AB844, s. 90 3Section 90. 149.14 (1) (a) of the statutes is amended to read:
AB844,36,104 149.14 (1) (a) The plan shall offer coverage for each eligible person in an
5annually renewable policy the coverage specified in this section for each eligible
6person
. If an eligible person is also eligible for medicare Medicare coverage, the plan
7shall not pay or reimburse any person for expenses paid for by medicare Medicare.
8If an eligible person is eligible for a type of medical assistance specified in s. 149.12
9(2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by
10Medical Assistance
.
AB844, s. 91 11Section 91. 149.14 (2) (a) of the statutes is amended to read:
AB844,36,1812 149.14 (2) (a) The plan shall provide every eligible person who is not eligible
13for medicare Medicare with major medical expense coverage. Major medical expense
14coverage offered under the plan under this section shall pay an eligible person's
15covered expenses, subject to sub. (3) and deductible, copayment, and coinsurance
16payments authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered
17individual. The maximum limit under this paragraph shall not be altered by the
18board, and no actuarially equivalent benefit may be substituted by the board.
AB844, s. 92 19Section 92. 149.14 (3) (intro.) of the statutes is amended to read:
AB844,37,820 149.14 (3) Covered expenses. (intro.) Except as provided in sub. (4), except
21as restricted by cost containment provisions under s. 149.17 (4) and except as
22reduced by the department under ss. 149.143 and 149.144, covered
Covered expenses
23for the coverage under this section the plan shall be the payment rates established
24by the department under s. 149.142 authority for the services provided by persons
25licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in

1sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and
2except as reduced by the department under ss. 149.143 and 149.144, covered
Covered
3expenses for the coverage under this section the plan shall also be the payment rates
4established by the department under s. 149.142 authority for, at a minimum, the
5following services and articles if the service or article is prescribed by a physician
6who is licensed under ch. 448 or in another state and who is certified under s. 49.45
7(2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45
8(2) (a) 11.:
AB844, s. 93 9Section 93. 149.14 (3) (b) of the statutes is repealed and recreated to read:
AB844,37,1110 149.14 (3) (b) Professional services for the diagnosis or treatment of injuries,
11illnesses, or conditions, other than mental or dental.
AB844, s. 94 12Section 94. 149.14 (3) (c) 1. of the statutes is repealed and recreated to read:
AB844,37,1613 149.14 (3) (c) 1. Inpatient hospital services, as defined in s. 632.89 (1) (d),
14outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment
15arrangements, as defined in s. 632.89 (1) (f), only to the extent required under s.
16632.89.
AB844, s. 95 17Section 95. 149.14 (3) (c) 2. of the statutes is repealed.
AB844, s. 96 18Section 96 . 149.14 (3) (c) 3. of the statutes is amended to read:
AB844,37,2219 149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated
20by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats.,
21services for the chronically mentally ill in community support programs operated
22under s. 51.421.
AB844, s. 97 23Section 97 . 149.14 (3) (c) 3. of the statutes, as affected by 2005 Wisconsin Act
24.... (this act), is amended to read:
AB844,38,4
1149.14 (3) (c) 3. Subject to the limits under subd. 2. and to rules promulgated
2by the department of health and family services under s. 149.14 (3) (c) 3., 2003 stats.

