is approved by the board and is not less than 140% 140 percent nor
7more than 200% 200 percent of the rate that a standard risk would be charged under
8an individual policy providing substantially the same coverage and deductibles
9cost-sharing provisions as are provided under the plan.
SB466, s. 39 10Section 39. 149.143 (2) (a) 3. of the statutes, as affected by 2003 Wisconsin Act
1133
, is amended to read:
SB466,15,1612 149.143 (2) (a) 3. By rule, after estimating the amount of manufacturer and
13labeler assessments that will be received under sub. (1) (bm) 1m.,
set the total
14insurer assessments under s. 149.13 for the new plan year by estimating and setting
15the assessments at the amount necessary to equal the amounts specified in sub. (1)
16(am) 4. and (bm) 1. 2m. a. and notify the commissioner of the amount.
SB466, s. 40 17Section 40. 149.143 (2) (a) 4. of the statutes, as affected by 2003 Wisconsin Act
1833
, is amended to read:
SB466,15,2419 149.143 (2) (a) 4. By the same rule as under subd. 3., after estimating the
20amount of the manufacturer and labeler assessments that will be received under
21sub. (1) (bm) 1m.,
adjust the provider payment rate for the new plan year, subject to
22s. 149.142 (1) (b), by estimating and setting the rate at the level necessary to equal
23the amounts specified in sub. (1) (am) 4. and (bm) 2. 2m. b. and as provided in s.
24149.145.
SB466, s. 41
1Section 41. 149.143 (2) (b) of the statutes, as affected by 2003 Wisconsin Act
233
, is amended to read:
SB466,16,83 149.143 (2) (b) In setting the premium rates under par. (a) 2., the insurer
4assessment amount under par. (a) 3., and the provider payment rate under par. (a)
54. for the new plan year, the department board shall include any increase or decrease
6necessary to reflect the amount, if any, by which the rates and amount set under par.
7(a) for the current plan year differed from the rates and amount which would have
8equaled the amounts specified in sub. (1) (am) and (bm) in the current plan year.
SB466, s. 42 9Section 42. 149.143 (2m) (a) (intro.) of the statutes is amended to read:
SB466,16,1110 149.143 (2m) (a) (intro.) The department board shall keep a separate
11accounting of the difference between the following:
SB466, s. 43 12Section 43. 149.143 (2m) (a) 2. of the statutes, as affected by 2003 Wisconsin
13Act 33
, is amended to read:
SB466,16,1614 149.143 (2m) (a) 2. The amount of premiums, including amounts received for
15premium, deductible, and prescription drug copayment subsidies, necessary to cover
1660% 60 percent of the plan costs for the plan year.
SB466, s. 44 17Section 44. 149.143 (2m) (b) 1. of the statutes, as affected by 2003 Wisconsin
18Act 33
, is amended to read:
SB466,16,2319 149.143 (2m) (b) 1. To reduce premiums in succeeding plan years as provided
20in sub. (1) (am) 2. For eligible persons with coverage under s. 149.14 (2) (a),
21premiums may not be reduced below 140% 140 percent of the rate that a standard
22risk would be charged under an individual policy providing substantially the same
23coverage and deductibles cost-sharing provisions as are provided under the plan.
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