619.12(2)(d)
(d) No person who is 65 years of age or older is eligible for coverage under the plan.
619.12(2)(e)1.1. Except as provided in
subd. 2., no person who is eligible for health care benefits provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.
619.12(2)(e)2.
2. Subdivision 1. does not apply to a person who is eligible for health care benefits under the small employer health insurance plan under
subch. II of ch. 635 if all of the following apply:
619.12(2)(e)2.a.
a. The person is certified in writing by a physician licensed under
ch. 448 to have a severe and chronic or long-lasting physical or mental illness or disability.
619.12(2)(e)2.b.
b. The board determines that the coverage under the small employer health insurance plan under
subch. II of ch. 635 is not substantially equivalent to or greater than the coverage under the plan.
619.12(2)(e)2.c.
c. The board finds that the person is eligible for coverage under the plan after a review process, determined by the commissioner by rule under
s. 619.123, that evaluates and approves the certification by the physician that the person has a severe and chronic or long-lasting physical or mental illness or disability.
619.12(2)(e)3.
3. The requirements under
sub. (1) (a) to
(d) do not apply to a person who is found eligible for coverage under the plan by the board under
subd. 2.
619.12(3)(a)(a) Except as provided in
pars. (b) and
(c), no person is eligible for coverage under the plan for whom a premium, deductible or coinsurance amount is paid or reimbursed by a federal, state, county or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.
619.12(3)(b)
(b) Persons for whom deductible or coinsurance amounts are paid or reimbursed under
ch. 47 for vocational rehabilitation, under
s. 49.68 for renal disease, under
s. 49.685 (8) for hemophilia, under
s. 49.683 for cystic fibrosis or under
s. 253.05 for maternal and child health services are not ineligible for coverage under the plan by reason of such payments or reimbursements.
619.12(3)(c)
(c) The commissioner, in consultation with the board, may promulgate rules specifying other deductible or coinsurance amounts that, if paid or reimbursed for persons, will not make the persons ineligible for coverage under the plan.
619.123
619.123
Rules for review of physician certification. The commissioner shall promulgate rules that establish the procedure to be used by the board under
s. 619.12 (2) (e) 2. c. The rules shall provide for an insurer that would be affected by the decision of the board to participate in the review process to contest or support the physician's certification.
619.123 History
History: 1991 a. 250.
619.125
619.125
Health insurance risk-sharing plan fund. There is created a health insurance risk-sharing plan fund, under the management of the board, to fund administrative expenses.
619.13
619.13
Participation of insurers. 619.13(1)(a)(a) Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under
par. (b) would be so minimal as to not exceed the estimated cost of levying the assessment.
619.13(1)(b)
(b) Except as provided by a rule promulgated under
s. 619.145 (4), every participating insurer shall share in the operating, administrative and subsidy expenses of the plan in proportion to the ratio of the insurer's total health care coverage revenue for residents of this state during the preceding calendar year to the aggregate health care coverage revenue of all participating insurers for residents of this state during the preceding calendar year, as determined by the commissioner.
619.13(1)(c)
(c) If assessments and other receipts by the commissioner, board or administering carrier exceed payments made to alternative plans in accordance with contracts entered into under
s. 619.145 (3) and the actual losses and administrative expenses of the plan, the excess shall be held at interest and used by the board to offset future losses or to reduce plan premiums. In this paragraph, "future losses" includes reserves for incurred but not reported claims.
619.13(1)(d)1.1. Each insurer's proportion of participation under
par. (b) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner.
619.13(1)(d)2.
2. If the commissioner finds that the commissioner's authority to require insurers to report under
chs. 600 to
646 and
655 is not adequate to permit the commissioner or the board to carry out the commissioner's or the board's responsibilities under this subchapter, the commissioner may promulgate rules requiring insurers to report the information necessary for the commissioner and the board to make the determinations required under this subchapter.
619.13(2)
(2) Any deficit incurred under the plan shall be recouped by assessments apportioned under
sub. (1) by the board among participating insurers, who may recover these amounts in the normal course of their respective businesses without time limitation.
619.135
619.135
Insurer assessments for premium and deductible reductions. 619.135(1)(a)(a) Whenever a person becomes eligible for and obtains coverage under the plan as a result of receiving a notice under
s. 619.12 (1) (am),
(b) or
(c), the commissioner shall levy an assessment of $1,750 against the insurer that issued the notice, except that the commissioner may not levy an assessment if the notice of cancellation under
s. 619.12 (1) (am) was issued on one of the permissible grounds under
s. 631.36 (2) (a).
619.135(1)(b)
(b) An insurer shall pay an assessment levied under
par. (a) within 30 days after receiving a notice of assessment.
