149.10(3m)(b)
(b) Subscriber contract charges received for health care coverage.
149.10(3m)(c)
(c) Health maintenance organization, limited service health organization or preferred provider plan charges received for health care coverage.
149.10(3m)(d)
(d) The sum of benefits paid and administrative costs incurred for health care coverage under a medical reimbursement plan.
149.10(4)
(4) "Health insurance" means surgical, medical, hospital, major medical and other health service coverage provided on an expense-incurred basis and fixed indemnity policies. "Health insurance" does not include ancillary coverages such as income continuation, short-term, accident only, credit insurance, automobile medical payment coverage, coverage issued as a supplement to liability coverage, loss of time or accident benefits.
149.10(4m)
(4m) "HIV" means any strain of human immunodeficiency virus, which causes acquired immunodeficiency syndrome.
149.10(4p)(a)1.
1. Risk distributing arrangements providing for compensation of damages or loss through the provision of services or benefits in kind rather than indemnity in money.
149.10(4p)(a)2.
2. Contracts of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction.
149.10(5)
(5) "Insurer" means any person or association of persons, including a health maintenance organization, limited service health organization or preferred provider plan offering or insuring health services on a prepaid basis, including, but not limited to, policies of health insurance issued by a currently licensed insurer, as defined in
s. 600.03 (27), nonprofit hospital or medical service plans under
ch. 613, cooperative medical service plans under
s. 185.981, or other entity whose primary function is to provide diagnostic, therapeutic or preventive services to a defined population in return for a premium paid on a periodic basis. "Insurer" includes any person providing health services coverage for individuals on a self-insurance basis without the intervention of other entities, as well as any person providing health insurance coverage under a medical reimbursement plan to persons. "Insurer" does not include a plan under
ch. 613 which offers only dental care.
149.10(7)
(7) "Medicare" means coverage under both part A and part B of Title XVIII of the federal social security act,
42 USC 1395 et seq., as amended.
149.10(8)
(8) "Plan" means the health care insurance plan established and administered under this chapter.
149.10(8c)
(8c) "Policy" means any document other than a group certificate used to prescribe in writing the terms of an insurance contract, including endorsements and riders and service contracts issued by motor clubs.
149.10(8j)
(8j) "Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage, whether or not the individual received any medical advice or recommendation, diagnosis, care or treatment related to the condition before that date.
149.10(8p)
(8p) "Premium" means any consideration for an insurance policy, and includes assessments, membership fees or other required contributions or consideration, however designated.
149.10(9)
(9) "Resident" means a person who has been legally domiciled in this state for a period of at least 30 days or, with respect to an eligible individual, an individual who resides in this state. For purposes of this chapter, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin or filing a Wisconsin income tax return. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state. A person with a developmental disability or another disability which prevents the person from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in this state by living in this state.
149.10(10)
(10) "Secretary" means the secretary of health and family services.
149.10(11)
(11) "State" means the same as in
s. 990.01 (40) except that it also includes the Panama Canal Zone.
149.10 History
History: 1997 a. 27 ss.
3014 to
3024,
4814,
4817 to
4824; Stats. 1997 s. 149.10.
149.11
149.11
Operation of plan. The department shall promulgate rules for the operation of a plan of health insurance coverage for an eligible person which satisfies the requirements of this chapter.
149.11 History
History: 1979 c. 313;
1997 a. 27 s.
4825; Stats. 1997 s. 149.11.
149.11 Annotation
Employe retirement income security act preempts any state law that relates to employe benefit plans. General Split Corp. v. Mitchell, 523 F Supp. 427 (1981).
149.115 History
History: 1997 a. 27 s.
4825f;
1997 a. 237.
149.12
149.12
Eligibility determination. 149.12(1)
(1) Except as provided in
subs. (1m) and
(2), the board or plan administrator shall certify as eligible a person who is covered by medicare because he or she is disabled under
42 USC 423, a person who submits evidence that he or she has tested positive for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV, a person who is an eligible individual, and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:
149.12(1)(a)
(a) A notice of rejection of coverage from one or more insurers.
149.12(1)(am)
(am) A notice of cancellation of coverage from one or more insurers.
149.12(1)(b)
(b) A notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.
149.12(1)(c)
(c) A notice of increase in premium exceeding the premium then in effect for the insured person by 50% or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.
149.12(1)(d)
(d) A notice of premium for a policy not yet in effect from 2 or more insurers which exceeds the premium applicable to a person considered a standard risk by 50% or more for the types of coverage provided by the plan.
149.12(1m)
(1m) The board or plan administrator may not certify a person as eligible under circumstances requiring notice under
sub. (1) (a) to
(d) if the required notices were issued by an insurance intermediary who is not acting as an administrator, as defined in
s. 633.01.
149.12(2)(b)1.1. Except as provided in
subd. 2., no person who is covered under the plan and who voluntarily terminates the coverage under the plan is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan.
149.12(2)(b)2.
2. Subdivision 1. does not apply to any person who is an eligible individual or to any person who terminates coverage under the plan because he or she is eligible to receive medical assistance benefits.
149.12(2)(c)
(c) No person on whose behalf the plan has paid out $1,000,000 or more is eligible for coverage under the plan.
149.12(2)(d)
(d) Except for a person who is an eligible individual, no person who is 65 years of age or older is eligible for coverage under the plan.
149.12(2)(e)
(e) No person who is eligible for creditable coverage, other than those benefits specified in
s. 632.745 (11) (b) 1. to
12., that is provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.
149.12(2)(f)
(f) No person who is eligible for medical assistance is eligible for coverage under the plan.
149.12(3)(a)(a) Except as provided in
pars. (b) to
(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.
149.12(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.
149.12(3)(bm)
(bm) Persons for whom premium costs for health insurance coverage are subsidized under
s. 252.16 are not ineligible for coverage under the plan by reason of such payments.
149.12(3)(c)
(c) The department 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.
149.125
149.125
Health insurance risk-sharing plan fund. There is created a health insurance risk-sharing plan fund, under the management of the department, to fund administrative expenses.
149.125 History
History: 1981 c. 20;
1983 a. 27;
1991 a. 315;
1997 a. 27 s.
4833; Stats. 1997 s. 149.125.
149.13
149.13
Participation of insurers. 149.13(1)
(1) 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
sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department of the insurers participating in the cost of administering the plan.
149.13(2)
(2) 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.
149.13(3)(a)(a) Each insurer's proportion of participation under
sub. (2) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the department under
s. 149.143 (2) (a) 3.
149.13(3)(b)
(b) If the department or 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 department, the commissioner or the board to carry out the department's, commissioner's or board's responsibilities under this chapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and board to make the determinations required under this chapter.
149.14(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.
149.14(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. 149.12, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.
149.14(2)
(2) Major medical expense coverage. 149.14(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 under this section 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 $1,000,000 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.
149.14(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.
149.14(3)
(3) Covered expenses. Except as restricted by cost containment provisions under
s. 149.17 (4) and except as reduced by the board under
s. 149.15 (3) (e) or by the department under
s. 149.143 or
149.144, covered expenses for the coverage under this section shall be the usual and customary charges for the services provided by persons licensed under
ch. 446 and certified under
s. 49.45 (2) (a) 11. Except as restricted by cost containment provisions under
s. 149.17 (4) and except as reduced by the board under
s. 149.15 (3) (e) or by the department under
s. 149.143 or
149.144, covered expenses for the coverage under this section shall also be the usual and customary charges for the following services and articles if the service or article is prescribed by a physician who is licensed under
ch. 448 or in another state and who is certified under
s. 49.45 (2) (a) 11. and if the service or article is provided by a provider certified under
s. 49.45 (2) (a) 11.:
149.14(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.
149.14(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.
149.14(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:
149.14(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).
149.14(3)(c)3.
3. Subject to the limits under
subd. 2. and to rules promulgated by the department, services for the chronically mentally ill in community support programs operated under
s. 51.421.
149.14(3)(d)
(d) Drugs requiring a physician's prescription.
149.14(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).
149.14(3)(g)
(g) Use of radium or other radioactive materials.
149.14(3)(k)
(k) Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids.
149.14(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.
149.14(3)(o)
(o) Transportation provided by a licensed ambulance service to the nearest facility qualified to treat the condition.
