SB466: Bill Text

SB466,4,12 149.10 (3) "Eligible person" means a resident of this state who qualifies under s. 149.12 whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.

SB466, s. 4 Section 4. 149.10 (5f) of the statutes is created to read:

SB466,5,4 149.10 (5f) "Labeler" means a person that receives prescription drugs from a manufacturer or wholesaler and repackages those drugs for later retail sale and that has a labeler code issued by the federal food and drug administration under 21 CFR 207.20 (b).

SB466, s. 5 Section 5. 149.10 (5r) of the statutes is created to read:

SB466,5,8 149.10 (5r) "Manufacturer" means a person engaged in the production, preparation, propagation, compounding, conversion, or processing of prescription drugs.

SB466, s. 6 Section 6. 149.11 of the statutes is amended to read:

SB466,5,15 149.11 Operation of plan. The department board shall promulgate rules for the design and operation of a plan of health insurance coverage for an eligible person which persons that satisfies the requirements of this chapter. The board shall consult with the department as necessary in promulgating the rules under this section. The department shall provide the board with the support necessary for the board to carry out its responsibilities under this chapter.

SB466, s. 7 Section 7. 149.115 of the statutes is amended to read:

SB466,5,21 149.115 Rules relating to creditable coverage. The commissioner, in consultation with the department and the board, shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.

SB466, s. 8 Section 8. 149.12 (1) (a) of the statutes is amended to read:

SB466,5,23 149.12 (1) (a) A notice of rejection of coverage from one 2 or more insurers.

SB466, s. 9 Section 9. 149.12 (1) (am) of the statutes is amended to read:

SB466,6,2 149.12 (1) (am) A notice of rejection of coverage from one or more insurers and a notice of cancellation of coverage from one or more insurers.

SB466, s. 10 Section 10. 149.12 (1) (b) of the statutes is amended to read:

SB466,6,8 149.12 (1) (b) A notice of rejection of coverage from one or more insurers and a notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage substantially compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.

SB466, s. 11 Section 11. 149.12 (1) (c) of the statutes is amended to read:

SB466,6,13 149.12 (1) (c) A notice of rejection of coverage from one or more insurers and a notice of increase in premium exceeding the premium then in effect for the insured person by 50% 50 percent or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.

SB466, s. 12 Section 12. 149.12 (3) (c) of the statutes is amended to read:

SB466,6,17 149.12 (3) (c) The department board 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.

SB466, s. 13 Section 13. 149.125 of the statutes is created to read:

SB466,6,24 149.125 Employment verification; maintenance of data; report. (1) In determining a person's initial and continued eligibility, the department shall verify, at the time that the person applies for coverage and periodically thereafter, information submitted by the person about his or her employment and whether creditable coverage is available to the person. The department shall use information obtained under s. 49.475 for verification purposes under this subsection.

SB466,7,4 (2) The department shall maintain and regularly update a computer data base with information about eligible persons that includes employment status and economic and demographic information. The department shall submit a quarterly report to the board on the information contained in the data base.

SB466, s. 14 Section 14. 149.13 (1) of the statutes is amended to read:

SB466,7,10 149.13 (1) Every insurer shall participate in the cost of administering the plan, except that the commissioner may by rule exempt as a class those insurers whose share as determined under sub. (2) would be so minimal as to not to exceed the estimated cost of levying the assessment. The commissioner shall advise the department board of the insurers participating in the cost of administering the plan.

SB466, s. 15 Section 15. 149.13 (3) of the statutes is amended to read:

SB466,7,16 149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the department board under s. 149.143 (2) (a) 3.

SB466,7,23 (b) If the department or the, commissioner, or board 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 board's responsibilities under this chapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the department, commissioner, and board to make the determinations required under this chapter.

SB466, s. 16 Section 16. 149.13 (4) of the statutes is amended to read:

SB466,8,4 149.13 (4) Notwithstanding subs. (1) to (3), the department, with the agreement of the commissioner and the board, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan.

