SB40,742,86
3. The individual or pregnant woman was covered by a group health plan that
7was provided by a subscriber through his or her employer, and the subscriber's
8employer discontinued health plan coverage for all employees.
SB40,742,109
4. The pregnant woman's coverage was continuation coverage and the
10continuation coverage was exhausted in accordance with
29 CFR 2590.701-
2 (4).
SB40,742,1211
5. The individual's or pregnant woman's coverage terminated due to the death
12or change in marital status of the subscriber.
SB40,742,1313
6. Any other reason determined by the department to be a good cause reason.
SB40,742,18
14(9) Employer verification of insurance coverage. (a) 1. Except as provided
15in subd. 2., for an applicant or recipient with a family income that exceeds 150
16percent of the poverty line, the department shall verify insurance coverage and
17access information directly with the employer through which the applicant or
18recipient may have health insurance coverage or access to coverage.
SB40,742,1919
2. Subdivision 1. does not apply to any of the following:
SB40,742,2020
a. A pregnant woman.
SB40,742,2121
b. A child described in sub. (4) (a) 2. or (b) 2.
SB40,742,2222
c. An individual described in sub. (4) (a) 5.
SB40,743,223
(b) An employer that receives a request from the department for insurance
24coverage and access to coverage information shall supply the information requested
1by the department in the format specified by the department within 30 calendar days
2after receiving the request.
SB40,743,103
(c) 1. Subject to subds. 2. and 3., an employer that does not comply with the
4requirements under par. (b) shall be required to pay, within 45 days after the
5requested information was due, a penalty equal to the full per member per month
6cost of coverage under BadgerCare Plus for the individual about whom the
7information is requested, and for each of the individual's family members with
8coverage under BadgerCare Plus, for each month in which the individual and the
9individual's family members are covered before the employer provides the
10information.
SB40,743,1511
2. An employer with fewer than 250 employees may not be required to pay more
12than $1,000 in penalties under this paragraph that are attributable to any 6-month
13period. An employer with 250 or more employees may not be required to pay more
14than $15,000 in penalties under this paragraph that are attributable to any 6-month
15period.
SB40,743,2016
3. Notwithstanding subd. 1., an employer shall not be subject to any penalties
17if the employer, at least once per year, timely provides to the department, in the
18manner and format specified by the department, information from which the
19department may determine whether the employer provides its employees with
20access to health insurance coverage.
SB40,743,2221
4. All penalty assessments collected under this paragraph shall be credited to
22the appropriation accounts under s. 20.435 (4) (jw) and (jz).
SB40,744,223
(d) An employer may contest a penalty assessment under par. (c) by sending
24a written request for hearing to the division of hearings and appeals in the
1department of administration. Proceedings before the division are governed by ch.
2227.
SB40,744,6
3(10) Cost sharing. (a)
Copayments. Except as provided in s. 49.45 (18) (am),
4all cost-sharing provisions under s. 49.45 (18) apply to a recipient with coverage of
5the benefits described in s. 49.46 (2) (a) and (b) to the same extent as they apply to
6a person eligible for medical assistance under s. 49.46, 49.468, or 49.47.
SB40,744,137
(b)
Premiums. 1. Except as provided in subd. 4., a recipient who is an adult,
8who is not a pregnant woman, and whose family income is greater than 150 percent
9but not greater than 200 percent of the poverty line shall pay a premium for coverage
10under BadgerCare Plus that does not exceed 5 percent of his or her family income.
11If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the
12premium may not exceed 5 percent of family income calculated before depreciation
13was deducted.
SB40,744,1814
2. Except as provided in subds. 3. and 4., a recipient who is a child whose family
15income is greater than 200 percent of the poverty line shall pay a premium for
16coverage of the benefits described in sub. (11) that does not exceed the full per
17member per month cost of coverage for a child with a family income of 300 percent
18of the poverty line.
SB40,744,2319
3. Except as provided in subd. 4., a recipient who is an unborn child, or a
20pregnant woman eligible under sub. (4) (b) 1., whose family income is greater than
21200 percent of the poverty line shall pay a premium for coverage of the benefits
22described in sub. (11) that does not exceed the full per member per month cost of
23coverage for an adult with a family income of 300 percent of the poverty line.
SB40,744,2424
4. None of the following shall pay a premium:
SB40,745,2
1a. A child who is a Native American or an Alaskan Native with a family income
2that does not exceed 300 percent of the poverty line.
SB40,745,33
b. A child who is eligible under sub. (4) (a) 2. or (b) 2.
SB40,745,44
c. A child whose family income does not exceed 200 percent of the poverty line.
SB40,745,65
d. A pregnant woman whose family income does not exceed 200 percent of the
6poverty line.
SB40,745,77
e. A child who obtains eligibility under sub. (7) (b) 2.
SB40,745,88
f. An individual who is eligible under sub. (4) (a) 5.
SB40,745,129
5. If a recipient who is required to pay a premium under this paragraph or
10under sub. (4) (c) does not pay a premium when due, the recipient's coverage
11terminates and the recipient is not eligible for BadgerCare Plus for 6 calendar
12months following the date on which the recipient's coverage terminated.