31., services for the chronically mentally ill in community support programs operated
4under s. 51.421.
AB844, s. 98 5Section 98. 149.14 (3) (d) of the statutes is amended to read:
AB844,38,66 149.14 (3) (d) Drugs requiring a physician's prescription, subject to sub. (4c).
AB844, s. 99 7Section 99. 149.14 (3) (e) of the statutes is amended to read:
AB844,38,148 149.14 (3) (e) Services For persons eligible for Medicare, services of a licensed
9skilled nursing facility for eligible persons eligible for medicare, to the extent
10required by s. 632.895 (3) and for not more than an aggregate 120 days during a
11calendar year, if the services are of the type which that would qualify as reimbursable
12services under medicare Medicare. Coverage under this paragraph which that is not
13required by s. 632.895 (3) is subject to the any deductible and coinsurance
14requirements under sub. (5) provided by the authority.
AB844, s. 100 15Section 100. 149.14 (3) (f) of the statutes is created to read:
AB844,38,1716 149.14 (3) (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only
17to the extent required under s. 632.895 (2).
AB844, s. 101 18Section 101. 149.14 (3) (m) of the statutes is amended to read:
AB844,38,2119 149.14 (3) (m) Oral surgery for excision of partially or completely unerupted,
20impacted teeth and oral surgery with respect to the gums and other tissues of the
21mouth when not performed in connection with the extraction or repair of teeth.
AB844, s. 102 22Section 102. 149.14 (3) (o) of the statutes is amended to read:
AB844,38,2523 149.14 (3) (o) Transportation Emergency and other medically necessary
24transportation
provided by a licensed ambulance service to the nearest facility
25qualified to treat the a covered condition.
AB844, s. 103
1Section 103. 149.14 (3) (p) of the statutes is renumbered 149.14 (3) (em).
AB844, s. 104 2Section 104. 149.14 (4) of the statutes, as affected by 2005 Wisconsin Act ....
3(this act), is repealed and recreated to read:
AB844,39,124 149.14 (4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority
5shall establish the plan design, after taking into consideration the levels of health
6insurance coverage provided in the state and medical economic factors, as
7appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit
8levels, deductibles, copayment and coinsurance requirements, exclusions, and
9limitations under the plan that the authority determines generally reflect and are
10commensurate with comprehensive health insurance coverage offered in the private
11individual market in the state. The authority may develop additional benefit designs
12that are responsive to market conditions.
AB844, s. 105 13Section 105. 149.14 (4) (d) of the statutes is amended to read:
AB844,39,1714 149.14 (4) (d) That part of any charge for services or articles rendered or
15prescribed by a physician, dentist, or other health care personnel that exceeds the
16payment rate established by the department authority under s. 149.142 and reduced
17under ss. 149.143 and 149.144
or any charge not medically necessary.
AB844, s. 106 18Section 106. 149.14 (4) (m) of the statutes is amended to read:
AB844,39,2019 149.14 (4) (m) Experimental treatment, as determined by the department
20authority.
AB844, s. 107 21Section 107. 149.14 (4c) of the statutes is repealed.
AB844, s. 108 22Section 108. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and
23amended to read:
AB844,40,424 149.142 (2m) Payment is payment in full. Except for copayments, coinsurance,
25or deductibles required or authorized under the plan, a provider of a covered service

1or article shall accept as payment in full for the covered service or article the payment
2rate determined under ss. 149.142, 149.143 and 149.144 sub. (1) and may not bill an
3eligible person who receives the service or article for any amount by which the charge
4for the service or article is reduced under s. 149.142, 149.143 or 149.144 sub. (1).
AB844, s. 109 5Section 109. 149.14 (5) of the statutes, as affected by 2005 Wisconsin Act ....
6(this act), is repealed and recreated to read:
AB844,40,97 149.14 (5) Deductible and copayment subsidies. (a) The authority shall
8establish and provide subsidies for deductibles paid by eligible persons with coverage
9under s. 149.14 (2) (a) and household incomes specified in s. 149.165 (2) (a) 1. to 5.
AB844,40,1110 (b) The authority may provide subsidies for prescription drug copayment
11amounts paid by eligible persons specified in par. (a).
AB844, s. 110 12Section 110. 149.14 (5) (b) of the statutes is amended to read:
AB844,40,1613 149.14 (5) (b) Except as provided in pars. (c) and (e) par. (c), if the covered costs
14incurred by the eligible person exceed the deductible for major medical expense
15coverage in a calendar year, the plan shall pay at least 80% of any additional covered
16costs incurred by the person during the calendar year.
AB844, s. 111 17Section 111. 149.14 (5) (c) of the statutes is amended to read:
AB844,40,2318 149.14 (5) (c) Except as provided in par. (e), if If the aggregate of the covered
19costs not paid by the plan under par. (b) and the deductible exceeds $500 for an
20eligible person receiving medicare, $2,000 for any other eligible person during a
21calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100%
22of all covered costs incurred by the eligible person during the calendar year after the
23payment ceilings under this paragraph are exceeded.
AB844, s. 112 24Section 112. 149.14 (5) (d) of the statutes is repealed.
AB844, s. 113 25Section 113. 149.14 (5) (e) of the statutes is repealed.
AB844, s. 114
1Section 114. 149.14 (5m) of the statutes is repealed.
AB844, s. 115 2Section 115. 149.14 (6) (a) of the statutes is repealed.
AB844, s. 116 3Section 116. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).
AB844, s. 117 4Section 117. 149.14 (7) (b) of the statutes is amended to read:
AB844,41,85 149.14 (7) (b) The department authority has a cause of action against an
6eligible participant for the recovery of the amount of benefits paid which that are not
7for covered expenses under the plan. Benefits under the plan may be reduced or
8refused as a setoff against any amount recoverable under this paragraph.
AB844, s. 118 9Section 118. 149.14 (7) (c) of the statutes is amended to read:
AB844,41,1310 149.14 (7) (c) The department authority is subrogated to the rights of an
11eligible person to recover special damages for illness or injury to the person caused
12by the act of a 3rd person to the extent that benefits are provided under the plan.
13Section 814.03 (3) applies to the department under this paragraph.
AB844, s. 119 14Section 119. 149.14 (8) of the statutes is repealed.
AB844, s. 120 15Section 120. 149.141 of the statutes is created to read:
AB844,41,18 16149.141 Premiums. (1) Percentage of costs. Except as provided in sub. (2),
17the authority shall set premium rates for coverage under the plan at a level that is
18sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1).
AB844,41,20 19(2) Limitation. In no event may plan premium rates exceed 200 percent of rates
20applicable to individual standard risks.
AB844, s. 121 21Section 121. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
22amended to read:
AB844,42,823 149.142 (1) Establishment of rates. Except as provided in par. (b), the
24department
The authority shall establish provider payment rates for covered
25expenses that consist of the allowable charges paid under s. 49.46 (2) for the services

