SB273,35,2120 1. The authority has determined that at least one qualified dental plan is
21available to supplement the plan's coverage.
SB273,35,2522 2. The carrier makes prominent disclosure at the time it offers the plan, in a
23form approved by the authority, that the plan does not provide the full range of
24essential pediatric benefits and that qualified dental plans providing those benefits
25and other dental benefits not covered by the plan are offered through the exchange.
SB273,36,2
1(b) The premium rates and contract language have been filed with and not
2disapproved by the commissioner.
SB273,36,63 (c) The plan provides at least a bronze level of coverage, as determined under
4s. 636.30 (1) (e), unless the plan is certified as a qualified catastrophic plan, meets
5the requirements of the federal act for catastrophic plans, and will only be offered to
6individuals eligible for catastrophic coverage.
SB273,36,107 (d) The plan's cost-sharing requirements do not exceed the limits established
8under section 1302 (c) (1) of the federal act and, if the plan is offered through the
9SHOP Exchange, the plan's deductible does not exceed the limits established under
10section 1302 (c) (2) of the federal act.
SB273,36,1111 (e) The health carrier offering the plan satisfies all of the following:
SB273,36,1312 1. Is licensed and in good standing to offer health insurance coverage in this
13state.
SB273,36,1714 2. Offers at least one qualified health plan in the silver level and at least one
15qualified health plan in the gold level through each component of the exchange in
16which the carrier participates. In this subdivision, "component" refers to the SHOP
17Exchange and the exchange for individual coverage.
SB273,36,2018 3. Charges the same premium rate for each qualified health plan without
19regard to whether the plan is offered directly from the carrier or through an
20insurance intermediary.
SB273,36,2221 4. Does not charge any cancellation fees or penalties in violation of s. 636.25
22(3).
SB273,36,2423 5. Complies with the regulations developed by the secretary under section 1311
24(d) of the federal act and such other requirements as the authority may establish.
SB273,37,6
1(f) The plan meets the requirements of certification as required by any rules
2promulgated under s. 636.46 (1) and by the secretary under section 1311 (c) of the
3federal act, including minimum standards in the areas of marketing practices,
4network adequacy, essential community providers in underserved areas,
5accreditation, quality improvement, uniform enrollment forms, and descriptions of
6coverage and information on quality measures for health benefit plan performance.
SB273,37,97 (g) The authority determines that making the plan available through the
8exchange is in the interest of qualified individuals and qualified employers in this
9state.
SB273,37,11 10(2) The authority shall not exclude a health benefit plan for any of the following
11reasons or in any of the following ways:
SB273,37,1212 (a) On the basis that the plan is a fee-for-service plan.
SB273,37,1313 (b) Through the imposition of premium price controls by the authority.
SB273,37,1614 (c) On the basis that the plan provides treatments necessary to prevent
15patients' deaths in circumstances the authority determines are inappropriate or too
16costly.
SB273,37,18 17(3) The authority shall require each health carrier seeking certification of a
18health benefit plan as a qualified health plan to do all of the following:
SB273,37,2519 (a) Submit a justification for any premium increase before implementation of
20that increase. The carrier shall prominently post the information on its Internet Web
21site. The authority shall take this information, along with the information and the
22recommendations provided to the authority by the commissioner under section 2794
23(b) of the federal Public Health Service Act (42 USC 300gg-94 (b)), into consideration
24when determining whether to allow the carrier to make the plan available through
25the authority.
SB273,38,3
1(b) 1. Make available to the public, in the format described in subd. 2., and
2submit to the authority, the secretary, and the commissioner, accurate and timely
3disclosure of all of the following:
SB273,38,44 a. Claims payment policies and practices.
SB273,38,55 b. Periodic financial disclosures.
SB273,38,66 c. Data on enrollment.
SB273,38,77 d. Data on disenrollment.
SB273,38,88 e. Data on the number of claims that are denied.
SB273,38,99 f. Data on rating practices.
SB273,38,1110 g. Information on cost-sharing and payments with respect to any
11out-of-network coverage.
SB273,38,1212 h. Information on enrollee and participant rights under title I of the federal act.
SB273,38,1313 i. Other information as determined appropriate by the secretary.
SB273,38,1514 2. The information required in subd. 1. shall be provided in plain language, as
15that term is defined in section 1311 (e) (3) (B) of the federal act.
SB273,38,2216 (c) Permit individuals to learn, in a timely manner upon the request of the
17individual, the amount of cost-sharing, including deductibles, copayments, and
18coinsurance, under the individual's plan or coverage that the individual would be
19responsible for paying with respect to the furnishing of a specific item or service by
20a participating provider. At a minimum, this information shall be made available
21to the individual through an Internet Web site and through other means for
22individuals without access to the Internet.
SB273,39,2 23(4) The authority shall not exempt any health carrier seeking certification of
24a health benefit plan as a qualified health plan, regardless of the type or size of the
25carrier, from state licensure or solvency requirements and shall apply the criteria of

1this section in a manner that assures equitable treatment of all health carriers
2participating in the exchange.