SB466, s. 17 Section 17. 149.132 of the statutes is created to read:

SB466,8,12 149.132 Participation of manufacturers and labelers. (1) Any manufacturer or labeler of prescription drugs that are sold, or otherwise provided, to persons in this state who receive health care coverage benefits under the Medical Assistance program under subch. IV of ch. 49, the Badger Care health care program under s. 49.665, or the prescription drug assistance for elderly persons program under s. 49.688 is required to sell prescription drugs for the prescribed use and purchase by eligible persons covered under the plan.

SB466,8,19 (2) As a condition of coverage under the plan of the prescription drugs of a manufacturer or labeler, the manufacturer or labeler shall pay an assessment on the total claims that the plan paid, in the previous calendar year, to pharmacists and pharmacies for the prescription drugs of the manufacturer or labeler. The assessment amount per claim shall be equal to the rebate paid under the Medical Assistance program by the manufacturer or labeler for the prescription drug that is the subject of the claim.

SB466,8,24 (3) The plan administrator shall notify each manufacturer and each labeler of the amount paid by the plan in claims for the prescription drugs of each manufacturer and labeler and shall advise the board and the department of the amounts. The department shall levy and collect the assessments and deposit the amounts collected in the health insurance risk-sharing plan fund.

SB466, s. 18 Section 18. 149.14 (3) (intro.) of the statutes is renumbered 149.14 (3) and amended to read:

SB466,9,15 149.14 (3) Covered expenses. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department board under ss. 149.143 and 149.144, covered expenses for the coverage under this section shall be the payment rates established by the department under s. 149.142 for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department board under ss. 149.143 and 149.144, covered expenses for the coverage under this section shall also be the payment rates established by the department under s. 149.142 for the following services and articles specified by the board 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.:

SB466, s. 19 Section 19. 149.14 (3) (a) to (r) of the statutes are repealed.

SB466, s. 20 Section 20. 149.14 (4) of the statutes is repealed.

SB466, s. 21 Section 21. 149.14 (4c) of the statutes is repealed.

SB466, s. 22 Section 22. 149.14 (5) (d) of the statutes is amended to read:

SB466,9,24 149.14 (5) (d) Notwithstanding pars. (a) to (c), the department board 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 department board under s. 149.17 (4).

SB466, s. 23 Section 23. 149.14 (5) (e) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,10,13 149.14 (5) (e) Subject to sub. (8) (b), the department board may, by rule under s. 149.17 (4), establish for prescription drug coverage under sub. (3) (d) this section copayment amounts, coinsurance rates, and copayment and coinsurance out-of-pocket limits over which the plan will pay 100% 100 percent of covered costs under sub. (3) (d) for prescription drugs. The department board may provide subsidies for prescription drug copayment amounts paid by eligible persons under s. 149.165 (2) (a) 1. to 5. Any copayment amount, coinsurance rate, or out-of-pocket limit established under this paragraph is subject to the approval of the board. Copayments and coinsurance paid by an eligible person under this paragraph are separate from and do not count toward the deductible and covered costs not paid by the plan under pars. (a) to (c).

SB466, s. 24 Section 24. 149.14 (5m) (c) of the statutes is amended to read:

SB466,10,16 149.14 (5m) (c) Other economic factors that the department and the board consider considers relevant.

SB466, s. 25 Section 25. 149.14 (7) (b) and (c) of the statutes are amended to read:

SB466,10,21 149.14 (7) (b) The department board has a cause of action against an eligible participant person for the recovery of the amount of benefits paid which that 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.

SB466,10,25 (c) The department board 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 board under this paragraph.

SB466, s. 26 Section 26. 149.14 (8) of the statutes is amended to read:

SB466,11,7 149.14 (8) Applicability of medical assistance provisions. (a) Except as provided in par. (b), the department board may, by rule under s. 149.17 (4), apply to the plan the same utilization and cost control procedures that apply under rules promulgated by the department to medical assistance under subch. IV of ch. 49. The board shall consult with the department as necessary in the application of the utilization and cost control procedures specified in this paragraph.

SB466,11,10 (b) The department board may not apply to eligible persons for covered services or articles the same copayments that apply to recipients of medical assistance under subch. IV of ch. 49 for services or articles covered under that program.