1and articles provided plus an enhancement determined by the department authority.
2The rates shall be based on the allowable charges paid under s. 49.46 (2), projected
3plan costs, and trend factors. Using the same methodology that applies to medical
4assistance under subch. IV of ch. 49, the department authority shall establish
5hospital outpatient per visit reimbursement rates and hospital inpatient
6reimbursement rates that are specific to diagnostically related groups of eligible
7persons. The adjustments to the usual and customary rates shall be sufficient to
8cover 20 percent of plan costs, as provided in s. 149.143 (3).
AB844, s. 122 9Section 122. 149.142 (1) (b) of the statutes is repealed.
AB844, s. 123 10Section 123. 149.142 (2) of the statutes is repealed.
AB844, s. 124 11Section 124. 149.143 of the statutes is repealed and recreated to read:
AB844,42,17 12149.143 Payment of plan costs. (1) Costs excluding subsidies. The
13authority shall pay plan costs, excluding any premium, deductible, and copayment
14subsidies, first from federal funds, if any, that are transferred to the fund under s.
1520.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in
16a policy year. The remainder of the plan costs, excluding premium, deductible, and
17copayment subsidy costs, shall be paid as follows:
AB844,42,1818 (a) Sixty percent from premiums paid by eligible persons.
AB844,42,1919 (b) Twenty percent from insurer assessments under s. 149.13.
AB844,42,2120 (c) Twenty percent from adjustments to provider payment rates under s.
21149.142.
AB844,42,25 22(2) Subsidy costs. The authority shall pay for premium, deductible, and
23copayment subsidies in a policy year first from federal funds, if any, that are
24transferred to the fund under s. 20.145 (5) (m) in that year. The remainder of the
25subsidy costs shall be paid as follows:
AB844,43,1
1(a) Fifty percent from insurer assessments under s. 149.13.
AB844,43,22 (b) Fifty percent from adjustments to provider payment rates under s. 149.142.
AB844, s. 125 3Section 125. 149.144 of the statutes is repealed.
AB844, s. 126 4Section 126. 149.145 of the statutes is repealed.
AB844, s. 127 5Section 127. 149.146 (1) (a) and (b) of the statutes are consolidated,
6renumbered 149.14 (2) (c) 1. and amended to read:
AB844,43,217 149.14 (2) (c) 1. Beginning on January 1, 1998, in In addition to the coverage
8required under s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons
9who are not eligible for medicare Medicare a choice of coverage, as described in
10section 2744 (a) (1) (C), P.L. 104-191. Any such choice of coverage shall be major
11medical expense coverage. (b) An eligible person under par. (a) who is not eligible
12for Medicare
may elect once each year, at the time and according to procedures
13established by the department authority, among the coverages offered under this
14section and s. 149.14 paragraph and par. (a). If an eligible person elects new
15coverage, any preexisting condition exclusion imposed under the new coverage is met
16to the extent that the eligible person has been previously and continuously covered
17under this chapter the plan. No preexisting condition exclusion may be imposed on
18an eligible person who elects new coverage if the person was an eligible individual
19when first covered under this chapter the plan and the person remained
20continuously covered under this chapter the plan up to the time of electing the new
21coverage.
AB844, s. 128 22Section 128. 149.146 (2) (a) of the statutes is renumbered 149.14 (2) (c) 2. and
23amended to read:
AB844,44,424 149.14 (2) (c) 2. Except as specified by the department, the terms of coverage
25under s. 149.14, including deductible reductions under s. 149.14 (5) (a) and

