SB12: Bill Text

SB12,25,12 (a) The individual is seeking to enroll in a qualified health plan offered to individuals through the exchange under subch. II.

SB12,25,13 (b) The individual resides in this state.

SB12,25,15 (c) At the time of enrollment, the individual is not incarcerated in a correctional facility, other than incarceration pending the disposition of charges.

SB12,25,18 (d) The individual is, and is reasonably expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States.

SB12,25,20 (10) "Secretary" means the secretary of the federal department of health and human services.

SB12,25,22 (11) "SHOP Exchange" means a small business health options program established under s. 636.30 (1) (q).

SB12,25,24 (12) (a) "Small employer" means an employer that employed an average of not more than 100 employees during the preceding calendar year.

SB12,25,25 (b) For purposes of this subsection, all of the following apply:

SB12,26,2 1. All persons treated as a single employer under section 414 (b), (c), (m), or (o) of the Internal Revenue Code shall be treated as a single employer.

SB12,26,4 2. An employer and any predecessor employer shall be treated as a single employer.

SB12,26,6 3. All employees shall be counted, including part-time employees and employees who are not eligible for coverage through the employer.

SB12,26,10 4. If an employer was not in existence during the entire preceding calendar year, the determination of whether that employer is a small employer shall be based on the average number of employees that it is reasonably expected that employer will employ on business days in the current calendar year.

SB12,26,15 5. An employer that makes enrollment in qualified health plans available to its employees through the SHOP Exchange and that would cease to be a small employer by reason of an increase in the number of its employees shall continue to be treated as a small employer for purposes of this chapter as long as it continuously makes enrollment through the SHOP Exchange available to its employees.

SB12,26,17 subchapter II operation of exchange

SB12,26,21 636.25 General matters. (1) The authority shall establish and operate a Wisconsin Health Benefit Exchange and shall make qualified health plans, with effective dates on or before January 1, 2014, available to qualified individuals and qualified employers.

SB12,26,23 (2) (a) The authority may not make available any health benefit plan that is not a qualified health plan.

SB12,27,3 (b) The authority shall allow a health carrier to offer a plan that provides limited scope dental benefits meeting the requirements of section 9832 (c) (2) (A) of the Internal Revenue Code through the exchange, either separately or in conjunction with a qualified health plan, if the plan provides pediatric dental benefits meeting the requirements of section 1302 (b) (1) (J) of the federal act.

SB12,27,9 (3) Neither the authority nor a carrier offering health benefit plans through the exchange may charge an individual a fee or penalty for termination of coverage if the individual enrolls in another type of minimum essential coverage because the individual has become newly eligible for that coverage or because the individual's employer-sponsored coverage has become affordable under the standards of section 36B (c) (2) (C) of the Internal Revenue Code.

SB12,27,14 (4) The authority may enter into information-sharing agreements with federal and state agencies and entities operating exchanges in other states to carry out its responsibilities under this chapter, provided that such agreements include adequate protections with respect to the confidentiality of the information to be shared and comply with all state and federal laws and rules and regulations.

SB12,27,17 636.30 Exchange duties and powers. (1) In addition to all other duties imposed under this chapter, the authority shall do all of the following relating to the exchange:

SB12,27,21 (a) Implement procedures for the certification, recertification, and decertification, consistent with guidelines developed by the secretary under section 1311 (c) of the federal act and s. 636.42, of health benefit plans as qualified health plans.

SB12,27,23 (b) Provide for the operation of a toll-free telephone hotline to respond to requests for assistance.

SB12,27,25 (c) Provide for enrollment periods, as provided under section 1311 (c) (6) of the federal act.

SB12,28,3 (d) Maintain an Internet site through which enrollees and prospective enrollees of qualified health plans may obtain standardized comparative information on such plans.

SB12,28,8 (e) Assign a rating to each qualified health plan offered through the exchange in accordance with the criteria developed by the secretary under section 1311 (c) (3) of the federal act, and determine each qualified health plan's level of coverage in accordance with regulations issued by the secretary under section 1302 (d) (2) (A) of the federal act.

SB12,28,11 (f) Use a standardized format for presenting health benefit options in the exchange, including the use of the uniform outline of coverage established under section 2715 of the federal Public Health Service Act (42 USC 300gg-15).

SB12,28,13 (g) Establish quality improvement standards for health benefit plans offered through the exchange.

SB12,28,15 (h) Establish a system for enrolling eligible groups and individuals, using a standard application form developed by the commissioner under s. 636.46 (2).

SB12,28,17 (i) Establish procedures for collecting premiums and remitting premium payments and providing enrollment information to health carriers.

