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 usual and customary payment rates, as determined by the authority, for the services and articles provided plus an adjustment determined by the authority. 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).
149.143
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 any federal funds under
s. 149.11 (2) (a) 3. 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 any federal funds under
s. 149.11 (2) (a) 3. received in that year. The remainder of the subsidy costs shall be paid as follows:
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)
(2) 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 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 by the percentage of the premium shown after the amounts:
149.165(2)(a)
(a) If equal to or greater than $0 and less than $10,000, by at least 30 percent.
149.165(2)(b)
(b) If equal to or greater than $10,000 and less than $14,000, by at least 25 percent.
149.165(2)(c)
(c) If equal to or greater than $14,000 and less than $17,000, by at least 20 percent.
149.165(2)(d)
(d) If equal to or greater than $17,000 and less than $20,000, by at least 15 percent.
149.165(2)(e)
(e) If equal to or greater than $20,000 and less than $25,000, by at least 10 percent.
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) to
(e), except for the first dollar amount listed in
sub. (2) (a), 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.
149.17
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.
149.18
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.
149.45(1)(b)
(b) Have a seal and alter the seal at pleasure; have perpetual existence; and maintain an office.
149.45(1)(c)
(c) Hire employees, define their duties, and fix their rate of compensation.
149.45(1)(f)
(f) Appoint any technical or professional advisory committee that the authority finds necessary to assist the authority in exercising its duties and powers. The authority shall define the duties of the committee, and provide reimbursement for the expenses of the committee.
149.45(1)(h)
(h) Accept gifts, grants, loans, or other contributions from private or public sources.
149.45(2)
(2) The authority may not issue bonds.
149.45 History
History: 2005 a. 74.
149.47
149.47
Contracting for professional services. 149.47(1)(1) Whenever contracting for professional services, the authority shall solicit competitive sealed bids or competitive sealed proposals, whichever is appropriate. Each request for competitive sealed proposals shall state the relative importance of price and other evaluation factors.
149.47(2)(a)(a) When the estimated cost exceeds $25,000, the authority may invite competitive sealed bids or proposals by publishing a class 2 notice under
ch. 985 or by posting notice on the Internet at a site determined or approved by the authority. The notice shall describe the contractual services to be purchased, the intent to make the procurement by solicitation of bids or proposals, any requirement for surety, and the date the bids or proposals will be opened, which shall be at least 7 days after the date of the last insertion of the notice or at least 7 days after the date of posting on the Internet.
149.47(2)(b)
(b) When the estimated cost is $25,000 or less, the authority may award the contract in accordance with simplified procedures established by the authority for such transactions.
149.47(2)(c)
(c) For purposes of clarification, the authority may discuss the requirements of the proposed contract with any person who submits a bid or proposal and shall permit any offerer to revise his or her bid or proposal to ensure its responsiveness to those requirements.
149.47(3)(a)(a) The authority shall determine which bids or proposals are reasonably likely to be awarded the contract and shall provide each offerer of such a bid or proposal a fair and equal opportunity to discuss the bid or proposal. The authority may negotiate with each offerer in order to obtain terms that are advantageous to the authority. Prior to the award of the contract, any offerer may revise his or her bid or proposal. The authority shall keep a written record of all meetings, conferences, oral presentations, discussions, negotiations, and evaluations of bids or proposals under this section.
149.47(3)(b)
(b) In opening, discussing, and negotiating bids or proposals, the authority may not disclose any information that would reveal the terms of a competing bid or proposal.
149.47(4)(a)(a) After receiving each offerer's best and final offer, the authority shall determine which proposal is most advantageous and shall award the contract to the person who offered it. The authority's determination shall be based only on price and the other evaluation factors specified in the request for bids or proposals. The authority shall state in writing the reason for the award and shall place the statement in the contract file.
149.47(4)(b)
(b) Following the award of the contract, the authority shall prepare a register of all bids or proposals.
149.47 History
History: 2005 a. 74.
