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. 149.142(1)(a)(a) Except as provided in
par. (b), the department shall establish payment rates for covered expenses that consist of the allowable charges paid under
s. 49.46 (2) for the services and articles provided plus an enhancement determined by the department. The rates shall be based on the allowable charges paid under
s. 49.46 (2), projected plan costs and trend factors. Using the same methodology that applies to medical assistance under
subch. IV of ch. 49, the department shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons.
149.142(1)(b)
(b) The payment rate for a prescription drug shall be the allowable charge paid under
s. 49.46 (2) (b) 6. h. for the prescription drug. Notwithstanding
s. 149.17 (4), the department may not reduce the payment rate for prescription drugs below the rate specified in this paragraph, and the rate may not be adjusted under
s. 149.143 or
149.144.
149.142 History
History: 1999 a. 9;
2001 a. 16.
149.143
149.143
Payment of plan costs. 149.143(1)
(1) The department shall pay or recover the operating costs of the plan from the appropriation under
s. 20.435 (4) (v) and administrative costs of the plan from the appropriation under
s. 20.435 (4) (u). For purposes of determining premiums, insurer assessments and provider payment rate adjustments, the department shall apportion and prioritize responsibility for payment or recovery of plan costs from among the moneys constituting the fund as follows:
149.143(1)(am)
(am) A total of 60% from the following sources, calculated as follows:
149.143(1)(am)1.
1. First, from premiums from eligible persons with coverage under
s. 149.14 (2) (a) set at a rate that is 140% to 150% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan and from eligible persons with coverage under
s. 149.14 (2) (b) set in accordance with
s. 149.14 (5m), including amounts received for premium, deductible, and prescription drug copayment subsidies under
s. 149.144, and from premiums collected from eligible persons with coverage under
s. 149.146 set in accordance with
s. 149.146 (2) (b).
149.143(1)(am)2.
2. Second, from moneys specified under
sub. (2m), to the extent that the amounts under
subd. 1. are insufficient to pay 60% of plan costs.
149.143(1)(am)3.
3. Third, by increasing premiums from eligible persons with coverage under
s. 149.14 (2) (a) to more than the rate at which premiums were set under
subd. 1. but not more than 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan and from eligible persons with coverage under
s. 149.14 (2) (b) by a comparable amount in accordance with
s. 149.14 (5m), including amounts received for premium, deductible, and prescription drug copayment subsidies under
s. 149.144, and by increasing premiums from eligible persons with coverage under
s. 149.146 in accordance with
s. 149.146 (2) (b), to the extent that the amounts under
subds. 1. and
2. are insufficient to pay 60% of plan costs.
149.143(1)(am)4.
4. Fourth, notwithstanding
par. (bm), by increasing insurer assessments, excluding assessments under
s. 149.144, and adjusting provider payment rates, subject to
s. 149.142 (1) (b) and excluding adjustments to those rates under
s. 149.144, in equal proportions and to the extent that the amounts under
subds. 1. to
3. are insufficient to pay 60% of plan costs.
149.143(2)(a)(a) Prior to each plan year, the department shall estimate the operating and administrative costs of the plan and the costs of the premium reductions under
s. 149.165, the deductible reductions under
s. 149.14 (5) (a), and any prescription drug copayment reductions under
s. 149.14 (5) (e) for the new plan year and do all of the following:
149.143(2)(a)1.a.a. Estimate the amount of enrollee premiums that would be received in the new plan year if the enrollee premiums were set at a level sufficient, when including amounts received for premium, deductible, and prescription drug copayment subsidies under
s. 149.144 and from premiums collected from eligible persons with coverage under
s. 149.146 set in accordance with
s. 149.146 (2) (b), to cover 60% of the estimated plan costs for the new plan year.
149.143(2)(a)2.
2. After making the determinations under
subd. 1., by rule set premium rates for the new plan year, including the rates under
s. 149.146 (2) (b), in the manner specified in
sub. (1) (am) 1. and
3. and such that a rate for coverage under
s. 149.14 (2) (a) is approved by the board and is not less than 140% nor more than 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan.
149.143(2)(a)3.
3. By rule set the total insurer assessments under
s. 149.13 for the new plan year by estimating and setting the assessments at the amount necessary to equal the amounts specified in
sub. (1) (am) 4. and
(bm) 1. and notify the commissioner of the amount.
149.143(2)(a)4.
4. By the same rule as under
subd. 3. adjust the provider payment rate for the new plan year, subject to
s. 149.142 (1) (b), by estimating and setting the rate at the level necessary to equal the amounts specified in
sub. (1) (am) 4. and
(bm) 2. and as provided in
s. 149.145.
149.143(2)(b)
(b) In setting the premium rates under
par. (a) 2., the insurer assessment amount under
par. (a) 3. and the provider payment rate under
par. (a) 4. for the new plan year, the department shall include any increase or decrease necessary to reflect the amount, if any, by which the rates and amount set under
par. (a) for the current plan year differed from the rates and amount which would have equaled the amounts specified in
sub. (1) (am) and
(bm) in the current plan year.
149.143(2m)(a)(a) The department shall keep a separate accounting of the difference between the following:
149.143(2m)(a)1.
1. The amount of premiums received in a plan year from all eligible persons, including amounts received for premium, deductible, and prescription drug copayment subsidies.
149.143(2m)(a)2.
2. The amount of premiums, including amounts received for premium, deductible, and prescription drug copayment subsidies, necessary to cover 60% of the plan costs for the plan year.
149.143(2m)(b)
(b) Any amount by which the amount under
par. (a) 1. exceeds the amount under
par. (a) 2. may be used only as follows:
149.143(2m)(b)1.
1. To reduce premiums in succeeding plan years as provided in
sub. (1) (am) 2. For eligible persons with coverage under
s. 149.14 (2) (a), premiums may not be reduced below 140% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan.
149.143(2m)(b)2.
2. For other needs of eligible persons, with the approval of the board.
149.143(2m)(b)3.
3. For distribution to eligible persons, notwithstanding any requirements in this chapter related to setting premium amounts. The department, with the approval of the board and the concurrence of the plan actuary, shall determine the policies, eligibility criteria, methodology, and other factors to be used in making any distribution under this subdivision.
149.143(3)(a)(a) If, during a plan year, the department determines that the amounts estimated to be received as a result of the rates and amount set under
sub. (2) (a) 2. to
4. and any adjustments in insurer assessments and the provider payment rate under
s. 149.144 will not be sufficient to cover plan costs, the department may by rule increase the premium rates set under
sub. (2) (a) 2. for the remainder of the plan year, subject to
s. 149.146 (2) (b) and the maximum specified in
sub. (2) (a) 2., by rule increase the assessments set under
sub. (2) (a) 3. for the remainder of the plan year, subject to
sub. (1) (bm) 1., and by the same rule under which assessments are increased adjust the provider payment rate set under
sub. (2) (a) 4. for the remainder of the plan year, subject to
sub. (1) (bm) 2. and
s. 149.142 (1) (b).
149.143(3)(b)
(b) If the department increases premium rates and insurer assessments and adjusts the provider payment rate under
par. (a) and determines that there will still be a deficit and that premium rates have been increased to the maximum extent allowable under
par. (a), the department may further adjust, in equal proportions, assessments set under
sub. (2) (a) 3. and the provider payment rate set under
sub. (2) (a) 4., without regard to
sub. (1) (bm) but subject to
s. 149.142 (1) (b).
149.143(3m)
(3m) Subject to
s. 149.14 (4m), insurers and providers may recover in the normal course of their respective businesses without time limitation assessments or provider payment rate adjustments used to recoup any deficit incurred under the plan.
149.143(4)
(4) Using the procedure under
s. 227.24, the department may promulgate rules under
sub. (2) or
(3) for the period before the effective date of any permanent rules promulgated under
sub. (2) or
(3), but not to exceed the period authorized under
s. 227.24 (1) (c) and
(2). Notwithstanding
s. 227.24 (1) and
(3), the department is not required to make a finding of emergency.
149.143(5)(a)(a) Annually, no later than April 30, the department shall perform a reconciliation with respect to plan costs, premiums, insurer assessments, and provider payment rate adjustments based on data from the previous calendar year. On the basis of the reconciliation, the department shall make any necessary adjustments in premiums, insurer assessments, or provider payment rates, subject to
s. 149.142 (1) (b), for the fiscal year beginning on the first July 1 after the reconciliation, as provided in
sub. (2) (b).
149.143(5)(b)
(b) Except as provided in
sub. (3) and
s. 149.144, the department shall adjust the provider payment rates to meet the providers' specified portion of the plan costs no more than once annually, subject to
s. 149.142 (1) (b). The department may not determine the adjustment on an individual provider basis or on the basis of provider type, but shall determine the adjustment for all providers in the aggregate, subject to
s. 149.142 (1) (b).
149.143 Cross-reference
Cross Reference: See also ch.
HFS 119, Wis. adm. code.
