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.
149.14(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).
149.14(3)(r)
(r) Processing charges for blood including, but not limited to, the cost of collecting, testing, fractionating and distributing blood.
149.14(4)
(4) Exclusions. Covered expenses for the coverage under this section shall not include the following:
149.14(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. Breast reconstruction of the affected tissue incident to a mastectomy shall not be considered treatment for cosmetic purposes.
149.14(4)(b)
(b) Care which is primarily for custodial or domiciliary purposes which do not qualify as eligible services under medicare.
149.14(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.
149.14(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.
149.14(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.
149.14(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.
149.14(4)(i)
(i) Routine physical examinations, including routine examinations to determine the need for eyeglasses and hearing aids.
149.14(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.
149.14(4)(L)
(L) Personal supplies or services provided by a hospital or nursing home, or any other nonmedical or nonprescribed supply or service.
149.14(4)(m)
(m) Experimental treatment, as determined by the department.
149.14(4m)
(4m) Payment is payment in full. Except for copayments, coinsurance or deductibles required or authorized under the plan, a provider of a covered service or article shall accept as payment in full for the covered service or article the payment rate determined under
ss. 149.143,
149.144 and
149.15 (3) (e) and may not bill an eligible person who receives the service or article for any amount by which the charge for the service or article is reduced under
s. 149.143,
149.144 or
149.15 (3) (e).
149.14(5)(a)(a) The plan shall offer a deductible in combination with appropriate premiums determined under this chapter 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. 149.165. For eligible persons under
s. 149.165 (2) (a), the deductible shall be $500. For eligible persons under
s. 149.165 (2) (b), the deductible shall be $600. For eligible persons under
s. 149.165 (2) (c), the deductible shall be $700. For eligible persons under
s. 149.165 (2) (d), 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.
149.14(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.
149.14(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.
149.14(5)(d)
(d) Notwithstanding
pars. (a) to
(c), the department 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 department under
s. 149.17 (4).
149.14(6)(a)(a) Except as provided in
par. (b), 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.
149.14(6)(b)1.1. In this paragraph, "eligible individual" means an individual for whom all of the following apply:
149.14(6)(b)1.a.
a. The aggregate of the individual's periods of creditable coverage is 18 months or more.
149.14(6)(b)1.b.
b. The individual's most recent period of creditable coverage was under a group health plan, governmental plan, federal governmental plan or church plan, or under any health insurance offered in connection with any of those plans.
149.14(6)(b)1.c.
c. The individual does not have health insurance and is not eligible for coverage under a group health plan or a state plan under title XIX of the federal Social Security Act or any successor program.
149.14(6)(b)1.d.
d. The individual's most recent period of creditable coverage was not terminated for any reason related to fraud or intentional misrepresentation of material fact or a failure to pay premiums.
