Ins 19.03(1)(1) The commissioner shall request, under s. 601.42, Stats., all eligible health carriers to submit data and information from prior and current benefit years including: compliant plan membership, premium experience at a metal and federally facilitated marketplace status level, advanced premium tax credit enrollee information, and other information as requested by the commissioner.

Ins 19.03(2)(2) The commissioner shall publish the preliminary payment parameters and a public hearing notice in the Wisconsin Administrative Register and to the OCI website. The commissioner shall hold a public hearing seeking public comment regarding the preliminary payment parameters for the subsequent benefit year.

Ins 19.03(3)(3) The commissioner shall set the final payment parameters after consultation with an actuarial firm, consideration of comments received from the public hearing, the goals established in s. 601.83 (2), Stats., and any additional information as appropriate.

Ins 19.03(4)(4) The commissioner shall publish the final payment parameters in the Wisconsin Administrative Register and to the OCI website by May 15 of the calendar year prior to the applicable benefit year.

Ins 19.03 HistoryHistory: CR 19-088: cr. Register November 2021 No. 791, eff. 12-1-21; correction in (4) made under s. 35.17, Stats., Register November 2021 No. 791.

Ins 19.07Ins 19.07 Eligible claims. For claims to be eligible for reinsurance payment, the eligible health carrier shall comply with s. 601.83, Stats., and submit claims that comply with the following criteria:

Ins 19.07(1)(1) The claims that were paid for as covered benefits by the eligible health carrier under the terms and conditions of the carrier’s compliant plan for the applicable benefit year including but not limited to medical, surgical, and prescription drug services and treatments.

Ins 19.07(2)(2) The claims that were paid by the eligible health carrier after January 1, of the applicable benefit year and before April 30, of the following calendar year, or a date established by the commissioner.

Ins 19.07(3)(3) The cumulative amount of the claims paid that exceeds the applicable attachment point. Claims reported shall not include any amount of cost sharing required to be paid by the enrolled individual or the person responsible for the payment of the enrolled individual’s cost sharing. Cost sharing may include any of the following; deductibles, co-insurance, co-payment, visit fees, or similar costs.

Ins 19.07(4)(4) The cumulative amount of paid claims shall be reduced by any reimbursement received by the eligible health carrier for the enrolled individual through subrogation, recoupment of overpayments from providers, application of negotiated rates reductions with providers, or recoupment of third-party payment including workers compensation or civil litigation.

Ins 19.10Ins 19.10 Reporting requirements. All eligible health carriers shall provide all requested information as ordered by the commissioner pursuant to s. 601.42, Stats. Information collected under ss. Ins 19.07 and 19.11 may be used on an aggregate basis by the commissioner to satisfy federal and state reporting requirements. Additional data may be requested to inform federal and state reports including: second lowest cost silver rates by rating area demonstrating rates with and without reinsurance payments, actual average premium rates for compliant plans, and actual enrollment for compliant plans.

Ins 19.10 HistoryHistory: CR 19-088: cr. Register November 2021 No. 791, eff. 12-1-21; correction made under s. 35.17, Stats., Register November 2021 No. 791.

Ins 19.11(1)(1) Eligible health carriers shall provide the information required by this section to the commissioner within 45-days from the end of each financial quarter. The data shall be extracted from the health carrier’s claims systems or similar database that tracks enrolled individual’s claims.

Ins 19.11(2)(2) Each quarterly report shall be transmitted to the commissioner, pursuant to s. 601.42, Stats., through a secure file transfer portal in a format designated by the commissioner. Instructions for submission of required information shall be provided to the eligible health carriers by the commissioner. Information in the report shall include all of the following:

Ins 19.11(2)(d)(d) For each identified enrolled individual, the total amount of eligible claims paid, consistent with s. Ins 19.07.

Ins 19.11(2)(e)(e) The dollar amount of paid claims eligible for reinsurance payment for each identified enrolled individual.

Ins 19.11(3)(3) The eligible health carrier shall use the same enrolled individual’s unique identifier in each quarterly and annual report to the commissioner. For enrolled individuals with claims in more than one quarter, the amounts submitted shall reflect the cumulative dollar amount of eligible claims for that enrolled individual.

Ins 19.11(4)(4) The eligible carrier shall report the information required by sub. (2) (a) and (b), and all applicable information for that reporting quarter even if an eligible health carrier does not have updated or eligible claims to identify.

Ins 19.11(5)(5) All eligible health carriers who submit quarterly reports in accordance with this section shall retain a copy of the data and all supporting claims and enrollment data in an auditable format for 6 years from the last day of the applicable benefit year.

Ins 19.11(6)(6) An authorized representative of the eligible health carrier shall complete an affirmation that the data submitted is accurate, complete, and in compliance with s. Ins 19.07. The affirmation shall be transmitted to the commissioner on the same date as the data file transfer in a format designated by the commissioner. Instructions for submission of required information shall be provided to the eligible health carriers by the commissioner.

Ins 19.12(1)(1) Eligible health carriers shall provide a final annual report to the commissioner by or before May 15 of each calendar year after the applicable benefit year, or a date established by the commissioner. The final annual report shall be completed using data as submitted to CMS through the health carrier’s EDGE server that is compliant with all applicable EDGE server requirements. In the event the EDGE server data is no longer available, the eligible health carrier shall use data extracted from the health carrier’s claims systems or similar database that tracks enrolled insured’s validated claims.