SB466: Bill Text

SB466, s. 45 Section 45. 149.143 (2m) (b) 2. of the statutes is amended to read:

SB466,17,2 149.143 (2m) (b) 2. For other needs of eligible persons, with the approval of the board including the purpose specified in s. 149.15 (4) (d).

SB466, s. 46 Section 46. 149.143 (2m) (b) 3. of the statutes is amended to read:

SB466,17,8 149.143 (2m) (b) 3. For distribution to eligible persons, notwithstanding any requirements in this chapter related to setting premium amounts. The department board, with the approval of the board and the concurrence of the plan actuary, shall determine the policies, eligibility criteria, methodology, and other factors to be used in making any distribution under this subdivision.

SB466, s. 47 Section 47. 149.143 (2m) (c) of the statutes is created to read:

SB466,17,11 149.143 (2m) (c) The board shall consult with the department as necessary for the accounting under par. (a).

SB466, s. 48 Section 48. 149.143 (3) (a) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,17,24 149.143 (3) (a) If, during a plan year, the department board determines that the amounts estimated to be received as a result of the rates and amount set under sub. (2) (a) 2. to 4. and any adjustments in insurer assessments and the provider payment rate under s. 149.144 will not be sufficient to cover plan costs, the department board may by rule increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year, subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (bm) 1., and by the same rule under which assessments are increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder of the plan year, subject to sub. (1) (bm) 2. and s. 149.142 (1) (b).

SB466, s. 49 Section 49 . 149.143 (3) (a) of the statutes, as affected by 2003 Wisconsin Act .... (this act), is amended to read:

SB466,18,13 149.143 (3) (a) If, during a plan year, the board determines that the amounts estimated to be received in manufacturer and labeler assessments and as a result of the rates and amount set under sub. (2) (a) 2. to 4. and any adjustments in insurer assessments and the provider payment rate under s. 149.144 will not be sufficient to cover plan costs, the board may by rule increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year, subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (bm) 1. 2m. a., and by the same rule under which assessments are increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder of the plan year, subject to sub. (1) (bm) 2. 2m. b. and s. 149.142 (1) (b).

SB466, s. 50 Section 50. 149.143 (3) (b) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,18,22 149.143 (3) (b) If the department board increases premium rates and insurer assessments and adjusts the provider payment rate under par. (a) and determines that there will still be a deficit and that premium rates have been increased to the maximum extent allowable under par. (a), the department board may further adjust, in equal proportions, assessments set under sub. (2) (a) 3. and the provider payment rate set under sub. (2) (a) 4., without regard to sub. (1) (bm) but subject to s. 149.142 (1) (b).

SB466, s. 51 Section 51. 149.143 (4) of the statutes is amended to read:

SB466,19,3 149.143 (4) Using the procedure under s. 227.24, the department board may promulgate rules under sub. (2) or (3) for the period before the effective date of any permanent rules promulgated under sub. (2) or (3), but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the department board is not required to make a finding of emergency.

SB466, s. 52 Section 52. 149.143 (5) (a) of the statutes is amended to read:

SB466,19,13 149.143 (5) (a) Annually, no later than April 30, the department board shall perform a reconciliation with respect to plan costs, premiums, insurer assessments, and provider payment rate adjustments based on data from the previous calendar year. On the basis of the reconciliation, the department board shall make any necessary adjustments in premiums, insurer assessments, or provider payment rates, subject to s. 149.142 (1) (b), for the fiscal year beginning on the first July 1 after the reconciliation, as provided in sub. (2) (b). The board shall consult with the department as necessary in performing the reconciliation and in making the adjustments under this paragraph.