SB466, s. 27 Section 27. 149.142 (1) of the statutes is amended to read:

SB466,11,21 149.142 (1) (a) Except as provided in par. (b), the department board shall establish payment rates for covered expenses that consist of the allowable charges paid under s. 49.46 (2) for the services and articles provided plus an enhancement determined by the department board. The rates shall be based on the allowable charges paid under s. 49.46 (2), projected plan costs, and trend factors. Using the same methodology that applies to medical assistance under subch. IV of ch. 49, the department board shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons. The board shall consult with the department in establishing the payment and reimbursement rates under this paragraph.

SB466,12,2 (b) The payment rate for a prescription drug shall be the allowable charge paid under s. 49.46 (2) (b) 6. h. for the prescription drug. Notwithstanding s. 149.17 (4), the department board may not reduce the payment rate for prescription drugs below the rate specified in this paragraph, and the rate may not be adjusted under s. 149.143 or 149.144.

SB466, s. 28 Section 28. 149.142 (3) of the statutes is created to read:

SB466,12,8 149.142 (3) Whenever a claim is processed for payment, the adjustment of a provider's payment rate under sub. (1) and any adjustment under s. 149.143 or 149.144 shall be calculated and applied on a per-claim basis. The adjustment shall be disclosed on the explanation-of-benefits form provided to the eligible person and to the provider.

SB466, s. 29 Section 29. 149.143 (1) (intro.) of the statutes is amended to read:

SB466,12,15 149.143 (1) (intro.) The department shall pay or recover the operating costs of the plan from the appropriation under s. 20.435 (4) (v) and administrative costs of the plan from the appropriation under s. 20.435 (4) (u). For purposes of determining premiums, insurer assessments, and provider payment rate adjustments, the department board shall apportion and prioritize responsibility for payment or recovery of plan costs from among the moneys constituting the fund as follows:

SB466, s. 30 Section 30. 149.143 (1) (am) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,12,19 149.143 (1) (am) A total of 60% 60 percent from the following sources, calculated as follows:

SB466,13,3 1. First, from premiums from eligible persons with coverage under s. 149.14 (2) (a) set at a rate that is 140% 140 percent to 150% 150 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan and from eligible persons with coverage under s. 149.14 (2) (b) set in accordance with s. 149.14 (5m), including amounts received for premium, deductible, and prescription drug copayment subsidies under s. 149.144, and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b).

SB466,13,5 2. Second, from moneys specified under sub. (2m), to the extent that the amounts under subd. 1. are insufficient to pay 60% 60 percent of plan costs.

SB466,13,16 3. Third, by increasing premiums from eligible persons with coverage under s. 149.14 (2) (a) to more than the rate at which premiums were set under subd. 1. but not more than 200% 200 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan and from eligible persons with coverage under s. 149.14 (2) (b) by a comparable amount in accordance with s. 149.14 (5m), including amounts received for premium, deductible, and prescription drug copayment subsidies under s. 149.144, and by increasing premiums from eligible persons with coverage under s. 149.146 in accordance with s. 149.146 (2) (b), to the extent that the amounts under subds. 1. and 2. are insufficient to pay 60% 60 percent of plan costs.

SB466,13,21 4. Fourth, notwithstanding par. (bm), by increasing insurer assessments, excluding assessments under s. 149.144, and adjusting provider payment rates, subject to s. 149.142 (1) (b) and excluding adjustments to those rates under s. 149.144, in equal proportions and to the extent that the amounts under subds. 1. to 3. are insufficient to pay 60% 60 percent of plan costs.

SB466, s. 31 Section 31. 149.143 (1) (bm) (intro.) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,13,24 149.143 (1) (bm) (intro.) A total of 40% 40 percent as follows:

SB466, s. 32 Section 32. 149.143 (1) (bm) 1. of the statutes, as affected by 2003 Wisconsin Act 33, is renumbered 149.143 (1) (bm) 2m. a.

