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) If the plan administrator is the fiscal agent under
s. 49.45 (2) (b) 2., the plan administrator shall account for costs related to the plan separately from costs related to medical assistance.
149.16(5)
(5) The department shall obtain the approval of the board before implementing any contract with the plan administrator.
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 Cross-reference
Cross Reference: See also s.
HFS 119.12, Wis. adm. code.
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.
149.17 Cross-reference
Cross Reference: See also ch.
HFS 119, Wis. adm. code.
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.
149.25
149.25
Case management pilot program. 149.25(1)(a)
(a) "Chronic disease" means any disease, illness, impairment, or other physical condition that requires health care and treatment over a prolonged period and, although amenable to treatment, is irreversible and frequently progresses to increasing disability or death.
149.25(1)(b)
(b) "Health professional shortage area" means an area that is designated by the federal department of health and human services under
42 CFR part 5, appendix A, as having a shortage of medical care professionals.
149.25(2)
(2) Program and eligibility requirements. 149.25(2)(a)(a) The department shall conduct a 3-year pilot program, beginning on July 1, 2002, under which eligible persons who qualify under
par. (b) are provided community-based case management services.
149.25(2)(b)
(b) To be eligible to participate in the pilot program, an eligible person must satisfy any of the following criteria:
149.25(2)(b)2.
2. Be taking 2 or more prescribed medications on a regular basis.
149.25(2)(b)3.
3. Within 6 months of applying for the pilot program, have been treated 2 or more times at a hospital emergency room or have been admitted 2 or more times to a hospital as an inpatient.
149.25(2)(c)1.1. Participation in the pilot program shall be voluntary and limited to no more than 300 eligible persons. The department shall ensure that all eligible persons are advised in a timely manner of the opportunity to participate in the pilot program and of how to apply for participation.
149.25(2)(c)2.
2. If more than 300 eligible persons apply to participate, the department shall select pilot program participants from among those who qualify under
par. (b) according to standards determined by the department, except that the department shall give preference to eligible persons who reside in medically underserved areas or health professional shortage areas.
149.25(3)
(3) Provider organization and services requirements. 149.25(3)(a)(a) The department shall select and contract with an organization to provide the community-based case management services under the pilot program. To be eligible to provide the services, an organization must satisfy all of the following criteria:
149.25(3)(a)1.
1. Be a private, nonprofit, integrated health care system that provides access to health care in a medically underserved area of the state or in a health professional shortage area.
149.25(3)(a)2.
2. Operate an existing community-based case management program with demonstrated successful client and program outcomes.
149.25(3)(a)3.
3. Demonstrate an ability to assemble and coordinate an interdisciplinary team of health care professionals, including physicians, nurses, and pharmacists, for assessment of a program participant's treatment plan.
149.25(3)(b)
(b) The community-based case management services under the pilot program shall be provided by a team, consisting of a nurse case manager, a pharmacist, and a social worker, working in collaboration with the eligible person's primary care physician or other provider. Services to be provided include all of the following:
149.25(3)(b)2.
2. Development of a treatment plan based on best practices.
149.25(3)(b)6.
6. Monitoring and reporting of patient outcomes and costs.
149.25(4)
(4) Evaluation study. The department shall conduct a study that evaluates the pilot program in terms of health care outcomes and cost avoidance. In the study, the department shall measure and compare, for pilot program participants and similarly situated eligible persons not participating in the pilot program, plan costs and utilization of services, including inpatient hospital days, rates of hospital readmission within 30 days for the same diagnosis, and prescription drug utilization. The department shall submit a report on the results of the study, including the department's conclusions and recommendations, to the legislature under
s. 13.172 (2) and to the governor.
149.25 History
History: 2001 a. 16.