1prescription drug copayment reductions under s. 149.14 (5) (e), do not apply to the
2coverage offered under this section.
Premium reductions under s. 149.165 and
3deductible subsidies and prescription drug copayment subsidies under s. 149.14 (5)

4do not apply to the coverage offered under this section paragraph.
AB844, s. 129 5Section 129. 149.146 (2) (am) of the statutes is repealed.
AB844, s. 130 6Section 130. 149.146 (2) (b) of the statutes is repealed.
AB844, s. 131 7Section 131. 149.15 of the statutes is repealed.
AB844, s. 132 8Section 132. 149.16 of the statutes is repealed.
AB844, s. 133 9Section 133. 149.165 (1) of the statutes is amended to read:
AB844,44,1310 149.165 (1) Except as provided in s. 149.146 (2) (a), the department The
11authority
shall reduce the premiums established under s. 149.11 in conformity with
12ss. 149.14 (5m), 149.143 and 149.17
s. 149.141 for the eligible persons and in the
13manner set forth in subs. (2) and (3).
AB844, s. 134 14Section 134. 149.165 (2) (a) (intro.) of the statutes is amended to read:
AB844,44,1915 149.165 (2) (a) (intro.) Subject to sub. (3m), if the household income, as defined
16in s. 71.52 (5) and as determined under sub. (3), of an eligible person with coverage
17under s. 149.14 (2) (a) is equal to or greater than the first amount and less than the
182nd amount listed in any of the following, the department authority shall reduce the
19premium for the eligible person to the rate shown after the amounts:
AB844, s. 135 20Section 135. 149.165 (2) (bc) of the statutes is amended to read:
AB844,45,421 149.165 (2) (bc) Subject to sub. (3m), if the household income, as defined in s.
2271.52 (5) and as determined under sub. (3), of an eligible person with coverage under
23s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd
24amount listed in par. (a) 1., 2., 3., 4., or 5., the department authority shall reduce the
25premium established for the eligible person by the same percentage as the

1department authority reduces, under par. (a), the premium established for an
2eligible person with coverage under s. 149.14 (2) (a) who has a household income
3specified in the same subdivision under par. (a) as the household income of the
4eligible person with coverage under s. 149.14 (2) (b).
AB844, s. 136 5Section 136. 149.165 (3) (a) of the statutes is amended to read:
AB844,45,86 149.165 (3) (a) Subject to par. (b), the department authority shall establish and
7implement the method for determining the household income of an eligible person
8under sub. (2).
AB844, s. 137 9Section 137. 149.165 (3) (b) (intro.) of the statutes is amended to read:
AB844,45,1310 149.165 (3) (b) (intro.) In determining household income under sub. (2), the
11department authority shall consider information submitted by an eligible person on
12a completed federal profit or loss from farming form, schedule F, if all of the following
13apply:
AB844, s. 138 14Section 138. 149.165 (3m) of the statutes is amended to read:
AB844,45,1815 149.165 (3m) The board authority may approve adjustment of the household
16income dollar amounts listed in sub. (2) (a) 1. to 5., except for the first dollar amount
17listed in sub. (2) (a) 1., to reflect changes in the consumer price index for all urban
18consumers, U.S. city average, as determined by the U.S. department of labor.
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