149.146(2)(b)1.
1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under
s. 149.14 (2) (a) and
(5) (a).
149.146(2)(b)2.
2. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as the coverage offered under this section.
149.146 History
History: 1997 a. 27 ss.
4860c,
4860d; Stats. 1997 s. 149.146;
1997 a. 237;
1999 a. 9,
165.
149.15
149.15
Board of governors. 149.15(1)(1) The plan shall have a board of governors consisting of representatives of 2 participating insurers which are nonprofit corporations, representatives of 2 other participating insurers, 3 health care provider representatives, including one representative of the State Medical Society of Wisconsin, one representative of the Wisconsin Health and Hospital Association and one representative of an integrated multidisciplinary health system, and 3 public members, including one representative of small businesses in the state, appointed by the secretary for staggered 3-year terms. In addition, the commissioner, or a designated representative from the office of the commissioner, and the secretary, or a designated representative from the department, shall be members 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 secretary or the secretary's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative and the secretary or the secretary's representative, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.
149.15(2)
(2) Annually, the board shall make a report to the appropriate standing committees under
s. 13.172 (3) and to the members of the plan 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.
149.15(2m)
(2m) Annually, beginning in 1999, the board shall submit a report on or before June 30 to the legislature under
s. 13.172 (2) and to the governor on the operation of the plan, including any recommendations for changes to the plan.
149.15(3)
(3) The board shall do all of the following:
149.15(3)(a)
(a) Establish procedures under which applicants and participants may have grievances reviewed by an impartial body and reported to the board.
149.15(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 as provided under
s. 149.143. 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.
149.15(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.
149.15(3)(g)
(g) Establish oversight committees to address various administrative issues, such as financial management of the plan and plan administrator performance standards. A representative of the department may not be the chairperson of any committee established under this paragraph.
149.15(4)
(4) The board may do any of the following:
149.15(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.
149.15(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.
149.15(5)
(5) The department may, by rule, establish additional powers and duties of the board.
149.15(6)
(6) If any provision of this chapter conflicts with
s. 625.11 or
625.12, this chapter prevails.
149.15(7)(a)(a) The board is not liable for any obligation of the plan.
149.16
149.16
Plan administrator. 149.16(3)(a)(a) The plan administrator shall perform all eligibility and administrative claims payment functions relating to the plan.
149.16(3)(b)
(b) The plan administrator 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 department.
149.16(3)(c)
(c) The plan administrator shall perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
149.16(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.
149.16(3)(c)2.
2. Evaluating the eligibility of each claim for payment under the plan.
149.16(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.
149.16(3)(e)
(e) The plan administrator, under the direction of the department, shall pay claims expenses from the premium payments received from or on behalf of covered persons under the plan. If the plan administrator's payments for claims expenses exceed premium payments, the board shall forward to the department, and the department shall provide to the plan administrator, additional funds for payment of claims expenses.
149.16(4)
(4) The plan administrator shall account for costs related to the plan separately from costs related to medical assistance under
subch. IV of ch. 49.
149.16(5)
(5) The department shall obtain the approval of the board before implementing any contract with the plan administrator.
149.16 History
History: 1997 a. 27 ss.
3030,
3031,
4882 to
4884c,
4886;
1999 a. 9.
149.165
149.165
Reductions in premiums for low-income eligible persons. 149.165(2)(a)(a) Subject to
sub. (3m), if the household income, as defined in
s. 71.52 (5) and as determined under
sub. (3), of an eligible person with coverage under
s. 149.14 (2) (a) is equal to or greater than the first amount and less than the 2nd amount listed in any of the following, the department shall reduce the premium for the eligible person to the rate shown after the amounts:
149.165(2)(a)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
s. 149.14 (2) (a) and
(5) (a).
149.165(2)(a)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
s. 149.14 (2) (a) and
(5) (a).
149.165(2)(a)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
s. 149.14 (2) (a) and
(5) (a).
149.165(2)(a)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
s. 149.14 (2) (a) and
(5) (a).
149.165(2)(a)5.
5. If equal to or greater than $20,000 and less than $25,000, to 130% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under
s. 149.14 (2) (a) and
(5) (a).
149.165(2)(bc)
(bc) Subject to
sub. (3m), if the household income, as defined in
s. 71.52 (5) and as determined under
sub. (3), of an eligible person with coverage under
s. 149.14 (2) (b) is equal to or greater than the first amount and less than the 2nd amount listed in
par. (a) 1.,
2.,
3.,
4. or
5., the department shall reduce the premium established for the eligible person by the same percentage as the department reduces, under
par. (a), the premium established for an eligible person with coverage under
s. 149.14 (2) (a) who has a household income specified in the same subdivision under
par. (a) as the household income of the eligible person with coverage under
s. 149.14 (2) (b).
149.165(3)(a)(a) Subject to
par. (b), the department shall establish and implement the method for determining the household income of an eligible person under
sub. (2).
149.165(3)(b)
(b) In determining household income under
sub. (2), the department shall consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:
149.165(3m)
(3m) The board may approve adjustment of the household income dollar amounts listed in
sub. (2) (a) 1. to
5., except for the first dollar amount listed in
sub. (2) (a) 1., to reflect changes in the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.
149.165(4)
(4) The department shall reimburse the plan for premium reductions under
sub. (2) and deductible reductions under
s. 149.14 (5) (a) with moneys transferred to the fund from the appropriation account under
s. 20.435 (4) (ah).
149.165 History
History: 1985 a. 29;
1987 a. 27;
1987 a. 312 s.
17;
1991 a. 39;
1997 a. 27 ss.
4889 to
4894; Stats. 1997 s. 149.165;
1999 a. 9,
165.
149.17
149.17
Contents of plan. The plan shall include, but is not limited to, the following:
149.17(2)
(2) A schedule of premiums, deductibles, copayments and coinsurance payments that complies with all requirements of this chapter.
149.17(3)
(3) Procedures for applicants and participants to have grievances reviewed by an impartial body.
149.17(4)
(4) Cost containment provisions established by the department by rule, including managed care requirements.
149.175
149.175
Waiver or exemption from provisions prohibited. Except as provided in
s. 149.13 (1), the department may not waive, or authorize the board to waive, any of the requirements of this chapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this chapter.
149.175 History
History: 1991 a. 39;
1997 a. 27 s.
4901; Stats. 1997 s. 149.175.
149.18
149.18
Chapters 600 to 645 applicable. Except as otherwise provided in this chapter, the plan shall comply and be administered in compliance with
chs. 600 to
645.
149.18 History
History: 1979 c. 313;
1981 c. 314;
1997 a. 27 s.
4902; Stats. 1997 s. 149.18.
149.20
149.20
Rule-making in consultation with board. In promulgating any rules under this chapter, the department shall consult with the board.
149.20 History
History: 1997 a. 27.