SB466, s. 53 Section 53 . 149.143 (5) (a) of the statutes, as affected by 2003 Wisconsin Act .... (this act), is amended to read:

SB466,19,24 149.143 (5) (a) Annually, no later than April 30, the board shall perform a reconciliation with respect to plan costs, premiums, insurer assessments, manufacturer and labeler assessments, and provider payment rate adjustments based on data from the previous calendar year. On the basis of the reconciliation, the board shall make any necessary adjustments in premiums, insurer assessments, or provider payment rates, subject to s. 149.142 (1) (b), for the fiscal year beginning on the first July 1 after the reconciliation, as provided in sub. (2) (b). The board shall consult with the department as necessary in performing the reconciliation and in making the adjustments under this paragraph.

SB466, s. 54 Section 54. 149.143 (5) (b) of the statutes is amended to read:

SB466,20,6 149.143 (5) (b) Except as provided in sub. (3) and s. 149.144, the department board shall adjust the provider payment rates to meet the providers' specified portion of the plan costs no more than once annually, subject to s. 149.142 (1) (b). The department board may not determine the adjustment on an individual provider basis or on the basis of provider type, but shall determine the adjustment for all providers in the aggregate, subject to s. 149.142 (1) (b).

SB466, s. 55 Section 55. 149.144 of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,20,18 149.144 Adjustments to insurer assessments and provider payment rates for premium, deductible, and prescription drug copayment reductions. The department board shall, by rule, adjust in equal proportions the amount of the assessment assessments set under s. 149.143 (2) (a) 3. and the provider payment rate set under s. 149.143 (2) (a) 4., subject to ss. 149.142 (1) (b) and 149.143 (1) (am), sufficient to reimburse the plan for premium reductions under s. 149.165 (2) and (3), deductible reductions under s. 149.14 (5) (a), and any prescription drug copayment reductions under s. 149.14 (5) (e). The department board shall notify the commissioner so that the commissioner may levy any increase in insurer assessments.

SB466, s. 56 Section 56. 149.145 of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,21,8 149.145 Program budget. The department, in consultation with the board, shall establish a program budget for each plan year. The program budget shall be based on the provider payment rates specified in s. 149.142 and in the most recent provider contracts that are in effect and on the funding sources specified in ss. 149.143 (1) and 149.144, including the methodologies specified in ss. 149.143, 149.144, and 149.146 for determining premium rates, insurer assessments, and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b) and subject to s. 149.142 (1) (b), from the program budget the department board shall derive the actual provider payment rate for a plan year that reflects the providers' proportional share of the plan costs, consistent with ss. 149.143 and 149.144. The department may not implement a program budget established under this section unless it is approved by the board shall consult with the department as necessary in deriving the actual provider payment rate.

SB466, s. 57 Section 57 . 149.145 of the statutes, as affected by 2003 Wisconsin Act .... (this act), is amended to read:

SB466,21,21 149.145 Program budget. The board shall establish a program budget for each plan year. The program budget shall be based on the provider payment rates specified in s. 149.142 and in the most recent provider contracts that are in effect and on the funding sources specified in ss. 149.143 (1) and 149.144, including the methodologies specified in ss. 149.143, 149.144, and 149.146 for determining premium rates, insurer and manufacturer and labeler assessments, and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b) and subject to s. 149.142 (1) (b), from the program budget the board shall derive the actual provider payment rate for a plan year that reflects the providers' proportional share of the plan costs, consistent with ss. 149.143 and 149.144. The board shall consult with the department as necessary in deriving the actual provider payment rate.

SB466, s. 58 Section 58. 149.146 (1) (b) of the statutes is amended to read:

SB466,22,6 149.146 (1) (b) An eligible person under par. (a) may elect once each year, at the time and according to procedures established by the department board, among the coverages offered under this section and s. 149.14. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under this chapter. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under this chapter and the person remained continuously covered under this chapter up to the time of electing the new coverage.

SB466, s. 59 Section 59. 149.146 (2) (a) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,22,13 149.146 (2) (a) Except as specified by the department board, the terms of coverage under s. 149.14, including deductible reductions under s. 149.14 (5) (a) and prescription drug copayment reductions under s. 149.14 (5) (e), do not apply to the coverage offered under this section. Premium reductions under s. 149.165 do not apply to the coverage offered under this section.