SB12,28,20 (j) Establish, in consultation with the commissioner, the method for determining the amount of the surcharge under s. 636.45 (1) and establish the procedure for imposing and collecting the surcharge.

SB12,28,22 (k) Establish a plan for publicizing the exchange and the eligibility requirements and enrollment procedures.

SB12,28,24 (L) Establish and operate a service center to provide information to small employers, individuals, enrollees, and insurance intermediaries about the exchange.

SB12,29,2 (m) Establish a mechanism for regular communication and cooperation with insurance intermediaries.

SB12,29,4 (n) Establish an independent and binding appeals process for resolving disputes over eligibility and other determinations made by the authority.

SB12,29,9 (o) In accordance with section 1413 of the federal act, inform individuals of eligibility requirements for Medical Assistance under subch. IV of ch. 49 or any other applicable state or local public program and if, through screening of the application by the authority, the authority determines that any individual is eligible for any such program, assist that individual to enroll in that program.

SB12,29,13 (p) Establish and make available by electronic means a calculator to determine the actual cost of coverage after application of any premium tax credit under section 36B of the Internal Revenue Code and any cost-sharing reduction under section 1402 of the federal act.

SB12,29,17 (q) Establish a SHOP Exchange through which qualified employers may access health care coverage for their employees and which shall enable any qualified employer to specify the level of coverage at which its employees may enroll in any qualified health plan offered through the SHOP Exchange.

SB12,29,20 (r) Perform duties required of the authority by the secretary or the federal secretary of the treasury related to determining eligibility for premium tax credits, reduced cost-sharing, or individual responsibility requirement exemptions.

SB12,29,24 (s) Select entities, which may include insurance intermediaries, that are qualified to serve as navigators in accordance with section 1311 (i) of the federal act and standards developed by the secretary, and award grants to enable navigators to do all of the following:

SB12,30,2 1. Conduct public education activities to raise awareness of the availability of qualified health plans.

SB12,30,6 2. Distribute fair and impartial information concerning enrollment in qualified health plans and concerning the availability of premium tax credits under section 36B of the Internal Revenue Code and cost-sharing reductions under section 1402 of the federal act.

SB12,30,7 3. Facilitate enrollment in qualified health plans.

SB12,30,13 4. Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the federal Public Health Service Act (42 USC 300gg-93), or to any other appropriate state agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health benefit plan, coverage, or determination under that plan or coverage.

SB12,30,15 5. Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the exchange.

SB12,30,18 (t) Assist in the coordination of any necessary administrative operations between the department of corrections and the department of health services to ensure all of the following:

SB12,30,21 1. That an individual, upon placement in a correctional facility, is disenrolled for the duration of his or her incarceration from any health care coverage in which he or she is enrolled.

SB12,31,2 2. That an individual who is incarcerated in a correctional facility, but scheduled to be released from incarceration in the near future, is enrolled prior to release, through the exchange and effective upon the date of his or her release, in Medical Assistance, a qualified health plan, or some other form of minimum essential coverage on the date of his or her release from incarceration.

SB12,31,8 (u) For those persons whose alcohol or other drug abuse or mental health treatment is not covered by a federally administered program, coordinate the relationships among the Medical Assistance program, the exchange, and the county departments under s. 51.42 or 51.437 to provide outpatient and inpatient mental health and alcohol or other drug abuse treatment with all of the following goals for the coordination:

SB12,31,10 1. Maximizing coverage and improving access through the exchange for outpatient and inpatient treatment of mental illness and alcohol or other drug abuse.

SB12,31,12 2. Improving the quality of treatment for persons with alcohol or other drug dependence or a mental illness.

SB12,31,14 3. Fully integrating the treatment for physical conditions, alcohol or other drug abuse, and mental illness.

SB12,31,19 4. Reducing the cost of the county departments under ss. 51.42 and 51.437 to taxpayers by avoiding unnecessary overlap between the improved coverage of alcohol or other drug abuse treatment or mental illness treatment by health plans offered through the exchange and the services provided by county departments under s. 51.42 or 51.437.

SB12,31,22 (v) Review the rate of premium growth within the exchange and outside the exchange, and consider the information in developing recommendations on whether to continue limiting qualified employer status to small employers.

SB12,31,25 (w) Credit the amount of any free choice voucher to the monthly premium of the plan in which a qualified employee is enrolled, in accordance with section 10108 of the federal act, and collect the amount credited from the offering employer.

SB12,32,2 (x) Consult with stakeholders relevant to carrying out the activities required under this chapter, including any of the following:

SB12,32,3 1. Educated health care consumers who are enrollees in qualified health plans.

SB12,32,5 2. Individuals and entities with experience in facilitating enrollment in qualified health plans.

