149.14(3)(m)
(m) Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth.
149.14(3)(o)
(o) Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat a covered condition.
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) Plan design. Subject to
subs. (1) to
(3),
(5), and
(6), the authority shall establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate. Subject to
subs. (1) to
(3),
(5), and
(6), the authority shall provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state. The authority may develop additional benefit designs that are responsive to market conditions.
149.14(5)
(5) Deductible and copayment subsidies. 149.14(5)(b)
(b) The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in
par. (a).
149.14(6)
(6) Preexisting conditions. 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 authority has a cause of action against an eligible participant for the recovery of the amount of benefits paid that 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 authority 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. .
149.14 Cross-reference
Cross Reference: See also s.
HFS 119.12, Wis. adm. code.
149.141(1)(1)
Percentage of costs. Except as provided in
sub. (2), the authority shall set premium rates for coverage under the plan at a level that is sufficient to cover 60 percent of plan costs, as provided in
s. 149.143 (1).
149.141(2)
(2) Limitation. In no event may plan premium rates exceed 200 percent of rates applicable to individual standard risks.
149.141 History
History: 2005 a. 74.
149.142
149.142
Provider payment rates. 149.142(1)
(1)
Establishment of rates. The authority shall establish provider 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 authority. 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 authority shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons. The adjustments to the usual and customary rates shall be sufficient to cover the portion of plan costs specified in
s. 149.143 (1) (c) and
(2) (b).
149.142(2m)
(2m) 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
sub. (1) 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
sub. (1).
149.142 History
History: 1999 a. 9;
2001 a. 16;
2005 a. 74, ss.
111,
124 to
126.
149.143
149.143
Payment of plan costs. 149.143(1)
(1)
Costs excluding subsidies. The authority shall pay plan costs, excluding any premium, deductible, and copayment subsidies, first from federal funds, if any, that are transferred to the fund under
s. 20.145 (5) (m) and that exceed premium, deductible, and copayment subsidy costs in a policy year. The remainder of the plan costs, excluding premium, deductible, and copayment subsidy costs, shall be paid as follows:
149.143(1)(a)
(a) Sixty percent from premiums paid by eligible persons.
149.143(2)
(2) Subsidy costs. The authority shall pay for premium, deductible, and copayment subsidies in a policy year first from federal funds, if any, that are transferred to the fund under
s. 20.145 (5) (m) in that year. The remainder of the subsidy costs shall be paid as follows:
149.143 Cross-reference
Cross Reference: See also ch.
HFS 119, Wis. adm. code.
149.165
149.165
Reductions in premiums for low-income eligible persons. 149.165(1)(1) The authority shall reduce the premiums established under
s. 149.141 for the eligible persons and in the manner set forth in
subs. (2) and
(3).
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 authority 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 authority shall reduce the premium established for the eligible person by the same percentage as the authority 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 authority 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 authority 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 authority 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(1)
(1) Subject to
s. 149.143, a rating plan calculated in accordance with generally accepted actuarial principles.
149.17(3)
(3) Procedures for applicants and participants to have grievances reviewed by an impartial body.
149.17 Cross-reference
Cross Reference: See also ch.
HFS 119, Wis. adm. code.
149.18
149.18
Chapters 600 to 645 applicable. Except as otherwise provided in this subchapter, 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;
2005 a. 74.
HEALTH INSURANCE RISK-SHARING
PLAN AUTHORITY
149.41
149.41
Creation and organization of authority. 149.41(1)(1) There is created a public body corporate and politic to be known as the "Health Insurance Risk-Sharing Plan Authority." The board of directors of the authority shall consist of the commissioner of insurance, or his or her designee, as a nonvoting member, and the following members, who shall be nominated by the governor, and with the advice and consent of the senate appointed, for 3-year terms:
149.41(1)(a)
(a) Four members who represent insurers participating in the plan.
149.41(1)(b)
(b) Four members who represent health care providers, including one representative of the Wisconsin Medical Society, one representative of the Wisconsin Hospital Association, Inc., one representative of the Pharmacy Society of Wisconsin, and one representative of health care providers that provide services to persons with coverage under the plan.
149.41(1)(c)
(c) Five other members, at least one of whom represents small businesses that purchase private health insurance, one of whom is a professional consumer advocate who is familiar with the plan, and at least 2 of whom are persons with coverage under the plan.
149.41(2)
(2) A vacancy on the board shall be filled in the same manner as the original appointment to the board for the remainder of the unexpired term, if any.
149.41(3)
(3) A member of the board may not be compensated for his or her services but shall be reimbursed for actual and necessary expenses, including travel expenses, incurred in the performance of his or her duties.
149.41(4)
(4) Annually, the governor shall appoint one member other than the commissioner as chairperson, and the members of the board may elect other officers as they consider appropriate. Seven voting members of the board constitute a quorum for the purpose of conducting the business and exercising the powers of the authority, notwithstanding the existence of any vacancy. The board may take action upon a vote of a majority of the members present, unless the bylaws of the authority require a larger number.
149.41(5)
(5) The board may appoint an executive director who shall not be a member of the board and who shall serve at the pleasure of the board. The authority may delegate by resolution to one or more of its members or its executive director any powers and duties that it considers proper. The executive director shall receive such compensation as may be determined by the board. The executive director or other person designated by resolution of the board shall keep a record of the proceedings of the authority and shall be custodian of all books, documents, and papers filed with the authority, the minute book or journal of the authority, and its official seal. The executive director or other person may cause copies to be made of all minutes and other records and documents of the authority and may give certificates under the official seal of the authority to the effect that such copies are true copies, and all persons dealing with the authority may rely upon such certificates.
149.41 History
History: 2005 a. 74.
149.43
149.43
Duties of authority. In addition to all other duties imposed under this chapter, the authority shall do all of the following:
149.43(1)
(1) Adopt policies for the administration of this chapter.
149.43(3)
(3) Establish the authority's annual budget and monitor the fiscal management of the authority.
149.43(4)
(4) Beginning on July 1, 2006, do, or contract with another person to do, all of the following:
149.43(4)(a)
(a) Perform all eligibility and administrative claims payment functions relating to the plan.
149.43(4)(b)
(b) Establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the authority.
149.43(4)(c)
(c) Perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
149.43(4)(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.
149.43(4)(c)2.
2. Evaluating the eligibility of each claim for payment under the plan.
149.43(4)(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.
149.43(5)
(5) Seek to qualify or maintain the plan as a state pharmacy assistance program, as defined in
42 CFR 423.464.
149.43(6)
(6) Annually submit a report to the legislature under
s. 13.172 (2) and to the governor on the operation of the plan.
149.43 History
History: 2005 a. 74.
149.45
149.45
Powers of authority. 149.45(1)(1) Except as restricted under
sub. (2), the authority shall have all the powers necessary or convenient to carry out the purposes and provisions of this chapter. In addition to all other powers granted by this chapter, the authority may:
149.45(1)(a)
(a) Adopt bylaws and policies and procedures for the regulation of its affairs and the conduct of its business.
