SB12,29,43 (n) Establish an independent and binding appeals process for resolving
4disputes over eligibility and other determinations made by the authority.
SB12,29,95 (o) In accordance with section 1413 of the federal act, inform individuals of
6eligibility requirements for Medical Assistance under subch. IV of ch. 49 or any other
7applicable state or local public program and if, through screening of the application
8by the authority, the authority determines that any individual is eligible for any such
9program, assist that individual to enroll in that program.
SB12,29,1310 (p) Establish and make available by electronic means a calculator to determine
11the actual cost of coverage after application of any premium tax credit under section
1236B of the Internal Revenue Code and any cost-sharing reduction under section
131402 of the federal act.
SB12,29,1714 (q) Establish a SHOP Exchange through which qualified employers may access
15health care coverage for their employees and which shall enable any qualified
16employer to specify the level of coverage at which its employees may enroll in any
17qualified health plan offered through the SHOP Exchange.
SB12,29,2018 (r) Perform duties required of the authority by the secretary or the federal
19secretary of the treasury related to determining eligibility for premium tax credits,
20reduced cost-sharing, or individual responsibility requirement exemptions.
SB12,29,2421 (s) Select entities, which may include insurance intermediaries, that are
22qualified to serve as navigators in accordance with section 1311 (i) of the federal act
23and standards developed by the secretary, and award grants to enable navigators to
24do all of the following:
SB12,30,2
11. Conduct public education activities to raise awareness of the availability of
2qualified health plans.
SB12,30,63 2. Distribute fair and impartial information concerning enrollment in qualified
4health plans and concerning the availability of premium tax credits under section
536B of the Internal Revenue Code and cost-sharing reductions under section 1402
6of the federal act.
SB12,30,77 3. Facilitate enrollment in qualified health plans.
SB12,30,138 4. Provide referrals to any applicable office of health insurance consumer
9assistance or health insurance ombudsman established under section 2793 of the
10federal Public Health Service Act (42 USC 300gg-93), or to any other appropriate
11state agency or agencies, for any enrollee with a grievance, complaint, or question
12regarding their health benefit plan, coverage, or determination under that plan or
13coverage.
SB12,30,1514 5. Provide information in a manner that is culturally and linguistically
15appropriate to the needs of the population being served by the exchange.
SB12,30,1816 (t) Assist in the coordination of any necessary administrative operations
17between the department of corrections and the department of health services to
18ensure all of the following:
SB12,30,2119 1. That an individual, upon placement in a correctional facility, is disenrolled
20for the duration of his or her incarceration from any health care coverage in which
21he or she is enrolled.
SB12,31,222 2. That an individual who is incarcerated in a correctional facility, but
23scheduled to be released from incarceration in the near future, is enrolled prior to
24release, through the exchange and effective upon the date of his or her release, in

1Medical Assistance, a qualified health plan, or some other form of minimum
2essential coverage on the date of his or her release from incarceration.
SB12,31,83 (u) For those persons whose alcohol or other drug abuse or mental health
4treatment is not covered by a federally administered program, coordinate the
5relationships among the Medical Assistance program, the exchange, and the county
6departments under s. 51.42 or 51.437 to provide outpatient and inpatient mental
7health and alcohol or other drug abuse treatment with all of the following goals for
8the coordination:
SB12,31,109 1. Maximizing coverage and improving access through the exchange for
10outpatient and inpatient treatment of mental illness and alcohol or other drug abuse.
SB12,31,1211 2. Improving the quality of treatment for persons with alcohol or other drug
12dependence or a mental illness.
SB12,31,1413 3. Fully integrating the treatment for physical conditions, alcohol or other drug
14abuse, and mental illness.
SB12,31,1915 4. Reducing the cost of the county departments under ss. 51.42 and 51.437 to
16taxpayers by avoiding unnecessary overlap between the improved coverage of
17alcohol or other drug abuse treatment or mental illness treatment by health plans
18offered through the exchange and the services provided by county departments
19under s. 51.42 or 51.437.
SB12,31,2220 (v) Review the rate of premium growth within the exchange and outside the
21exchange, and consider the information in developing recommendations on whether
22to continue limiting qualified employer status to small employers.
SB12,31,2523 (w) Credit the amount of any free choice voucher to the monthly premium of
24the plan in which a qualified employee is enrolled, in accordance with section 10108
25of the federal act, and collect the amount credited from the offering employer.
SB12,32,2
1(x) Consult with stakeholders relevant to carrying out the activities required
2under this chapter, including any of the following:
SB12,32,33 1. Educated health care consumers who are enrollees in qualified health plans.
SB12,32,54 2. Individuals and entities with experience in facilitating enrollment in
5qualified health plans.
SB12,32,66 3. Representatives of small businesses and self-employed individuals.
SB12,32,77 4. The department of health services.
SB12,32,88 5. Advocates for enrolling hard-to-reach populations.