SB273,39,6 3(5) (a) The provisions of this chapter that are applicable to qualified health
4plans shall also apply to the extent relevant to qualified dental plans except as
5modified in accordance with pars. (b), (c), and (d) or by regulations adopted by the
6authority.
SB273,39,87 (b) The carrier shall be licensed to offer dental coverage, but need not be
8licensed to offer other health benefits.
SB273,39,149 (c) The plan shall be limited to dental and oral health benefits, without
10substantially duplicating the benefits typically offered by health benefit plans
11without dental coverage and shall include, at a minimum, the essential pediatric
12dental benefits prescribed by the secretary under section 1302 (b) (1) (J) of the federal
13act, and such other dental benefits as the authority or the secretary may specify by
14regulation.
SB273,39,1915 (d) Carriers may jointly offer a comprehensive plan through the exchange in
16which the dental benefits are provided by a carrier through a qualified dental plan
17and the other benefits are provided by a carrier through a qualified health plan,
18provided that the plans are priced separately and are also made available for
19purchase separately at the same price.
SB273,39,24 20636.43 Insurer requirements. (1) Any health carrier that is authorized to
21do business in this state in one or more lines of insurance that includes health
22insurance may offer health benefit plans through the exchange. After the exchange
23becomes operational, no health carrier may offer or issue a health benefit plan in this
24state to an individual or to a small employer except through the exchange.
SB273,40,3
1(2) For the purpose of determining premiums, a carrier may pool together all
2individuals and employees who have coverage under all of the qualified health plans
3issued by the carrier through the exchange.
SB273,40,7 4(3) A carrier that offers qualified health plans through the exchange shall
5establish a toll-free hotline for providing information to enrollees and other
6individuals and shall furnish such reasonable reports as the authority determines
7necessary for the administration of the exchange.
SB273,40,11 8(4) The authority may audit any carrier that provides coverage under a
9qualified health plan through the exchange for the purpose of ensuring that the
10carrier is providing covered individuals with the benefits provided for under this
11subchapter in a manner that does all of the following:
SB273,40,1212 (a) Complies with the provisions of this chapter.
SB273,40,1313 (b) Promotes positive health outcomes.
SB273,40,1414 (c) Advances value-based and evidence-based medical practices.
SB273,40,1715 (d) Avoids unnecessary operating and capital costs arising from inappropriate
16utilization or inefficient delivery of health care services, unwarranted duplication of
17services and infrastructure, or creation of excess care delivery capacity.
SB273,40,1818 (e) Holds down the growth of health care costs.
SB273,41,2 19636.44 Intermediaries. An insurance intermediary that enrolls a qualified
20individual in a qualified health plan through the exchange shall be paid a
21commission by the carrier offering the qualified health plan. An insurance
22intermediary that enrolls the employees of a qualified employer in one or more
23qualified health plans through the exchange shall be paid a commission by each
24carrier offering a qualified health plan selected by an employee of the qualified
25employer. The authority shall determine the commission amounts that must be paid

1to intermediaries under this section after considering information provided to the
2commissioner under s. 628.81 with respect to health insurance.
SB273,41,7 3636.45 Funding; publication of costs. (1) For payment of administrative
4expenses, the authority may impose a surcharge on each health carrier offering
5qualified health plans through the exchange. The surcharge shall be based on the
6carrier's total premium or flat dollar amount per enrollee collected through the
7exchange.
SB273,41,11 8(2) The authority shall publish the average costs of licensing, regulatory fees,
9and any other payments required by the authority, and the administrative costs of
10the authority, on an Internet Web site to educate consumers on such costs. This
11information shall include information on moneys lost to waste, fraud, and abuse.
SB273,41,15 12636.46 Rules; application form. (1) The commissioner may promulgate
13rules to implement the provisions of this chapter. Rules promulgated under this
14section shall not conflict with or prevent the application of regulations promulgated
15by the secretary under the federal act.
SB273,41,17 16(2) The commissioner shall develop a standard application form for use in the
17exchange.
SB273,41,24 18636.48 Relation to other laws. Nothing in this chapter, and no action taken
19by the authority under this chapter, shall be construed to preempt or supersede the
20authority of the commissioner to regulate the business of insurance within this state.
21Except as expressly provided to the contrary in this chapter, all health carriers
22offering qualified health plans in this state shall comply fully with all applicable
23health insurance laws of this state and rules promulgated and orders issued by the
24commissioner.
SB273,42,2
1Subchapter III
2 badger Health benefit authority
SB273,42,15 3636.70 Creation and organization of authority. (1) There is created a
4public body corporate and politic to be known as the "Badger Health Benefit
5Authority." The board of directors of the authority shall consist of the commissioner,
6or his or her designee; the secretary of employee trust funds, or his or her designee;
7the person who is appointed by the secretary of health services to be the director of
8the Medical Assistance program, or his or her designee; the executive director, or his
9or her designee, of the Health Insurance Risk-Sharing Plan Authority, if that
10organization exists; the executive director, or his or her designee, of the Wisconsin
11Collaborative for Healthcare Quality, if that organization exists; the executive
12director, or his or her designee, of the the Wisconsin Health Information
13Organization, if that organization exists; and all of the following members, who shall
14be nominated by the governor, and with the advice and consent of the senate
15appointed for 3-year terms except as provided in sub. (2):
SB273,42,1616 (a) A member in good standing of the American Academy of Actuaries.