SB466, s. 33 Section 33. 149.143 (1) (bm) 1m. of the statutes is created to read:

SB466,14,5 149.143 (1) (bm) 1m. First, from manufacturer and labeler assessments under s. 149.132.

SB466, s. 34 Section 34. 149.143 (1) (bm) 2. of the statutes, as affected by 2003 Wisconsin Act 33, is renumbered 149.143 (1) (bm) 2m. b.

SB466, s. 35 Section 35. 149.143 (1) (bm) 2m. (intro.) of the statutes is created to read:

SB466,14,9 149.143 (1) (bm) 2m. (intro.) The remainder as follows:

SB466, s. 36 Section 36. 149.143 (2) (a) (intro.) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,14,16 149.143 (2) (a) (intro.) Prior to each plan year, the department board shall estimate the operating and administrative costs of the plan and the costs of the premium reductions under s. 149.165 (2) and (3), the deductible reductions under s. 149.14 (5) (a), and any prescription drug copayment reductions under s. 149.14 (5) (e) for the new plan year and do all of the following:

SB466, s. 37 Section 37. 149.143 (2) (a) 1. a. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,14,24 149.143 (2) (a) 1. a. Estimate the amount of enrollee premiums that would be received in the new plan year if the enrollee premiums were set at a level sufficient, when including amounts received for premium, deductible, and prescription drug copayment subsidies under s. 149.144 and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to cover 60% 60 percent of the estimated plan costs for the new plan year.

SB466, s. 38 Section 38. 149.143 (2) (a) 2. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,15,9 149.143 (2) (a) 2. After making the determinations under subd. 1., by rule set premium rates for the new plan year, including the rates under s. 149.146 (2) (b), in the manner specified in sub. (1) (am) 1. and 3. and such that a rate for coverage under s. 149.14 (2) (a) is approved by the board and is not less than 140% 140 percent nor more than 200% 200 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan.

SB466, s. 39 Section 39. 149.143 (2) (a) 3. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,15,16 149.143 (2) (a) 3. By rule, after estimating the amount of manufacturer and labeler assessments that will be received under sub. (1) (bm) 1m., set the total insurer assessments under s. 149.13 for the new plan year by estimating and setting the assessments at the amount necessary to equal the amounts specified in sub. (1) (am) 4. and (bm) 1. 2m. a. and notify the commissioner of the amount.

SB466, s. 40 Section 40. 149.143 (2) (a) 4. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,15,24 149.143 (2) (a) 4. By the same rule as under subd. 3., after estimating the amount of the manufacturer and labeler assessments that will be received under sub. (1) (bm) 1m., adjust the provider payment rate for the new plan year, subject to s. 149.142 (1) (b), by estimating and setting the rate at the level necessary to equal the amounts specified in sub. (1) (am) 4. and (bm) 2. 2m. b. and as provided in s. 149.145.

SB466, s. 41 Section 41. 149.143 (2) (b) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,16,8 149.143 (2) (b) In setting the premium rates under par. (a) 2., the insurer assessment amount under par. (a) 3., and the provider payment rate under par. (a) 4. for the new plan year, the department board shall include any increase or decrease necessary to reflect the amount, if any, by which the rates and amount set under par. (a) for the current plan year differed from the rates and amount which would have equaled the amounts specified in sub. (1) (am) and (bm) in the current plan year.

SB466, s. 42 Section 42. 149.143 (2m) (a) (intro.) of the statutes is amended to read:

SB466,16,11 149.143 (2m) (a) (intro.) The department board shall keep a separate accounting of the difference between the following:

SB466, s. 43 Section 43. 149.143 (2m) (a) 2. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,16,16 149.143 (2m) (a) 2. The amount of premiums, including amounts received for premium, deductible, and prescription drug copayment subsidies, necessary to cover 60% 60 percent of the plan costs for the plan year.

SB466, s. 44 Section 44. 149.143 (2m) (b) 1. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,16,23 149.143 (2m) (b) 1. To reduce premiums in succeeding plan years as provided in sub. (1) (am) 2. For eligible persons with coverage under s. 149.14 (2) (a), premiums may not be reduced below 140% 140 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan.