2007 - 2008 LEGISLATURE
SENATE SUBSTITUTE AMENDMENT 1,
TO 2007 SENATE BILL 226
October 29, 2007 - Offered by Senator Breske.
SB226-SSA1,1,5 1An Act to repeal 149.14 (2) (c) 2., 149.165 (2) (bc) and 149.165 (4); to renumber
2149.14 (2) (c) 1.; to renumber and amend 149.12 (2) (e) and 149.165 (2) (a);
3to amend 20.435 (4) (jz), 20.435 (4) (jz), 149.14 (3) (intro.), 149.14 (5) (a),
4149.142 (1) and 149.165 (3m); and to create 149.12 (2) (e) 2. and 149.14 (3c) of
5the statutes; relating to: changes to the Health Insurance Risk-Sharing Plan.
Analysis by the Legislative Reference Bureau
Under current law, the Health Insurance Risk-Sharing Plan (HIRSP)
Authority administers HIRSP, which provides health insurance coverage for persons
who are covered under Medicare because they are disabled, persons who have tested
positive for human immunodeficiency virus (HIV), persons who have been refused
coverage, or coverage at an affordable price, in the private health insurance market
because of their mental or physical health condition, and persons who do not
currently have health insurance coverage, but who were covered under certain types
of health insurance coverage (creditable coverage) for at least 18 months in the past.
HIRSP is funded by premiums paid by covered persons, insurer assessments, and
provider payment discounts.
This substitute amendment makes the following changes to HIRSP and the
HIRSP Authority:

1. Currently, to receive payment under HIRSP, all providers of services and
articles must be certified to provide those services and articles under the Medical
Assistance (MA) program. The substitute amendment makes an exception from this
requirement for prescription drugs that are provided by a network of pharmacies
that are approved by the HIRSP Authority Board of Directors. In addition, the
substitute amendment authorizes the HIRSP Authority to certify providers on a
temporary basis to provide services or articles to HIRSP enrollees. These providers
would not be certified to provide services and articles under MA; they would have to
be licensed to provide the services or articles that they are providing to HIRSP
enrollees but not necessarily licensed in this state; and the certification could be done
retroactively after the services or articles were provided.
2. Currently, payments to providers must consist of the allowable charges for
services and articles under MA with an enhancement determined by the HIRSP
Authority. The adjustments must take into account provider discounts. The
substitute amendment requires payments to providers to consist of usual and
customary payment rates, determined by the HIRSP Authority, with adjustments
that take into account provider discounts.
3. Under current law, HIRSP enrollees with incomes below a specified level who
are covered under certain HIRSP coverage options are eligible for premium and
deductible subsidies. The substitute amendment makes all persons with coverage
under HIRSP with incomes below that specified level eligible for the premium and
deductible subsidies.
4. For HIRSP enrollees who receive premium subsidies, current law describes
the amount of the reduction in an enrollee's premium in terms of requiring an
enrollee's regular HIRSP premium to be reduced to a specified percentage of the rate
that a standard risk would be charged under an individual policy providing
substantially the same coverage and deductibles as HIRSP. The substitute
amendment changes the way the premium reduction is described by establishing
discounts, so that an enrollee's regular premium is reduced by a specified percentage
of the premium, such as 30 percent or 20 percent.
5. Under current law, with certain exceptions, anyone who is eligible for certain
types of health care coverage provided by an employer is ineligible for coverage under
HIRSP. The substitute amendment authorizes the HIRSP Authority Board to
specify other exceptions, subject to the approval of the Commissioner of Insurance.
6. Under current law, as enacted by the budget bill, 2007 Wisconsin Act 20, the
amount of any premium subsidy that would have been paid under HIRSP on behalf
of an enrollee who terminates coverage under HIRSP and obtains coverage under an
MA demonstration project providing health care benefits for low-income childless
adults must be transferred to the department of health and family services (DHFS)
for use for that demonstration project. The bill removes the requirement that any
moneys be transferred from HIRSP to DHFS for the MA demonstration project.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB226-SSA1, s. 1
1Section 1. 20.435 (4) (jz) of the statutes, as affected by 2007 Wisconsin Act 20,
2section 392w, is amended to read:
SB226-SSA1,3,73 20.435 (4) (jz) Badger Care cost sharing , and employer penalty assessments ,
4and premium subsidies
. All moneys received from payments under s. 49.665 (5), all
5moneys transferred under s. 149.165 (4),
and all moneys received from penalty
6assessments under s. 49.665 (7) (b) 2. to be used for the Badger Care health care
7program under s. 49.665 and for the demonstration project under s. 49.45 (23).