SB12,32,6 3. Representatives of small businesses and self-employed individuals.

SB12,32,7 4. The department of health services.

SB12,32,8 5. Advocates for enrolling hard-to-reach populations.

SB12,32,9 (y) Meet all of the following financial integrity requirements:

SB12,32,12 1. Keep an accurate accounting of all activities, receipts, and expenditures and annually submit to the secretary, the governor, the commissioner, and the legislature a report concerning such accountings.

SB12,32,16 2. Fully cooperate with any investigation conducted by the secretary under the secretary's authority under the federal act and allow the secretary, in coordination with the inspector general of the federal department of health and human services, to do all of the following:

SB12,32,17 a. Investigate the affairs of the authority.

SB12,32,18 b. Examine the properties and records of the authority.

SB12,32,20 c. Require periodic reports in relation to the activities undertaken by the authority.

SB12,33,2 3. In carrying out its activities under this chapter, not use any funds intended for the administrative and operational expenses of the authority for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or state legislative or regulatory modifications, except that this subdivision does not prohibit the authority from advocating, as part of administering the exchange, for policies that the authority determines are in the best interest of the exchange or of individuals and employees receiving coverage through the exchange.

SB12,33,3 (2) The authority may do all of the following relating to the exchange:

SB12,33,5 (a) Contract with a 3rd-party administrator for the provision of services on behalf of the exchange.

SB12,33,6 (b) Establish risk adjustment mechanisms for the exchange.

SB12,33,7 (c) Enter into agreements with or establish sub-exchanges.

SB12,33,9 (d) Create any other exchange, or component of the exchange, that is provided for under federal law.

SB12,33,13 (3) The authority shall seek grants to the fullest extent to which it is eligible, including amounts under section 1311 (a) (1) and (4) of the federal act, or other funding from the federal or state government for which it may be eligible and from private foundations for the purpose of the exchange.

SB12,33,15 636.42 Health benefit plan certification. (1) The authority may certify a health benefit plan as a qualified health plan if all of the following are true:

SB12,33,19 (a) The plan provides the essential health benefits package described in section 1302 (a) of the federal act, except that the plan is not required to provide essential benefits that duplicate the minimum benefits of qualified dental plans, as provided in sub. (5), if all of the following are satisfied:

SB12,33,21 1. The authority has determined that at least one qualified dental plan is available to supplement the plan's coverage.

SB12,33,25 2. The carrier makes prominent disclosure at the time it offers the plan, in a form approved by the authority, that the plan does not provide the full range of essential pediatric benefits and that qualified dental plans providing those benefits and other dental benefits not covered by the plan are offered through the exchange.

SB12,34,2 (b) The premium rates and contract language have been filed with and not disapproved by the commissioner.

SB12,34,6 (c) The plan provides at least a bronze level of coverage, as determined under s. 636.30 (1) (e), unless the plan is certified as a qualified catastrophic plan, meets the requirements of the federal act for catastrophic plans, and will only be offered to individuals eligible for catastrophic coverage.

SB12,34,10 (d) The plan's cost-sharing requirements do not exceed the limits established under section 1302 (c) (1) of the federal act and, if the plan is offered through the SHOP Exchange, the plan's deductible does not exceed the limits established under section 1302 (c) (2) of the federal act.

SB12,34,11 (e) The health carrier offering the plan satisfies all of the following:

SB12,34,13 1. Is licensed and in good standing to offer health insurance coverage in this state.

SB12,34,17 2. Offers at least one qualified health plan in the silver level and at least one qualified health plan in the gold level through each component of the exchange in which the carrier participates. In this subdivision, "component" refers to the SHOP Exchange and the exchange for individual coverage.

SB12,34,20 3. Charges the same premium rate for each qualified health plan without regard to whether the plan is offered directly from the carrier or through an insurance intermediary.

SB12,34,22 4. Does not charge any cancellation fees or penalties in violation of s. 636.25 (3).

SB12,34,24 5. Complies with the regulations developed by the secretary under section 1311 (d) of the federal act and such other requirements as the authority may establish.

SB12,35,6 (f) The plan meets the requirements of certification as required by any rules promulgated under s. 636.46 (1) and by the secretary under section 1311 (c) of the federal act, including minimum standards in the areas of marketing practices, network adequacy, essential community providers in underserved areas, accreditation, quality improvement, uniform enrollment forms, and descriptions of coverage and information on quality measures for health benefit plan performance.

SB12,35,9 (g) The authority determines that making the plan available through the exchange is in the interest of qualified individuals and qualified employers in this state.

SB12,35,11 (2) The authority shall not exclude a health benefit plan for any of the following reasons or in any of the following ways: