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.
SB40, s. 1617
18Section
1617. 49.475 (2) of the statutes is repealed and recreated to read:
SB40,751,2019
49.475
(2) Requirements of 3rd parties. As a condition of doing business in this
20state, a 3rd party shall do all of the following:
SB40,751,2321
(a) Upon the department's request and in the manner prescribed by the
22department, provide information to the department necessary for the department to
23ascertain all of the following with respect to a recipient:
SB40,751,2524
1. Whether the recipient is being or has been provided coverage or a benefit or
25service by a 3rd party.
SB40,752,3
12. If subd. 1. applies, the nature and period of time of any coverage, benefit, or
2service provided, including the name, address, and identifying number of any
3applicable coverage plan.
SB40,752,74
(b) Accept assignment to the department of a right of a recipient to receive
53rd-party payment for an item or service for which payment under medical
6assistance has been made and accept the department's right to recover any
73rd-party payment made for which assignment has not been accepted.
SB40,752,108
(c) Respond to an inquiry by the department concerning a claim for payment
9of a health care item or service if the department submits the inquiry less than 36
10months after the date on which the health care item or service was provided.
SB40,752,1411
(d) If all of the following apply, agree not to deny a claim submitted by the
12department under par. (b) solely because of the claim's submission date, the type or
13format of the claim form, or failure by a recipient to present proper documentation
14at the time of delivery of the service, benefit, or item that is the basis of the claim:
SB40,752,1615
1. The department submits the claim less than 36 months after the date on
16which the health care item or service was provided.
SB40,752,1917
2. Action by the department to enforce the department's rights under this
18section with respect to the claim is commenced less than 72 months after the
19department submits the claim.
SB40, s. 1618
20Section
1618. 49.475 (3) (intro.) of the statutes is amended to read:
SB40,752,2321
49.475
(3) Written agreement. (intro.) Upon requesting
an insurer a 3rd party 22to provide the information under sub. (2)
(a), the department
and the 3rd party shall
23enter into a written agreement
with the insurer that satisfies all of the following:
SB40, s. 1619
24Section
1619. 49.475 (3) (a) of the statutes is amended to read:
SB40,753,2
149.475
(3) (a) Identifies
in detail the detailed format of the information to be
2disclosed provided to the department.
SB40, s. 1620
3Section
1620. 49.475 (3) (c) of the statutes is amended to read:
SB40,753,54
49.475
(3) (c) Specifies how the
insurer's 3rd party's reimbursable costs under
5sub. (5) will be determined and specifies the manner of payment.
SB40, s. 1621
6Section
1621. 49.475 (4) (a) of the statutes is amended to read:
SB40,753,107
49.475
(4) (a)
An insurer A 3rd party shall provide the information requested
8under sub. (2)
(a) within 180 days after receiving the department's request if it is the
9first time that the department has requested the
insurer 3rd party to disclose
10information under this section.
SB40, s. 1622
11Section
1622. 49.475 (4) (b) of the statutes is amended to read:
SB40,753,1512
49.475
(4) (b)
An insurer A 3rd party shall provide the information requested
13under sub. (2)
(a) within 30 days after receiving the department's request if the
14department has previously requested the
insurer 3rd party to disclose information
15under this section.
SB40, s. 1623
16Section
1623. 49.475 (4) (d) of the statutes is created to read:
SB40,753,1817
49.475
(4) (d) If a 3rd party other than an insurer fails to comply with par. (a)
18or (b), the department may so notify the attorney general.