SB226-SSA1, s. 2 8Section 2 . 20.435 (4) (jz) of the statutes, as affected by 2007 Wisconsin Acts
920
and .... (this act), is amended to read:
SB226-SSA1,3,1610 20.435 (4) (jz) Medical Assistance and Badger Care cost sharing and employer
11penalty assessments.
All moneys received from in cost sharing from medical
12assistance recipients, including
payments under s. 49.665 (5) and, all moneys
13received from penalty assessments under s. 49.665 (7) (b) 2., and 90 percent of all
14moneys received from penalty assessments under s. 49.471 (9) (c)
to be used for the
15Badger Care health care program under s. 49.665 and for the Medical Assistance
16program under subch. IV of ch. 49
.
SB226-SSA1, s. 3 17Section 3. 149.12 (2) (e) of the statutes is renumbered 149.12 (2) (e) 1. and
18amended to read:
SB226-SSA1,3,2219 149.12 (2) (e) 1. No Subject to subd. 2., no person who is eligible for creditable
20coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that is
21provided by an employer on a self-insured basis or through health insurance is
22eligible for coverage under the plan.
SB226-SSA1, s. 4 23Section 4. 149.12 (2) (e) 2. of the statutes is created to read:
SB226-SSA1,4,3
1149.12 (2) (e) 2. The board may specify, subject to the approval of the
2commissioner, other types of coverage provided by an employer that do not render
3a person ineligible for coverage under the plan.
SB226-SSA1, s. 5 4Section 5. 149.14 (2) (c) 1. of the statutes is renumbered 149.14 (2) (c).
SB226-SSA1, s. 6 5Section 6. 149.14 (2) (c) 2. of the statutes is repealed.
SB226-SSA1, s. 7 6Section 7. 149.14 (3) (intro.) of the statutes is amended to read:
SB226-SSA1,4,157 149.14 (3) Covered expenses. (intro.) Covered expenses for coverage under the
8plan shall be the payment rates established by the authority for services provided
9by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Covered
10expenses for coverage under the plan shall also be the payment rates established by
11the authority for, at a minimum, the following services and articles if the service or
12article is prescribed by a physician who is licensed under ch. 448 or in another state
13and who is certified under s. 49.45 (2) (a) 11. and if the service or article, except for
14prescription drugs that are provided by a network of pharmacies approved by the
15board,
is provided by a provider certified under s. 49.45 (2) (a) 11.:
SB226-SSA1, s. 8 16Section 8. 149.14 (3c) of the statutes is created to read:
SB226-SSA1,4,2317 149.14 (3c) Temporary provider certification. Notwithstanding the provider
18licensing and certification requirements under sub. (3) (intro.), for coverage of
19services or articles provided to an eligible person the authority may certify on a
20temporary basis a provider that is not licensed under ch. 446 or 448 but that is
21licensed in another state to provide the service or article, or a provider that is not
22certified under s. 49.45 (2) (a) 11. The certification under this subsection may be
23retroactive.
SB226-SSA1, s. 9 24Section 9. 149.14 (5) (a) of the statutes is amended to read:
SB226-SSA1,5,3
1149.14 (5) (a) The authority shall establish and provide subsidies for
2deductibles paid by eligible persons with coverage under s. 149.14 (2) (a) and
3household incomes specified in s. 149.165 (2) (a) 1. to 5 to (e).