SB466, s. 60 Section 60. 149.146 (2) (am) 4. of the statutes is amended to read:

SB466,22,19 149.146 (2) (am) 4. Notwithstanding subds. 1. to 3., the department board may establish different deductible amounts, a different coinsurance percentage, and different covered costs and deductible aggregate amounts from those specified in subds. 1. to 3. in accordance with cost containment provisions established by the department board under s. 149.17 (4).

SB466, s. 61 Section 61. 149.146 (2) (am) 5. of the statutes is amended to read:

SB466,23,4 149.146 (2) (am) 5. Subject to s. 149.14 (8) (b), the department board may, by rule under s. 149.17 (4), establish for prescription drug coverage under 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 for prescription drugs. Any copayment amount, coinsurance rate, or out-of-pocket limit established under this subdivision is subject to the approval of the board. Copayments and coinsurance paid by an eligible person under this subdivision are separate from and do not count toward the deductible and covered costs not paid by the plan under subds. 1. to 3.

SB466, s. 62 Section 62. 149.146 (2) (b) (intro.) of the statutes is amended to read:

SB466,23,10 149.146 (2) (b) (intro.) The schedule of premiums for coverage under this section shall be promulgated by rule by the department board, as provided in s. 149.143. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 149.14 (2) (a) by the same percentage as the percentage difference between the following:

SB466, s. 63 Section 63. 149.146 (2) (b) 1. of the statutes is amended to read:

SB466,23,14 149.146 (2) (b) 1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as provided under s. 149.14 (2) (a) and (5) (a).

SB466, s. 64 Section 64. 149.146 (2) (b) 2. of the statutes is amended to read:

SB466,23,18 149.146 (2) (b) 2. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as the coverage offered under this section.

SB466, s. 65 Section 65. 149.15 (1) of the statutes is amended to read:

SB466,24,13 149.15 (1) The plan shall have operate under the direction of a board of governors consisting of representatives of 2 participating insurers that are nonprofit corporations, representatives of 2 other participating insurers, 3 4 health care provider industry representatives, including one representative of the State Wisconsin Medical Society of Wisconsin, one representative of the Wisconsin Health and Hospital Association, one representative of Pharmaceutical Research and Manufacturers of America, and one representative of an integrated multidisciplinary health system, and 4 public members, including one representative of small businesses in the state, appointed by the 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 members of the board. The public members shall not be professionally affiliated with the practice of medicine, a hospital, or an insurer. At least one of the public members shall be an individual who has coverage under the plan. The secretary or the secretary's representative shall be board annually shall select 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.

SB466, s. 66 Section 66. 149.15 (3) (b) of the statutes is created to read:

SB466,24,22 149.15 (3) (b) Establish by rule the plan design, including covered benefits and exclusions. At least every 3 years, the board shall conduct a survey of health care plans available in the private market and make any adjustments to the plan that the board determines are advisable on the basis of the survey. Using the procedure under s. 227.24, the board may promulgate rules under this paragraph for the period before the effective date of any permanent rules promulgated under this paragraph, but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the board is not required to make a finding of emergency.

SB466, s. 67 Section 67. 149.15 (3) (c) of the statutes is repealed.

SB466, s. 68 Section 68. 149.15 (3) (e) of the statutes is created to read:

SB466,25,2 149.15 (3) (e) Select a plan administrator in a competitive, request-for-proposals process and enter into a contract with the person selected.

SB466, s. 69 Section 69. 149.15 (3) (f) of the statutes is repealed.

SB466, s. 70 Section 70. 149.15 (4) (c) of the statutes is created to read:

SB466,25,6 149.15 (4) (c) Contract with persons to provide professional services to the board and the plan.