SB12,32,99 (y) Meet all of the following financial integrity requirements:
SB12,32,1210 1. Keep an accurate accounting of all activities, receipts, and expenditures and
11annually submit to the secretary, the governor, the commissioner, and the legislature
12a report concerning such accountings.
SB12,32,1613 2. Fully cooperate with any investigation conducted by the secretary under the
14secretary's authority under the federal act and allow the secretary, in coordination
15with the inspector general of the federal department of health and human services,
16to do all of the following:
SB12,32,1717 a. Investigate the affairs of the authority.
SB12,32,1818 b. Examine the properties and records of the authority.
SB12,32,2019 c. Require periodic reports in relation to the activities undertaken by the
20authority.
SB12,33,221 3. In carrying out its activities under this chapter, not use any funds intended
22for the administrative and operational expenses of the authority for staff retreats,
23promotional giveaways, excessive executive compensation, or promotion of federal
24or state legislative or regulatory modifications, except that this subdivision does not
25prohibit the authority from advocating, as part of administering the exchange, for

1policies that the authority determines are in the best interest of the exchange or of
2individuals and employees receiving coverage through the exchange.
SB12,33,3 3(2) The authority may do all of the following relating to the exchange:
SB12,33,54 (a) Contract with a 3rd-party administrator for the provision of services on
5behalf of the exchange.
SB12,33,66 (b) Establish risk adjustment mechanisms for the exchange.
SB12,33,77 (c) Enter into agreements with or establish sub-exchanges.
SB12,33,98 (d) Create any other exchange, or component of the exchange, that is provided
9for under federal law.
SB12,33,13 10(3) The authority shall seek grants to the fullest extent to which it is eligible,
11including amounts under section 1311 (a) (1) and (4) of the federal act, or other
12funding from the federal or state government for which it may be eligible and from
13private foundations for the purpose of the exchange.
SB12,33,15 14636.42 Health benefit plan certification. (1) The authority may certify a
15health benefit plan as a qualified health plan if all of the following are true:
SB12,33,1916 (a) The plan provides the essential health benefits package described in section
171302 (a) of the federal act, except that the plan is not required to provide essential
18benefits that duplicate the minimum benefits of qualified dental plans, as provided
19in sub. (5), if all of the following are satisfied:
SB12,33,2120 1. The authority has determined that at least one qualified dental plan is
21available to supplement the plan's coverage.
SB12,33,2522 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.
SB12,34,2
1(b) The premium rates and contract language have been filed with and not
2disapproved by the commissioner.
SB12,34,63 (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.
SB12,34,107 (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.
SB12,34,1111 (e) The health carrier offering the plan satisfies all of the following:
SB12,34,1312 1. Is licensed and in good standing to offer health insurance coverage in this
13state.
SB12,34,1714 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.
SB12,34,2018 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.
SB12,34,2221 4. Does not charge any cancellation fees or penalties in violation of s. 636.25
22(3).
SB12,34,2423 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.
SB12,35,6
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.
SB12,35,97 (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.
SB12,35,11 10(2) The authority shall not exclude a health benefit plan for any of the following
11reasons or in any of the following ways:
SB12,35,1212 (a) On the basis that the plan is a fee-for-service plan.
SB12,35,1313 (b) Through the imposition of premium price controls by the authority.
SB12,35,1614 (c) On the basis that the plan provides treatments necessary to prevent
15patients' deaths in circumstances the authority determines are inappropriate or too
16costly.
SB12,35,18 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:
SB12,35,2519 (a) Submit a justification for any premium increase before implementation of
20that increase. The carrier shall prominently post the information on its Internet site.
21The 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 exchange.
SB12,36,3
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:
SB12,36,44 a. Claims payment policies and practices.
SB12,36,55 b. Periodic financial disclosures.
SB12,36,66 c. Data on enrollment.
SB12,36,77 d. Data on disenrollment.
SB12,36,88 e. Data on the number of claims that are denied.
SB12,36,99 f. Data on rating practices.
SB12,36,1110 g. Information on cost-sharing and payments with respect to any
11out-of-network coverage.
SB12,36,1212 h. Information on enrollee and participant rights under title I of the federal act.
SB12,36,1313 i. Other information as determined appropriate by the secretary.
SB12,36,1514 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.
SB12,36,2216 (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 site and through other means for individuals
22without access to the Internet.
SB12,37,2 23(4) The authority may 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.
SB12,37,6 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.
SB12,37,87 (b) The carrier shall be licensed to offer dental coverage, but need not be
8licensed to offer other health benefits.
SB12,37,149 (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.
SB12,37,1915 (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.
SB12,37,24 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.
SB12,38,3
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.
SB12,38,7 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.
SB12,38,11 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:
SB12,38,1212 (a) Complies with the provisions of this chapter.
SB12,38,1313 (b) Promotes positive health outcomes.
SB12,38,1414 (c) Advances value-based and evidence-based medical practices.
SB12,38,1715 (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.
SB12,38,1818 (e) Holds down the growth of health care costs.
SB12,39,2 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.
SB12,39,7 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.
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