619.135(1)(c)
(c) If an assessment levied under
par. (a) is not paid within the time prescribed, the commissioner shall impose a penalty against the insurer in an amount established by the commissioner by rule.
619.135(1)(d)
(d) All assessments and penalties collected under this subsection shall be credited to the appropriation under
s. 20.145 (7) (g).
619.135(2)
(2) If the moneys under
s. 20.145 (7) (a) and
(g) are insufficient to reimburse the plan for premium reductions under
s. 619.165 and deductible reductions under
s. 619.14 (5) (a), or the commissioner determines that the moneys under
s. 20.145 (7) (a) and
(g) will be insufficient to reimburse the plan for premium reductions under
s. 619.165 and deductible reductions under
s. 619.14 (5) (a), the commissioner shall, by rule, increase the amount of the assessment under
sub. (1) (a) or levy an assessment against every insurer, or a combination of both, sufficient to reimburse the plan for premium reductions under
s. 619.165 and deductible reductions under
s. 619.14 (5) (a).
619.135(3)
(3) In addition to the assessments under
subs. (1) (a) and
(2), the commissioner may, by rule, establish an assessment to be levied against each insurer that issues a notice of rejection under
s. 619.12 (1) (a) to a person who becomes eligible for and obtains coverage under the plan as a result of receiving the notice. Any assessments levied and collected under this subsection shall be credited to the appropriation under
s. 20.145 (7) (g).
619.135 History
History: 1991 a. 39.
619.14(1)(a)(a) The plan shall offer in an annually renewable policy the coverage specified in this section for each eligible person. If an eligible person is also eligible for medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by medicare.
619.14(1)(b)
(b) If an individual terminates medical assistance coverage and applies for coverage under the plan within 45 days after the termination and is subsequently found to be eligible under
s. 619.12, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.
619.14(2)
(2) Major medical expense coverage. 619.14(2)(a)(a) The plan shall provide every eligible person who is not eligible for medicare with major medical expense coverage. Major medical expense coverage offered under the plan shall pay an eligible person's covered expenses, subject to
sub. (3) and deductible and coinsurance payments authorized under
sub. (5), up to a lifetime limit of $500,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.
619.14(2)(b)
(b) The plan shall provide an alternative policy for those persons eligible for medicare which reduces the benefits payable under
par. (a) by the amounts paid under medicare.
619.14(3)
(3) Covered expenses. Except as restricted by cost containment provisions under
s. 619.17 (4) and except as reduced by the board under
s. 619.15 (3) (e), covered expenses shall be the usual and customary charges for the services provided by persons licensed under
ch. 446. Except as restricted by cost containment provisions under
s. 619.17 (4) and except as reduced by the board under
s. 619.15 (3) (e), covered expenses shall also be the usual and customary charges for the following services and articles when prescribed by a physician licensed under
ch. 448 or in another state:
619.14(3)(b)
(b) Basic medical-surgical services, including both in-hospital and out-of-hospital medical and surgical services, diagnostic services, anesthesia services and consultation services, subject to the limitations in this subsection.
619.14(3)(c)1.1. Inpatient treatment in a hospital as defined in
s. 632.89 (1) (c) or in a medical facility in another state approved by the board, for up to 30 days' confinement per calendar year due to alcoholism or drug abuse and up to 60 days' confinement per calendar year for nervous and mental disorders.
619.14(3)(c)2.
2. Outpatient services as defined in
s. 632.89 (1) (e) for alcoholism, drug abuse or nervous and mental disorders, as follows:
619.14(3)(c)2.b.
b. An additional $2,500 of covered expenses per calendar year, after satisfaction of the deductible and coinsurance requirements under
sub. (5).
619.14(3)(c)3.
3. Subject to the limits under
subd. 2. and to rules promulgated by the commissioner, services for the chronically mentally ill in community support programs operated under
s. 51.421.
619.14(3)(d)
(d) Drugs requiring a physician's prescription.
619.14(3)(e)
(e) Services of a licensed skilled nursing facility for eligible persons eligible for medicare, to the extent required by
s. 632.895 (3) and for not more than an aggregate 120 days during a calendar year, if the services are of the type which would qualify as reimbursable services under medicare. Coverage under this paragraph which is not required by
s. 632.895 (3) is subject to the deductible and coinsurance requirements under
sub. (5).
619.14(3)(g)
(g) Use of radium or other radioactive materials.
619.14(3)(k)
(k) Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids.
619.14(3)(m)
(m) Oral surgery for partially or completely unerupted, impacted teeth and oral surgery with respect to tissues of the mouth when not performed in connection with the extraction or repair of teeth.
619.14(3)(o)
(o) Transportation provided by a licensed ambulance service to the nearest facility qualified to treat the condition.
