SB12: Bill Text

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:

SB12,35,12 (a) On the basis that the plan is a fee-for-service plan.

SB12,35,13 (b) Through the imposition of premium price controls by the authority.

SB12,35,16 (c) On the basis that the plan provides treatments necessary to prevent patients' deaths in circumstances the authority determines are inappropriate or too costly.

SB12,35,18 (3) The authority shall require each health carrier seeking certification of a health benefit plan as a qualified health plan to do all of the following:

SB12,35,25 (a) Submit a justification for any premium increase before implementation of that increase. The carrier shall prominently post the information on its Internet site. The authority shall take this information, along with the information and the recommendations provided to the authority by the commissioner under section 2794 (b) of the federal Public Health Service Act (42 USC 300gg-94 (b)), into consideration when determining whether to allow the carrier to make the plan available through the exchange.

SB12,36,3 (b) 1. Make available to the public, in the format described in subd. 2., and submit to the authority, the secretary, and the commissioner, accurate and timely disclosure of all of the following:

SB12,36,4 a. Claims payment policies and practices.

SB12,36,5 b. Periodic financial disclosures.

SB12,36,6 c. Data on enrollment.

SB12,36,7 d. Data on disenrollment.

SB12,36,8 e. Data on the number of claims that are denied.

SB12,36,9 f. Data on rating practices.

SB12,36,11 g. Information on cost-sharing and payments with respect to any out-of-network coverage.

SB12,36,12 h. Information on enrollee and participant rights under title I of the federal act.

SB12,36,13 i. Other information as determined appropriate by the secretary.

SB12,36,15 2. The information required in subd. 1. shall be provided in plain language, as that term is defined in section 1311 (e) (3) (B) of the federal act.

SB12,36,22 (c) Permit individuals to learn, in a timely manner upon the request of the individual, the amount of cost-sharing, including deductibles, copayments, and coinsurance, under the individual's plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider. At a minimum, this information shall be made available to the individual through an Internet site and through other means for individuals without access to the Internet.

SB12,37,2 (4) The authority may not exempt any health carrier seeking certification of a health benefit plan as a qualified health plan, regardless of the type or size of the carrier, from state licensure or solvency requirements and shall apply the criteria of this section in a manner that assures equitable treatment of all health carriers participating in the exchange.

SB12,37,6 (5) (a) The provisions of this chapter that are applicable to qualified health plans shall also apply to the extent relevant to qualified dental plans, except as modified in accordance with pars. (b), (c), and (d) or by regulations adopted by the authority.

SB12,37,8 (b) The carrier shall be licensed to offer dental coverage, but need not be licensed to offer other health benefits.

SB12,37,14 (c) The plan shall be limited to dental and oral health benefits, without substantially duplicating the benefits typically offered by health benefit plans without dental coverage and shall include, at a minimum, the essential pediatric dental benefits prescribed by the secretary under section 1302 (b) (1) (J) of the federal act and such other dental benefits as the authority or the secretary may specify by regulation.

SB12,37,19 (d) Carriers may jointly offer a comprehensive plan through the exchange in which the dental benefits are provided by a carrier through a qualified dental plan and the other benefits are provided by a carrier through a qualified health plan, provided that the plans are priced separately and are also made available for purchase separately at the same price.

SB12,37,24 636.43 Insurer requirements. (1) Any health carrier that is authorized to do business in this state in one or more lines of insurance that includes health insurance may offer health benefit plans through the exchange. After the exchange becomes operational, no health carrier may offer or issue a health benefit plan in this state to an individual or to a small employer except through the exchange.

SB12,38,3 (2) For the purpose of determining premiums, a carrier may pool together all individuals and employees who have coverage under all of the qualified health plans issued by the carrier through the exchange.

SB12,38,7 (3) A carrier that offers qualified health plans through the exchange shall establish a toll-free hotline for providing information to enrollees and other individuals and shall furnish such reasonable reports as the authority determines necessary for the administration of the exchange.

SB12,38,11 (4) The authority may audit any carrier that provides coverage under a qualified health plan through the exchange for the purpose of ensuring that the carrier is providing covered individuals with the benefits provided for under this subchapter in a manner that does all of the following:

SB12,38,12 (a) Complies with the provisions of this chapter.

SB12,38,13 (b) Promotes positive health outcomes.

SB12,38,14 (c) Advances value-based and evidence-based medical practices.

SB12,38,17 (d) Avoids unnecessary operating and capital costs arising from inappropriate utilization or inefficient delivery of health care services, unwarranted duplication of services and infrastructure, or creation of excess care delivery capacity.

SB12,38,18 (e) Holds down the growth of health care costs.

SB12,39,2 636.44 Intermediaries. An insurance intermediary that enrolls a qualified individual in a qualified health plan through the exchange shall be paid a commission by the carrier offering the qualified health plan. An insurance intermediary that enrolls the employees of a qualified employer in one or more qualified health plans through the exchange shall be paid a commission by each carrier offering a qualified health plan selected by an employee of the qualified employer. The authority shall determine the commission amounts that must be paid to intermediaries under this section after considering information provided to the commissioner under s. 628.81 with respect to health insurance.

SB12,39,7 636.45 Funding; publication of costs. (1) For payment of administrative expenses, the authority may impose a surcharge on each health carrier offering qualified health plans through the exchange. The surcharge shall be based on the carrier's total premium or flat dollar amount per enrollee collected through the exchange.