SB40,745,15
13(11) Benchmark plan benefits and copayments. Recipients who are not eligible
14for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following
15benefits and pay the following copayments:
SB40,745,1816
(a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as
17defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and
18subject to the Badger Rx Gold program discounts.
SB40,745,2019
(b) Physicians' services, including one annual routine physical examination,
20with a copayment of no more than $15 per visit.
SB40,745,2421
(c) Inpatient hospital services as medically necessary, subject to coinsurance
22payment per inpatient stay of no more than 10 percent of the allowable payment
23rates under s. 49.46 (2) for the services provided and a copayment of no more than
24$50 per admission for psychiatric services.
SB40,746,5
1(d) Outpatient hospital services, subject to coinsurance payment of no more
2than 10 percent of the allowable payment rates under s. 49.46 (2) for the services
3provided, except that use of emergency room services for treatment of a condition
4that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall
5require a copayment of no more than $75.
SB40,746,66
(e) Laboratory and X-ray services, including mammography.
SB40,746,77
(f) Home health services, limited to 60 visits per year.
SB40,746,108
(g) Skilled nursing home services, limited to 30 days per year, and subject to
9coinsurance payment of no more than 10 percent of the allowable payment rates
10under s. 49.46 (2) for the services provided.
SB40,746,1311
(h) Inpatient rehabilitation services, limited to 60 days per year, and subject
12to coinsurance payment of no more than 10 percent of the allowable payment rates
13under s. 49.46 (2) for the services provided.
SB40,746,1614
(i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits
15per year for each type of therapy, and subject to coinsurance payment of no more than
1610 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
SB40,746,1917
(j) Cardiac rehabilitation, limited to 36 visits per year and subject to
18coinsurance payment of no more than 10 percent of the allowable payment rates
19under s. 49.46 (2) for the services provided.
SB40,746,2320
(k) Inpatient, outpatient, and transitional treatment for nervous or mental
21disorders and alcoholism and other drug abuse problems, with a copayment of no
22more than $15 per visit and coverage limits that are the same as those under the state
23employee health plan under s. 40.51 (6).
SB40,747,3
1(L) Durable medical equipment, limited to $2,500 per year, and subject to
2coinsurance payment of no more than 10 percent of the allowable payment rates
3under s. 49.46 (2) for the articles provided.
SB40,747,64
(m) Transportation to obtain emergency medical care only, as medically
5necessary, and subject to coinsurance payment of no more than 10 percent of the
6allowable payment rates under s. 49.46 (2) for the services provided.
SB40,747,87
(n) One refractive eye examination every 2 years, with a copayment of no more
8than $15 per visit.
SB40,747,139
(o) Fifty percent of allowable charges for preventive and basic dental services,
10including services for accidental injury and for the diagnosis and treatment of
11temporomandibular disorders. The coverage under this paragraph is limited to $750
12per year, applies only to pregnant women and children under 19 years of age, and
13requires an annual deductible of $200 and a copayment of no more than $15 per visit.
SB40,747,1414
(p) Early childhood developmental services, for children under 6 years of age.
SB40,747,1515
(q) Smoking cessation treatment, for pregnant women only.
SB40,747,1616
(r) Prenatal care coordination, for pregnant women at high risk only.
SB40,748,2
17(11m) Provider payments and requirements. The provider of a service or
18equipment under sub. (11) shall collect the specified or allowable copayment or
19coinsurance, unless the provider determines that the cost of collecting the copayment
20or coinsurance exceeds the amount to be collected. The department shall reduce
21payments for services or equipment under sub. (11) by the amount of the specified
22or allowable copayment or coinsurance. A provider may deny care or services or
23equipment under sub. (11) if the recipient does not pay the specified or allowable
24copayment or coinsurance. If a provider provides care or services or equipment
1under sub. (11) to a recipient who is unable to share costs as specified in sub. (11),
2the recipient is not relieved of liability for those costs.
SB40,748,5
3(12) Rules; notice of effective date. (a) 1. The department may promulgate
4any rules necessary for and consistent with its administrative responsibilities under
5this section, including additional eligibility criteria.
SB40,748,136
2. The department may promulgate emergency rules under s. 227.24 for the
7administration of this section for the period before the effective date of any
8permanent rules promulgated under subd. 1., but not to exceed the period authorized
9under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the
10department is not required to provide evidence that promulgating a rule under this
11subdivision as an emergency rule is necessary for the preservation of the public
12peace, health, safety, or welfare and is not required to provide a finding of emergency
13for a rule promulgated under this subdivision.
SB40,748,1714
(b) If the amendments to the state plan submitted under sub. (2) are approved
15and a waiver that is consistent with all of the provisions of this section is granted and
16in effect, the department shall publish a notice in the Wisconsin Administrative
17Register that states the date on which BadgerCare Plus is implemented.
SB40, s. 1606
18Section
1606. 49.472 (6) (a) of the statutes is amended to read:
SB40,748,2419
49.472
(6) (a) Notwithstanding sub. (4) (a) 3., from the appropriation account
20under s. 20.435 (4) (b),
(gp), or (w)
, or (xd), the department shall, on the part of an
21individual who is eligible for medical assistance under sub. (3), pay premiums for or
22purchase individual coverage offered by the individual's employer if the department
23determines that paying the premiums for or purchasing the coverage will not be more
24costly than providing medical assistance.
SB40, s. 1607
25Section
1607. 49.472 (6) (b) of the statutes is amended to read:
SB40,749,4
149.472
(6) (b) If federal financial participation is available, from the
2appropriation account under s. 20.435 (4) (b),
(gp), or (w)
, or (xd), the department may
3pay medicare Part A and Part B premiums for individuals who are eligible for
4medicare and for medical assistance under sub. (3).
SB40, s. 1608
5Section
1608. 49.473 (2) (a) of the statutes is amended to read:
SB40,749,86
49.473
(2) (a) The woman is not eligible for medical assistance under ss. 49.46
7(1) and (1m), 49.465, 49.468, 49.47,
49.471, and 49.472, and is not eligible for health
8care coverage under s. 49.665.
SB40, s. 1609
9Section
1609. 49.473 (5) of the statutes is amended to read:
SB40,749,1410
49.473
(5) The department shall audit and pay, from the appropriation
11accounts under s. 20.435 (4) (b),
(gp), and (o)
, and (xd), allowable charges to a provider
12who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman
13who meets the requirements under sub. (2) for all benefits and services specified
14under s. 49.46 (2).
SB40, s. 1610
15Section
1610. 49.475 (1) (a) of the statutes is renumbered 49.475 (1) (ar).
SB40, s. 1611
16Section
1611. 49.475 (1) (ag) of the statutes is created to read:
SB40,749,1817
49.475
(1) (ag) "Covered entity" means any of the following that is not an
18insurer:
SB40,749,1919
1. A nonprofit hospital, as defined in s. 46.21 (2) (m).
SB40,749,2320
2. An employer, as defined in s. 101.01 (4), labor union, or other group of persons
21organized in this state if the employer, labor union, or other group provides
22prescription drug coverage to covered individuals who reside or are employed in this
23state.
SB40,749,2524
3. A comprehensive or limited health care benefits program administered by
25the state that provides prescription drug coverage.
SB40, s. 1612
1Section
1612. 49.475 (1) (am) of the statutes is created to read:
SB40,750,52
49.475
(1) (am) "Covered individual" means an individual who is a member,
3participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary
4of a covered entity, or a dependent of the individual, and who receives prescription
5drug coverage from or through the covered entity.
SB40, s. 1613
6Section
1613. 49.475 (1) (c) of the statutes is created to read:
SB40,750,117
49.475
(1) (c) "Pharmacy benefits management" means the procurement of
8prescription drugs at a negotiated rate for dispensation in this state to covered
9individuals; the administration or management of prescription drug benefits
10provided by a covered entity for the benefit of covered individuals; or any of the
11following services provided in the administration of pharmacy benefits:
SB40,750,1212
1. Dispensation of prescription drugs by mail.
SB40,750,1413
2. Claims processing, retail network management, and payment of claims to
14pharmacies for prescription drugs dispensed to covered individuals.
SB40,750,1515
3. Clinical formulary development and management services.
SB40,750,1616
4. Rebate contracting and administration.
SB40,750,1817
5. Conduct of patient compliance, therapeutic intervention, generic
18substitution, and disease management programs.
SB40, s. 1614
19Section
1614. 49.475 (1) (d) of the statutes is created to read:
SB40,750,2120
49.475
(1) (d) "Pharmacy benefits manager" means a person that performs
21pharmacy benefits management functions.
SB40, s. 1615
22Section
1615. 49.475 (1) (e) of the statutes is created to read:
SB40,750,2423
49.475
(1) (e) "Recipient" means an individual or his or her spouse or dependent
24who has been or is one of the following:
SB40,751,2
11. A recipient of medical assistance or of a program administered under medical
2assistance under a waiver of federal Medicaid laws.
SB40,751,33
2. An enrollee of family care.
SB40,751,44
3. A recipient of the Badger Care health care program.
SB40,751,55
4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.
SB40,751,76
5. A participant in the program of prescription drug assistance for elderly
7persons under s. 49.688.
SB40,751,88
6. A woman who receives services that are reimbursed under s. 255.06.
SB40, s. 1616
9Section
1616. 49.475 (1) (f) of the statutes is created to read:
SB40,751,1210
49.475
(1) (f) "Third party" means an entity that by statute, rule, or contract
11is responsible for payment of a claim for a health care item or service. "Third party"
12includes all of the following:
SB40,751,1313
1. An insurer.
SB40,751,15142. An employee benefit plan described in
29 USC 1003 (a) that is not exempt
15under
29 USC 1003 (b) and is not a multiple employer welfare arrangement.
SB40,751,16163. A service benefit plan, as specified in
42 USC 1396a (25) (I).
SB40,751,1717
4. A pharmacy benefits manager.