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.
619.14(7)(b)
(b) The board has a cause of action against an eligible participant for the recovery of the amount of benefits paid which are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.
619.14(7)(c)
(c) The board is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan.
619.145(1)(1) The board may offer to persons eligible for coverage under
s. 619.12 the opportunity to enroll, on a voluntary basis, in an alternative plan that uses managed care and that the commissioner determines provides benefits that are substantially equivalent to or greater than the benefits provided under the plan. A person who enrolls in an alternative plan under this section is ineligible for coverage under the plan for 12 months after enrolling in the alternative plan.
619.145(2)
(2) An alternative plan that provides coverage under this section to persons eligible for coverage under
s. 619.12 may limit the number of such persons who may enroll in the alternative plan. Any such enrollment limitation may not be based on medical underwriting considerations.
619.145(3)
(3) An alternative plan that provides coverage under this section to persons eligible for coverage under
s. 619.12 shall contract with the board to provide such coverage. The contract shall specify all of the following:
619.145(3)(b)
(b) Requirements for managed care and marketing practices.
619.145(3)(c)
(c) Grievance procedures for persons with coverage under the alternative plan.
619.145(3)(d)
(d) The payment of fees or premiums to the alternative plan for the coverage provided to persons eligible under
s. 619.12.
619.145(3)(e)
(e) Subject to
sub. (4), a reduction in the alternative plan's assessment under
s. 619.13 for operating and administrative, but not subsidy, expenses of the plan.
619.145(3)(f)
(f) Any other terms that the board considers necessary.
619.145(4)
(4) A contract under
sub. (3) may not provide for a reduction in the assessment under
s. 619.13 against an alternative plan unless the assessment reduction has been adopted by rule under
s. 619.15 (4) (e).
619.145 History
History: 1991 a. 269.
619.15
619.15
Board of governors. 619.15(1)(1) The plan shall operate subject to the supervision and approval of a board consisting of representatives of 2 participating insurers which are nonprofit corporations, 2 other participating insurers, and 3 public members, appointed by the commissioner for staggered 3-year terms. In addition, the commissioner or a designated representative from the office of the commissioner shall be a member of the board. The public members shall not be professionally affiliated with the practice of medicine, a hospital or an insurer. At least 2 of the public members shall be individuals reasonably expected to qualify for coverage under the plan or the parent or spouse of such an individual. The commissioner or the commissioner's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.
619.15(2)
(2) Annually, the board shall make a report to the members of the plan and to the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under
s. 13.172 (3), summarizing the activities of the plan in the preceding calendar year. The annual report shall define the cost burden imposed by the plan on all policyholders in this state.
619.15(3)(a)
(a) Establish procedures under which applicants and participants may have grievances reviewed by an impartial body and reported to the board.
619.15(3)(c)
(c) Collect assessments from all insurers to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board. Assessment of the insurers shall occur at the end of each calendar year or other fiscal year end established by the board. Assessments are due and payable within 30 days of receipt by the insurer of the assessment notice.
619.15(3)(d)
(d) Develop and implement a program to publicize the existence of the plan, the eligibility requirements and procedures for enrollment, and to maintain public awareness of the plan.
619.15(3)(e)
(e) Establish for payment of covered expenses, a payment rate that is 10% less than the charges approved by the administering carrier for reimbursement of covered expenses under
s. 619.14 (3). A provider of a covered service or article may not bill an eligible person who receives the service or article for any amount by which the charge is reduced under this paragraph.
619.15(4)(a)
(a) Prepare and distribute certificate of eligibility forms and enrollment instruction forms to insurance solicitors, agents and brokers, and to the general public in this state.
619.15(4)(b)
(b) Provide for reinsurance of risks incurred by the plan, and may enter into reinsurance agreements with insurers to establish a reinsurance plan for risks of coverage described in the plan, or obtain commercial reinsurance to reduce the risk of loss through the pool.
619.15(4)(c)
(c) In addition to assessments imposed under
sub. (3) (c), levy interim assessments to ensure the financial ability of the plan to cover claims expense and administrative expenses incurred or estimated to be incurred in the operation of the plan prior to the end of the calendar year end or other fiscal year end established by the board. Interim assessments shall be due and payable within 30 days of receipt by an insurer of an interim assessment notice. Interim assessments shall be credited against each insurer's annual assessment.
619.15(4)(e)
(e) By rule provide for a reduction in the assessment under
s. 619.13 against an alternative plan that provides coverage to eligible persons.
619.15(5)
(5) The commissioner may, by rule, establish additional powers and duties of the board.
619.15(6)
(6) If any provision of this subchapter conflicts with
s. 625.11 or
625.12, this subchapter prevails.
619.15(7)(a)(a) The board is not liable for any obligation of the plan.
619.16
619.16
Administering carrier. 619.16(1)
(1) The board shall select an insurer through a competitive negotiation process to administer the plan. The board shall evaluate proposals submitted under this subsection based on criteria established by the board which shall include all of the following:
619.16(1)(a)
(a) The insurer's proven ability to handle large group accident and health insurance.
619.16(1)(b)
(b) The efficiency of the insurer's claim paying procedures.
619.16(1)(c)
(c) An estimate of total charges for administering the plan.
619.16(2)(a)(a) The administering carrier shall serve for a period of 3 years.
619.16(2)(b)
(b) At least one year prior to the expiration of each 3-year period of service by an administering carrier, the board shall invite all insurers, including the current administering carrier, to submit proposals to serve as the administering carrier for the succeeding 3-year period. Selection of the administering carrier for the succeeding period shall be made at least 6 months prior to the end of the current 3-year period.
619.16(3)(a)(a) The administering carrier shall perform all eligibility and administrative claims payment functions relating to the plan.
619.16(3)(b)
(b) The administering carrier shall establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the board.
619.16(3)(c)
(c) The administering carrier shall perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
619.16(3)(c)1.
1. Making available information relating to the proper manner of submitting a claim for benefits under the plan and distributing forms upon which submissions shall be made.
619.16(3)(c)2.
2. Evaluating the eligibility of each claim for payment under the plan.
619.16(3)(c)3.
3. Notifying each claimant within 30 days after receiving a properly completed and executed proof of loss whether the claim is accepted, rejected or compromised.
619.16(3)(d)
(d) The administering carrier shall submit regular reports to the board regarding the operation of the plan. The frequency, content and form of the report shall be as determined by the board.
619.16(3)(e)
(e) The administering carrier shall pay claims expenses from the premium payments received from or on behalf of covered persons under the plan. If the administering carrier's payments for claims expenses exceed the portion of premiums allocated by the board for payment of claims expenses, the board shall provide to the carrier additional funds for payment of claims expenses.
619.16(3)(em)
(em) The administering carrier shall make any payments required by a contract entered into under
s. 619.145 (3).
619.16(3)(f)1.1. The administering carrier shall be paid as provided in the board's contract with the carrier for its direct and indirect expenses incurred in the performance of its services from the plan premiums.