SB466, s. 71 Section 71. 149.15 (4) (d) of the statutes is created to read:

SB466,25,19 149.15 (4) (d) Notwithstanding ss. 625.11 (4) and 628.34 (3) (a) and any requirements in this chapter related to setting premium rates or amounts, establish for eligible persons with household incomes that exceed $100,000 a separate schedule of premium rates that are higher than the rates set for other eligible persons. Premium rates established under this paragraph may not exceed 200 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and cost-sharing provisions that are provided under the plan. The board shall use excess premiums collected under a schedule established under this paragraph to reduce premiums for eligible persons with low household incomes, as determined by the board. Household income under this paragraph shall be determined in the same manner as household income is determined under s. 149.165 (2) and (3).

SB466, s. 72 Section 72. 149.15 (5) of the statutes is repealed.

SB466, s. 73 Section 73. 149.16 of the statutes, as affected by 2003 Wisconsin Act 33, is repealed.

SB466, s. 74 Section 74. 149.165 (1) of the statutes is amended to read:

SB466,26,2 149.165 (1) Except as provided in s. 149.146 (2) (a), the department board shall reduce the premiums established under s. 149.11 in conformity with ss. 149.14 (5m), 149.143, and 149.17 for the eligible persons and in the manner set forth in subs. (2) and (3).

SB466, s. 75 Section 75. 149.165 (2) of the statutes is amended to read:

SB466,26,8 149.165 (2) (a) Subject to sub. subs. (3m) and (3r), if the household income, as defined in s. 71.52 (5) and as determined under sub. (3), of an eligible person with coverage under s. 149.14 (2) (a) is equal to or greater than the first amount and less than the 2nd amount listed in any of the following, the department board shall reduce the premium for the eligible person to the rate shown after the amounts:

SB466,26,12 1. If equal to or greater than $0 and less than $10,000, to 100% 100 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 provided under s. 149.14 (2) (a) and (5) (a).

SB466,26,16 2. If equal to or greater than $10,000 and less than $14,000, to 106.5% 106.5 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 provided under s. 149.14 (2) (a) and (5) (a).

SB466,26,20 3. If equal to or greater than $14,000 and less than $17,000, to 115.5% 115.5 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 provided under s. 149.14 (2) (a) and (5) (a).

SB466,26,24 4. If equal to or greater than $17,000 and less than $20,000, to 124.5% 124.5 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 provided under s. 149.14 (2) (a) and (5) (a).

SB466,27,4 5. If equal to or greater than $20,000 and less than $25,000, to 130% 130 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 provided under s. 149.14 (2) (a) and (5) (a).

SB466,27,13 (bc) Subject to sub. subs. (3m) and (3r), if the household income, as defined in s. 71.52 (5) and as determined under sub. (3), of an eligible person with coverage under s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd amount listed in par. (a) 1., 2., 3., 4., or 5., the department board shall reduce the premium established for the eligible person by the same percentage as the department board reduces, under par. (a), the premium established for an eligible person with coverage under s. 149.14 (2) (a) who has a household income specified in the same subdivision under par. (a) as the household income of the eligible person with coverage under s. 149.14 (2) (b).

SB466, s. 76 Section 76. 149.165 (3) (a) of the statutes is amended to read:

SB466,27,17 149.165 (3) (a) Subject to par. (b), the department board shall establish and implement the method for determining the household income of an eligible person under sub. (2).

SB466, s. 77 Section 77. 149.165 (3) (b) (intro.) of the statutes is amended to read:

SB466,27,22 149.165 (3) (b) (intro.) In determining household income under sub. (2), the department board shall consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:

SB466, s. 78 Section 78. 149.165 (3r) of the statutes is created to read:

SB466,28,3 149.165 (3r) The board shall use any excess premiums collected under a schedule established under s. 149.15 (4) (d) to further reduce the premium rates under sub. (2) (a) 1. to 5. and (bc).

SB466, s. 79 Section 79. 149.17 (4) of the statutes is amended to read:

SB466,28,6 149.17 (4) Cost containment provisions established by the department board by rule, including managed care requirements.

