SB770: Bill Text

SB770,10,14 (4) Reinsurance payment calculation. (a) The commissioner shall calculate a reinsurance payment with respect to each eligible health carrier's incurred claims costs for an enrolled individual's covered benefits in the applicable benefit year. If the claims costs for an enrolled individual do not exceed the attachment point set under sub. (2), the commissioner may not make a reinsurance payment with respect to that enrollee. If the claims costs for an enrolled individual exceed the attachment point, subject to par. (b), the commissioner shall make a reinsurance payment that is calculated as the product of the coinsurance rate and whichever of the following is less:

SB770,10,15 1. The claims costs minus the attachment point.

SB770,10,16 2. The reinsurance cap minus the attachment point.

SB770,10,22 (b) The commissioner shall ensure that any reinsurance payment made to an eligible health carrier does not exceed the total amount paid by the eligible health carrier for any claim. For purposes of this paragraph, the total amount paid of a claim is the amount paid by the eligible health carrier based upon the allowed amount less any deductible, coinsurance, or copayment paid by another person as of the time the data are submitted or made accessible under sub. (5) (c).

SB770,10,25 (5) Reinsurance payment requests. (a) An eligible health carrier may request reinsurance payments from the commissioner when the eligible health carrier meets the requirements of this subsection and sub. (4).

SB770,11,2 (b) An eligible health carrier shall make any requests for a reinsurance payment in accordance with any requirements established by the commissioner.

SB770,11,8 (c) Each eligible health carrier shall provide the commissioner with access to the data within the dedicated data environment established by the eligible health carrier under the federal risk adjustment program under 42 USC 18063. Each eligible health carrier shall submit to the commissioner attesting to compliance with the dedicated data environments, data requirements, establishment and usage of masked enrollee identification numbers, and data submission deadlines.

SB770,11,11 (d) Each eligible health carrier shall provide the access under par. (c) for each applicable benefit year by April 30 of the calendar year following the end of the applicable benefit year.

SB770,11,17 (e) Each eligible health carrier shall maintain for at least 6 years documents and records, by paper, electronic, or other media, sufficient to substantiate a request for a reinsurance payment made under this section. An eligible health carrier shall make the documents and records available to the commissioner, upon request, for purposes of verification, investigation, audit, or other review of a reinsurance payment request.

SB770,12,2 (f) The commissioner may have an eligible health carrier audited to assess the health carrier's compliance with the requirements of this section. The eligible health carrier shall ensure that its contractors, subcontractors, or agents cooperate with any audit under this paragraph. Within 30 days of receiving notice that an audit results in a proposed finding of material weakness or significant deficiency with respect to compliance with any requirement of this section, the eligible health carrier may provide a response to the proposed finding. Within 60 days of the issuance of a final audit report that includes a finding of material weakness or significant deficiency, the eligible health carrier shall do all of the following:

SB770,12,3 1. Provide a written corrective action plan to the commissioner for approval.

SB770,12,5 2. Implement the corrective action plan under subd. 1. as approved by the commissioner.

SB770,12,7 3. Provide the commissioner with written documentation of the corrective action after implementation.

SB770,12,9 (g) The commissioner may recover from an eligible health carrier any overpayment of reinsurance payments as determined under the audit under par. (f).

SB770,12,12 (h) A health carrier is not eligible to receive a reinsurance payment unless the health carrier agrees not to bring a lawsuit over any delay in reinsurance payments or any reduction in reinsurance payments in accordance with sub. (3) (c).

SB770,12,15 (6) Access to information. Information submitted by an eligible health carrier or obtained by the commissioner for purposes of the healthcare stability plan is proprietary and confidential under s. 601.465.

SB770,8 Section 8. 601.85 of the statutes is created to read:

SB770,12,18 601.85 Accounting, reports, and audits. (1) Accounting. The commissioner shall keep an accounting for each benefit year of all of the following:

SB770,12,20 (a) Funds appropriated for reinsurance payments and administrative and operational expenses.

SB770,12,21 (b) Requests for reinsurance payments received from eligible health carriers.

SB770,12,22 (c) Reinsurance payments made to eligible health carriers.

SB770,12,24 (d) Administrative and operational expenses incurred for the healthcare stability plan.

SB770,13,5 (2) Reports. By November 1 of the calendar year following the applicable benefit year or by 60 days following the final disbursement of reinsurance payments for the applicable benefit year, whichever is later, the commissioner shall make available to the public a report summarizing the healthcare stability plan's operations for each benefit year by posting the summary on the office's Internet site.

SB770,13,9 (3) Legislative auditor. The healthcare stability plan is subject to audit by the legislative audit bureau. The commissioner shall ensure that its contractors, subcontractors, or agents cooperate with any audit of the healthcare stability plan performed by the legislative audit bureau.

SB770,13,13 (4) Required recommendation report. By December 31, 2018, the commissioner shall submit to the governor recommendations on implementing a waiver under s. 601.83 (1) (b), any possible additional waivers to be requested, and any other options to stabilize the individual health care market in this state.

SB770,9 Section 9 . Subchapter VIII (title) of chapter 601 [precedes 601.93] of the statutes is created to read:

SB770,13,16 Chapter 601

SB770,13,17 Subchapter VIII

SB770,13,18 FIRE DEPARTMENT DUES

SB770,10 Section 10 . Subchapter VI (title) of chapter 601 [precedes 601.93] of the statutes is repealed.

SB770,11 Section 11 . Nonstatutory provisions.

SB770,14,4 (1) Payment parameters. For the 2019 benefit year, the commissioner of insurance shall set as payment parameters for the healthcare stability plan under subchapter VII of chapter 601 an attachment point of $50,000, a coinsurance rate of between 50 and 80 percent, and a reinsurance cap of $250,000. The commissioner of insurance may adjust the payment parameters to the extent necessary to secure federal approval of the waiver request under section 601.83 (1) (b) of the statutes. For subsequent benefit years, the commissioner of insurance may adjust the payment parameters in accordance with section 601.83 (2) of the statutes.

SB770,12 Section 12 . Fiscal changes.

SB770,14,9 (1) Lapse from Medical Assistance general purpose revenue appropriation. The secretary of health services shall ensure that there is lapsed to the general fund from the appropriation under section 20.435 (4) (b) of the statutes an amount up to $80,000,000, as determined by the secretary of administration.

SB770,14,10 (End)