SB273,42,1717 (b) A health economist.
SB273,42,1818 (c) An employee benefits specialist.
SB273,42,1919 (d) A representative of small employers.
SB273,42,2020 (e) A representative of an organization that represents consumer interests.
SB273,42,2121 (f) A representative of organized labor.
SB273,42,2222 (g) An individual with experience in health care administration.
SB273,43,2 23(2) No member of the board appointed under sub. (1) (a) to (g) may be a health
24care provider, as defined in s. 146.81 (1) (a) to (hp); an employee of a health care

1provider, as defined in s. 146.81 (1) (i) to (p); an employee of an insurer that is
2authorized to do business in the state; or an insurance intermediary.
SB273,43,4 3(3) A vacancy on the board shall be filled in the same manner as the original
4appointment to the board for the remainder of the unexpired term, if any.
SB273,43,7 5(4) A member of the board shall receive no compensation for services under this
6chapter but shall be reimbursed for actual and necessary expenses, including travel
7expenses, incurred in the discharge of the member's duties under this chapter.
SB273,43,12 8(5) The commissioner or the commissioner's designee shall be the chairperson
9of the board. Seven members of the board constitute a quorum for the purpose of
10conducting the business and exercising the powers of the authority, notwithstanding
11the existence of any vacancy. The board may take action upon a vote of a majority
12of the members present, unless the bylaws of the authority require a larger number.
SB273,43,24 13(6) The board shall appoint an executive director who shall not be a member
14of the board and who shall serve at the pleasure of the board. The executive director
15shall receive compensation commensurate with the duties of the office, as
16determined by the board. The executive director shall serve as secretary of the
17authority and shall keep a record of the proceedings of the authority and shall be
18custodian of all books, documents, and papers filed with the authority, the minute
19book or journal of the authority, and its official seal. The executive director or other
20person may cause copies to be made of all minutes and other records and documents
21of the authority and may give certificates under the official seal of the authority to
22the effect that such copies are true copies, and all persons dealing with the authority
23may rely upon such certificates. The executive director shall have all of the following
24duties:
SB273,44,2
1(a) Supervising the administrative affairs and the general management and
2operation of the authority.
SB273,44,43 (b) Planning, directing, coordinating, and executing administrative functions
4in conformity with the policies and directives of the board.
SB273,44,55 (c) Employing professional and clerical staff, as necessary.
SB273,44,76 (d) Reporting to the board on all operations under his or her control and
7supervision.
SB273,44,98 (e) Preparing an annual budget and managing the administrative expenses of
9the authority.
SB273,44,1110 (f) Undertaking any activities necessary to implement the powers and duties
11set forth in this chapter.
SB273,44,13 12636.72 Authority duties. In addition to all other duties imposed under this
13chapter, the authority shall do all of the following:
SB273,44,14 14(1) Establish its annual budget and monitor its fiscal management.
SB273,44,18 15(2) No later than two years after an exchange under subch. II begins operation,
16and annually thereafter, submit a report to the legislature under s. 13.172 (2) and
17to the governor on the operation of any exchange under subch. II, including a review
18of all of the following:
SB273,44,1919 (a) Progress toward the goals of the exchange.
SB273,44,2020 (b) The operations and administration of the exchange.
SB273,44,2221 (c) The types of health insurance plans available to eligible individuals and
22groups and the percentage of the total exchange enrollees served by each plan.
SB273,44,2523 (d) Surveys and reports on the insurers' experiences with different plans,
24including aggregated data on enrollees, claims, statistics, complaint data, and
25enrollee satisfaction data.
SB273,45,2
1(e) Significant observations regarding utilization and adoption of the
2exchange.
SB273,45,4 3(3) Annually submit to the governor and the legislative audit bureau a
4statement of its activities and financial condition.
SB273,45,6 5(4) Approve the use of any trademarks, seals, or logos by participating insurers
6and small employers.
SB273,45,8 7(5) Comply with the requirements of s. 16.413 as if the authority is a state
8agency.
SB273,45,12 9636.74 Authority powers. The authority has all of the powers necessary or
10convenient to carry out its duties under this chapter, except that it may not acquire
11or hold title to real estate or issue bonds. In addition, the authority may do any of
12the following:
SB273,45,14 13(1) Adopt bylaws and policies and procedures for the regulation of its affairs
14and the conduct of its business.
SB273,45,16 15(2) Have a seal and alter the seal at pleasure; have perpetual existence; and
16maintain an office.
SB273,45,17 17(3) Hire employees, define their duties, and fix their rate of compensation.
SB273,45,19 18(4) Delegate by resolution to one or more of its members any powers and duties
19that it considers proper.
SB273,45,20 20(5) Incur debt.
SB273,45,24 21(6) Appoint any technical or professional advisory committee that the
22authority finds necessary to assist the authority in exercising its duties and powers.
23If the authority appoints a committee, the authority shall define the duties of the
24committee and provide reimbursement for the expenses of the committee.
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