SB466, s. 80 Section 80. 149.175 of the statutes is amended to read:

SB466,28,12 149.175 Waiver or exemption from provisions prohibited. Except as provided in s. ss. 149.13 (1) and 149.132 (1) (b), the department or the board may not waive, or authorize the board to waive, any of the requirements of this chapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this chapter.

SB466, s. 81 Section 81. 149.20 of the statutes is amended to read:

SB466,28,17 149.20 Rule-making in consultation with Rules to be approved by board. In promulgating any Any rules proposed by the department under this chapter, the department shall consult with may not be promulgated without the approval of the board.

SB466, s. 82 Section 82. 149.25 (2) (a) of the statutes is amended to read:

SB466,28,22 149.25 (2) (a) The department shall conduct a 3-year pilot program, beginning on July 1, 2002, under which eligible persons who qualify under par. (b) are provided community-based case management services. The department shall consult with the board as necessary in conducting the pilot program.

SB466, s. 83 Section 83. 149.25 (4) of the statutes is amended to read:

SB466,29,7 149.25 (4) Evaluation study. The department, in consultation with the board, shall conduct a study that evaluates the pilot program in terms of health care outcomes and cost avoidance. In the study, the department shall measure and compare, for pilot program participants and similarly situated eligible persons not participating in the pilot program, plan costs and utilization of services, including inpatient hospital days, rates of hospital readmission within 30 days for the same diagnosis, and prescription drug utilization. The department shall submit a report on the results of the study, including the department's conclusions and recommendations, to the legislature under s. 13.172 (2) and to the governor.

SB466, s. 84 Section 84. 450.10 (2m) of the statutes is created to read:

SB466,29,11 450.10 (2m) If a manufacturer or labeler fails to pay an assessment levied under s. 149.132 within the time required for payment, the board may assess a forfeiture of not more than $1,000 for each day that the payment is past due.

SB466, s. 85 Section 85. Nonstatutory provisions.

SB466,29,20 (1) Federal grant funds. Notwithstanding section 149.143 (1) of the statutes, as affected by this act, any federal grant moneys received by the state under the Trade Adjustment Assistance Reform Act of 2002 and allocated to the Health Insurance Risk-Sharing Plan shall be used to pay plan costs before any moneys specified under section 149.143 (1) (am) and (bm) of the statutes, as affected by this act, are used. After the federal grant money has been used, plan costs shall be paid as provided under section 149.143 (1) (am) and (bm) of the statutes, as affected by this act.

SB466,29,24 (2) Selection of plan administrator. The board of governors of the Health Insurance Risk-Sharing Plan shall, no later than July 1, 2004, issue a request-for-proposals under section 149.15 (3) (e) of the statutes, as created by this act, for administration of the Health Insurance Risk-Sharing Plan.

SB466,30,6 (3) Drug manufacturer and labeler assessments. Notwithstanding section 149.132 of the statutes, as created by this act, the first assessment under section 149.132 of the statutes, as created by this act, that is payable by prescription drug manufacturers and labelers shall be calculated on prescription drug claims paid by the Health Insurance Risk-Sharing Plan from July 1, 2004, to December 31, 2004, rather than on total prescription drug claims paid in 2004.

SB466, s. 86 Section 86 . Initial applicability.

SB466,30,12 (1) Design. With respect to changes in plan design, including covered expenses and exclusions, deductibles, copayments, coinsurance, and out-of-pocket limits, the treatment of sections 149.11, 149.14 (3) (intro.) and (a) to (r), (4), (5) (d) and (e), and (8), 149.146 (1) (b) and (2) (a), (am) 4. and 5., and (b) (intro.) and 1., 149.15 (3) (b), and 149.17 (4) of the statutes first applies to the plan year beginning on January 1, 2005.

SB466,30,15 (2) Eligibility. The treatment of section 149.12 (1) (a), (am), (b), and (c) of the statutes first applies to applications for coverage under the Health Insurance Risk-Sharing Plan that are received on the effective date of this subsection.