619.14(3)(p)
(p) For persons not eligible for medicare, services of a licensed skilled nursing facility, only to the extent required by
s. 632.895 (3).
619.14(3)(r)
(r) Processing charges for blood including, but not limited to, the cost of collecting, testing, fractionating and distributing blood.
619.14(4)
(4) Exclusions. Covered expenses shall not include the following:
619.14(4)(a)
(a) Any charge for treatment for cosmetic purposes other than surgery for the repair or treatment of an injury or a congenital bodily defect.
619.14(4)(b)
(b) Care which is primarily for custodial or domiciliary purposes which do not qualify as eligible services under medicare.
619.14(4)(c)
(c) Any charge for confinement in a private room to the extent it is in excess of the institution's charge for its most common semiprivate room, unless a private room is prescribed as medically necessary by a physician. If the institution does not have semiprivate rooms, its most common semiprivate room charge shall be 90% of its lowest private room charge.
619.14(4)(d)
(d) That part of any charge for services or articles rendered or prescribed by a physician, dentist or other health care personnel which exceeds the prevailing charge in the locality where the service is provided or any charge not medically necessary.
619.14(4)(e)
(e) Any charge for services or articles the provision of which is not within the scope of authorized practice of the institution or individual providing the services or articles.
619.14(4)(f)
(f) Any expense incurred prior to the effective date of coverage under the plan for the person on whose behalf the expense is incurred.
619.14(4)(i)
(i) Routine physical examinations, including routine examinations to determine the need for eyeglasses and hearing aids.
619.14(4)(k)
(k) Services of blood donors and any fee for failure to replace the first 3 pints of blood provided to an eligible person each calendar year.
619.14(4)(L)
(L) Personal supplies or services provided by a hospital or nursing home, or any other nonmedical or nonprescribed supply or service.
619.14(4)(m)
(m) Experimental treatment, as determined by the board or its designee.
619.14(5)
(5) Premiums, deductibles and coinsurance. 619.14(5)(a)(a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter for major medical expense coverage required under this section. For coverage offered to those persons eligible for medicare, the plan shall offer a deductible equal to the deductible charged by part A of title XVIII of the federal social security act, as amended. The deductible amounts for all other eligible persons shall be dependent upon household income as determined under
s. 619.165. For eligible persons under
s. 619.165 (1) (b) 1., the deductible shall be $500. For eligible persons under
s. 619.165 (1) (b) 2., the deductible shall be $600. For eligible persons under
s. 619.165 (1) (b) 3., the deductible shall be $700. For eligible persons under
s. 619.165 (1) (b) 4., the deductible shall be $800. For all other eligible persons who are not eligible for medicare, the deductible shall be $1,000. With respect to all eligible persons, expenses used to satisfy the deductible during the last 90 days of a calendar year shall also be applied to satisfy the deductible for the following calendar year. The schedule of premiums shall be promulgated by rule by the commissioner. The commissioner shall set rates at 60% of the operating and administrative costs of the plan.
619.14(5)(b)
(b) Except as provided in
par. (c), if the covered costs incurred by the eligible person exceed the deductible for major medical expense coverage in a calendar year, the plan shall pay at least 80% of any additional covered costs incurred by the person during the calendar year.
619.14(5)(c)
(c) If the aggregate of the covered costs not paid by the plan under
par. (b) and the deductible exceeds $500 for an eligible person receiving medicare, $2,000 for any other eligible person during a calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100% of all covered costs incurred by the eligible person during the calendar year after the payment ceilings under this paragraph are exceeded.
619.14(5)(d)
(d) Notwithstanding
pars. (a) to
(c), the board may establish different deductible amounts, a different coinsurance percentage and different covered costs and deductible aggregate amounts from those specified in
pars. (a) to
(c) in accordance with cost containment provisions established by the commissioner under
s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under
s. 619.145.
619.14(5)(e)
(e) Using the procedure under
s. 227.24, the commissioner may promulgate rules under
par. (a) for the schedule of premiums for the period before the effective date of any permanent rules promulgated under
par. (a) for the schedule of premiums, but not to exceed the period authorized under
s. 227.24 (1) (c) and
(2). Notwithstanding
s. 227.24 (1) and
(3), the commissioner is not required to make a finding of emergency.
619.14(6)
(6) Preexisting conditions. No person who obtains coverage under the plan may be covered for any preexisting condition during the first 6 months of coverage under the plan if the person was diagnosed or treated for that condition during the 6 months immediately preceding the filing of an application with the plan.
619.14(7)(a)(a) Covered expenses under the plan shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care insurance, medicare, medical assistance or any other governmental program, except as otherwise provided by law.