SB226-SSA1, s. 10 4Section 10. 149.142 (1) of the statutes is amended to read:
SB226-SSA1,5,155 149.142 (1) Establishment of rates. The authority shall establish provider
6payment rates for covered expenses that consist of the allowable charges paid under
7s. 49.46 (2)
usual and customary payment rates, as determined by the authority, for
8the services and articles provided plus an enhancement adjustment determined by
9the authority. The rates shall be based on the allowable charges paid under s. 49.46
10(2), projected plan costs, and trend factors. Using the same methodology that applies
11to medical assistance under subch. IV of ch. 49, the authority shall establish hospital
12outpatient per visit reimbursement rates and hospital inpatient reimbursement
13rates that are specific to diagnostically related groups of eligible persons.
The
14adjustments to the usual and customary rates shall be sufficient to cover the portion
15of plan costs specified in s. 149.143 (1) (c) and (2) (b).
SB226-SSA1, s. 11 16Section 11. 149.165 (2) (a) of the statutes is renumbered 149.165 (2) and
17amended to read:
SB226-SSA1,5,2318 149.165 (2) Subject to sub. (3m), if the household income, as defined in s. 71.52
19(5) and as determined under sub. (3), of an eligible person with coverage under s.
20149.14 (2) (a)
is equal to or greater than the first amount and less than the 2nd
21amount listed in any of the following, the authority shall reduce the premium for the
22eligible person to the rate by the percentage of the premium shown after the
23amounts:
SB226-SSA1,6,224 (a) If equal to or greater than $0 and less than $10,000, to 100% of the rate that
25a standard risk would be charged under an individual policy providing substantially

1the same coverage and deductibles as provided under s. 149.14 (2) (a) and (5) (a)
by
2at least 30 percent
.
SB226-SSA1,6,63 (b) If equal to or greater than $10,000 and less than $14,000, to 106.5% of the
4rate that a standard risk would be charged under an individual policy providing
5substantially the same coverage and deductibles as provided under s. 149.14 (2) (a)
6and (5) (a)
by at least 25 percent.
SB226-SSA1,6,107 (c) If equal to or greater than $14,000 and less than $17,000, to 115.5% of the
8rate that a standard risk would be charged under an individual policy providing
9substantially the same coverage and deductibles as provided under s. 149.14 (2) (a)
10and (5) (a)
by at least 20 percent.
SB226-SSA1,6,1411 (d) If equal to or greater than $17,000 and less than $20,000, to 124.5% of the
12rate that a standard risk would be charged under an individual policy providing
13substantially the same coverage and deductibles as provided under s. 149.14 (2) (a)
14and (5) (a)
by at least 15 percent.
SB226-SSA1,6,1815 (e) If equal to or greater than $20,000 and less than $25,000, to 130% of the rate
16that a standard risk would be charged under an individual policy providing
17substantially the same coverage and deductibles as provided under s. 149.14 (2) (a)
18and (5) (a)
by at least 10 percent.
SB226-SSA1, s. 12 19Section 12. 149.165 (2) (bc) of the statutes is repealed.
SB226-SSA1, s. 13 20Section 13. 149.165 (3m) of the statutes is amended to read:
SB226-SSA1,6,2421 149.165 (3m) The authority may approve adjustment of the household income
22dollar amounts listed in sub. (2) (a) 1. to 5. to (e), except for the first dollar amount
23listed in sub. (2) (a) 1., to reflect changes in the consumer price index for all urban
24consumers, U.S. city average, as determined by the U.S. department of labor.
SB226-SSA1, s. 14
1Section 14. 149.165 (4) of the statutes, as created by 2007 Wisconsin Act 20,
2is repealed.
SB226-SSA1, s. 15 3Section 15. Initial applicability.
SB226-SSA1,7,64 (1) Premium discounts. The treatment of sections 149.14 (2) (c) 1. and 2. and
5(5) (a) and 149.165 (2) (a) and (bc) and (3m) of the statutes first applies to policy years
6beginning on January 1, 2008.
SB226-SSA1, s. 16 7Section 16. Effective dates. This act takes effect on the day after publication,
8except as follows:
SB226-SSA1,7,139 (1) Medical Assistance and Badger Care appropriation. The treatment of
10section 20.435 (4) (jz) (by Section 2 ) of the statutes takes effect on the date stated in
11the Wisconsin Administrative Register by the department of health and family
12services under section 49.471 (12) (b) of the statutes, as created by 2007 Wisconsin
13Act 20
, as the implementation date for BadgerCare Plus.
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