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.
619.16(3)(f)2.
2. In this paragraph "direct and indirect expenses" shall include that portion of the carrier's audited administrative costs, printing, claims administration, management, building overhead expenses, and other actual operating and administrative expenses approved by the board as allocable to the administration of the plan and included in the request for proposals.
619.165
619.165
Reductions in premiums for low-income eligible persons. 619.165(1)(a)(a) The board shall reduce the premiums established by the commissioner under
s. 619.11 in conformity with
ss. 619.14 (5) and
619.17, for the eligible persons and in the manner set forth in
pars. (b) to
(d).
619.165(1)(b)
(b) If the household income, as defined in
s. 71.52 (5) and as determined under
par. (d), of an eligible person is equal to or greater than the first amount and less than the 2nd amount listed in any of the following, the board shall reduce the premium for the eligible person, as established by the commissioner, to the rate shown after the amounts:
619.165(1)(b)1.
1. If equal to or greater than $0 and less than $10,000, to 100% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under the plan.
619.165(1)(b)2.
2. If equal to or greater than $10,000 and less than $14,000, to 106.5% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under the plan.
619.165(1)(b)3.
3. If equal to or greater than $14,000 and less than $17,000, to 115.5% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under the plan.
619.165(1)(b)4.
4. If equal to or greater than $17,000 and less than $20,000, to 124.5% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under the plan.
619.165(1)(d)
(d) The board shall establish and implement the method for determining the household income of an eligible person under
par. (b).
619.165(2)
(2) The board shall direct the administering carrier to collect, under
s. 619.16 (3) (b), from the eligible persons under
sub. (1) the premiums as reduced under
sub. (1) rather than the premiums established by the commissioner.
619.165(3)
(3) The commissioner shall forward to the board moneys received under
s. 20.145 (7) (a) and
(g) in an amount sufficient to reimburse the plan for premium reductions under
sub. (1) and deductible reductions under
s. 619.14 (5) (a).
619.167
619.167
Reductions in premiums for other eligible persons. 619.167(1)(1) The board may use the moneys appropriated under
s. 20.145 (7) (b) to reduce premiums during the fiscal year beginning on July 1, 1996, for eligible persons who do not receive a premium subsidy under
s. 619.165, who have a household income, as defined in
s. 71.52 (5), that is less than $40,000 and who apply to the board for a reduction in their premium.
619.167(2)
(2) If the board reduces premiums under
sub. (1), the board shall direct the administering carrier to collect, under
s. 619.16 (3) (b), from the eligible persons under
sub. (1) the premiums as reduced under
sub. (1) rather than the premiums established by the commissioner.
619.167(3)
(3) The commissioner shall forward to the board moneys appropriated under
s. 20.145 (7) (b) in an amount sufficient to pay for any premium reductions under
sub. (1).
619.167 History
History: 1995 a. 463.
619.17
619.17
Contents of plan. The plan shall include, but is not limited to, the following:
619.17(1)
(1) Subject to
s. 619.14 (5) (a), a rating plan calculated in accordance with generally accepted actuarial principles.
619.17(2)
(2) A schedule of premiums, deductibles and coinsurance payments which complies with all requirements of this subchapter.
619.17(3)
(3) Procedures for applicants and participants to have grievances reviewed by an impartial body.
619.17(4)(a)(a) Cost containment provisions established by the commissioner by rule.
619.175
619.175
Waiver or exemption from provisions prohibited. Except as provided in
s. 619.13 (1) (a), the commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.
619.175 History
History: 1991 a. 39.
619.18
619.18
Chapters 600 to 645 applicable. Except as otherwise provided in this subchapter, the plan shall comply and be administered in compliance with
chs. 600 to
645.
619.18 History
History: 1979 c. 313;
1981 c. 314.
