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, under
s. 253.05 for maternal and child health services or under
s. 49.686 for the cost of drugs for the treatment of HIV infection or AIDS 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.
149.12 Cross-reference
Cross Reference: See also chs.
HFS 119 and
Ins 8.42, Wis. adm. code.
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.
149.13(4)
(4) Notwithstanding
subs. (1) to
(3), the department, with the agreement of the commissioner, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan.
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, copayment 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 provided in
sub. (4), except as restricted by cost containment provisions under
s. 149.17 (4) and except as reduced by the department under
ss. 149.143 and
149.144, covered expenses for the coverage under this section shall be the payment rates established by the department under
s. 149.142 for the services provided by persons licensed under
ch. 446 and certified under
s. 49.45 (2) (a) 11. Except as provided in
sub. (4), except as restricted by cost containment provisions under
s. 149.17 (4) and except as reduced by the department under
ss. 149.143 and
149.144, covered expenses for the coverage under this section shall also be the payment rates established by the department under
s. 149.142 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, subject to
sub. (4c).
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 that exceeds the payment rate established by the department under
s. 149.142 and reduced under
ss. 149.143 and
149.144 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(4)(n)
(n) Services or drugs for the treatment of infertility, impotence or sterility.
149.14(4c)(a)(a) The department may require a pharmacist or pharmacy that provides a prescription drug to an eligible person to submit a payment claim directly to the plan administrator.
149.14(4c)(b)
(b) The department may limit coverage of prescription drugs under
sub. (3) (d) to those prescription drugs for which payment claims are submitted by pharmacists or pharmacies directly to the plan administrator.
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. 149.142,
149.143 and
149.144 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. 149.142,
149.143 or
149.144.
149.14(5)
(5) Deductibles, copayments, coinsurance, and out-of-pocket limits. 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) 1., the deductible shall be $500. For eligible persons under
s. 149.165 (2) (a) 2., the deductible shall be $600. For eligible persons under
s. 149.165 (2) (a) 3., the deductible shall be $700. For eligible persons under
s. 149.165 (2) (a) 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.
149.14(5)(b)
(b) Except as provided in
pars. (c) and
(e), 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) Except as provided in
par. (e), 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(5)(e)
(e) Subject to
sub. (8) (b), the department may, by rule under
s. 149.17 (4), establish for prescription drug coverage under
sub. (3) (d) copayment amounts, coinsurance rates, and copayment and coinsurance out-of-pocket limits over which the plan will pay 100% of covered costs under
sub. (3) (d). The department may provide subsidies for prescription drug copayment amounts paid by eligible persons under
s. 149.165 (2) (a) 1. to
5. Any copayment amount, coinsurance rate, or out-of-pocket limit established under this paragraph is subject to the approval of the board. Copayments and coinsurance paid by an eligible person under this paragraph are separate from and do not count toward the deductible and covered costs not paid by the plan under
pars. (a) to
(c).
149.14(5m)
(5m) Premium rates. For the coverage required under this section, the premium rates charged to eligible persons with coverage under
sub. (2) (b) shall be determined on the basis of the following factors:
149.14(5m)(a)
(a) A comparison between the average per capita amount of covered expenses paid by the plan in the previous calendar year on behalf of eligible persons with coverage under
sub. (2) (b) and the average per capita amount of covered expenses paid by the plan in the previous calendar year on behalf of eligible persons with coverage under
sub. (2) (a).
149.14(5m)(c)
(c) Other economic factors that the department and the board consider relevant.
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)
(b) An eligible individual who obtains coverage under the plan may not be subject to any preexisting condition exclusion under the plan.
149.14(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.
149.14(7)(b)
(b) The department 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.
149.14(7)(c)
(c) The department 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.
Section 814.03 (3) applies to the department under this paragraph.
149.14(8)
(8) Applicability of medical assistance provisions. 149.14(8)(a)(a) Except as provided in
par. (b), the department may, by rule under
s. 149.17 (4), apply to the plan the same utilization and cost control procedures that apply under rules promulgated by the department to medical assistance under
subch. IV of ch. 49.
149.14(8)(b)
(b) The department may not apply to eligible persons for covered services or articles the same copayments that apply to recipients of medical assistance under
subch. IV of ch. 49 for services or articles covered under that program.
149.14 Cross-reference
Cross Reference: See also s.
HFS 119.12, Wis. adm. code.
149.142
149.142
Provider payment rates.
