AB365-SSA3,39,20 (2) Timing of coverage. The effective date of coverage for a person who terminates coverage under the Medical Assistance program, applies within 45 days of the date of termination for coverage under the plan, and is determined to be eligible under s. 656.12 (1) is the date of termination of Medical Assistance coverage.

AB365-SSA3,40,3 (3) Major medical expense coverage. (a) The plan shall provide every eligible person who is not eligible for the Medicare program under 42 USC 1395 et seq. major medical expense coverage that pays an eligible person's covered expenses, subject to deductible, copayment, and coinsurance payments, up to a lifetime limit per covered individual of $1,000,000 or a higher amount, as determined by the authority. The plan shall provide an alternative policy that reduces the benefits payable under this paragraph by the amounts paid under the Medicare program for those persons eligible for the Medicare program.

AB365-SSA3,40,9 (b) In addition to coverage under par. (a), the plan shall offer to all eligible persons who are not eligible for the Medicare program under 42 USC 1395 et seq. a choice of coverage that includes at least one form of coverage that is comparable to comprehensive health insurance coverage offered in the individual market in this state or that is comparable to a standard option of coverage available under the group or individual health insurance laws of this state.

AB365-SSA3,40,13 (c) An eligible person who is not eligible for the Medicare program under 42 USC 1395 et seq. may elect once each year, at the time and according to the procedures established by the authority, among the coverages offered under pars. (a) and (b).

AB365-SSA3,40,17 (4) Covered services; payment rates. The commissioner shall establish a list, by rule, of acute and primary care services and prescription drugs that are required to be covered by the plan. The authority shall establish criteria for service providers under the plan and payment rates for those providers.

AB365-SSA3,40,19 (5) Plan design. (a) Subject to subs. (1) to (4), (7), and (8), the authority shall do all of the following:

AB365-SSA3,40,22 1. Establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate.

AB365-SSA3,41,2 2. 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.

AB365-SSA3,41,4 (b) The authority may develop additional benefit designs that are responsive to market conditions.

AB365-SSA3,41,7 (6) Deductible and copayment subsidies. (a) The authority shall establish and provide subsidies for deductibles paid by eligible persons with household incomes specified in s. 656.30 (2).

AB365-SSA3,41,9 (b) The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in par. (a).

AB365-SSA3,41,12 (7) Preexisting conditions. (a) The plan may not subject an eligible person who obtains coverage as an enrollee under the plan to any preexisting condition exclusion.

AB365-SSA3,41,15 (b) Upon initial application of an eligible person in the plan before enrollment, the plan shall cover any preexisting condition of the eligible person but the coverage may last no longer than 12 months.

AB365-SSA3,41,23 (8) Coordination of benefits. (a) Covered expenses under the plan may not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage that is 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, the Medicare program, the Medical Assistance program, or any other governmental program, except as otherwise provided by law.

AB365-SSA3,42,2 (b) The authority has a cause of action against an eligible person participating in the plan 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.

AB365-SSA3,42,5 (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.

AB365-SSA3,42,8 656.23 Premiums. (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. 656.27 (1).

AB365-SSA3,42,10 (2) Limitation. In no event may plan premium rates exceed 200 percent of rates applicable to individual standard risks.

AB365-SSA3,42,12 (3) State funds. Any state funds received for premium support shall be used to offset premium costs for persons covered under the plan.

AB365-SSA3,42,18 656.25 Provider payment rates. (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. 656.27 (1) (c) and (2) (b).

AB365-SSA3,42,24 (2) 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).

AB365-SSA3,43,6 656.27 Payment of plan costs. (1) Costs excluding subsidies. The authority shall pay plan costs, excluding any premium, deductible, and copayment subsidies, first from any federal funds under s. 656.10 (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:

AB365-SSA3,43,7 (a) Sixty percent from premiums paid by eligible persons.

AB365-SSA3,43,8 (b) Twenty percent from insurer assessments under s. 656.15.

AB365-SSA3,43,10 (c) Twenty percent from adjustments to provider payment rates under s. 656.25.

AB365-SSA3,43,14 (2) Subsidy costs. The authority shall pay for premium, deductible, and copayment subsidies in a policy year first from any federal funds under s. 656.10 (2) (a) 3. received in that year. The remainder of the subsidy costs shall be paid as follows:

AB365-SSA3,43,15 (a) Fifty percent from insurer assessments under s. 656.15.

AB365-SSA3,43,16 (b) Fifty percent from adjustments to provider payment rates under s. 656.25.

AB365-SSA3,43,19 656.30 Reductions in premiums for low-income eligible persons. (1) Definition. In this section, “household income” means household income, as defined in s. 71.52 (5), and as determined under sub. (3).