AB840,4,32 25.55 (3) Insurer and drug manufacturer and labeler assessments under ch.
3149.

AB840,4,85 49.475 (2) (a) (intro.) Information that the department needs to identify
6beneficiaries of medical assistance, and persons applying for coverage or who are
7covered under the Health Insurance Risk-Sharing Plan under ch. 149, who satisfy
8any of the following:

AB840,4,1210 149.10 (3) "Eligible person" means a resident of this state who qualifies under
11s. 149.12 whether or not the person is legally responsible for the payment of medical
12expenses incurred on the person's behalf.

AB840,5,214 149.10 (5f) "Labeler" means a person that receives prescription drugs from a
15manufacturer or wholesaler and repackages those drugs for later retail sale and that

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1has a labeler code issued by the federal food and drug administration under 21 CFR
2207.20 (b).

AB840,5,64 149.10 (5r) "Manufacturer" means a person engaged in the production,
5preparation, propagation, compounding, conversion, or processing of prescription
6drugs.

AB840,5,13 8149.11 Operation of plan. The department board shall promulgate rules for
9the design and operation of a plan of health insurance coverage for an eligible person
10which persons that satisfies the requirements of this chapter. The board shall
11consult with the department as necessary in promulgating the rules under this
12section. The department shall provide the board with the support necessary for the
13board to carry out its responsibilities under this chapter.

AB840,5,19 15149.115 Rules relating to creditable coverage. The commissioner, in
16consultation with the department and the board, shall promulgate rules that specify
17how creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that
18determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The
19rules shall comply with section 2701 (c) of P.L. 104-191.

AB840,5,2121 149.12 (1) (a) A notice of rejection of coverage from one 2 or more insurers.

AB840,5,2423 149.12 (1) (am) A notice of rejection of coverage from one or more insurers and
24a notice of cancellation of coverage from one or more insurers.

AB840,6,5

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1149.12 (1) (b) A notice of rejection of coverage from one or more insurers and
2a notice of reduction or limitation of coverage, including restrictive riders, from an
3insurer if the effect of the reduction or limitation is to substantially reduce coverage
4substantially compared to the coverage available to a person considered a standard
5risk for the type of coverage provided by the plan.

AB840,6,107 149.12 (1) (c) A notice of rejection of coverage from one or more insurers and
8a notice of increase in premium exceeding the premium then in effect for the insured
9person by 50% 50 percent or more, unless the increase applies to substantially all of
10the insurer's health insurance policies then in effect.

AB840,6,1412 149.12 (3) (c) The department board may promulgate rules specifying other
13deductible or coinsurance amounts that, if paid or reimbursed for persons, will not
14make the persons ineligible for coverage under the plan.

AB840,6,21 16149.125 Employment verification; maintenance of data; report. (1) In
17determining a person's initial and continued eligibility, the department shall verify,
18at the time that the person applies for coverage and periodically thereafter,
19information submitted by the person about his or her employment and whether
20creditable coverage is available to the person. The department shall use information
21obtained under s. 49.475 for verification purposes under this subsection.

AB840,6,25 22(2) The department shall maintain and regularly update a computer data base
23with information about eligible persons that includes employment status and
24economic and demographic information. The department shall submit a quarterly
25report to the board on the information contained in the data base.

AB840,7,62 149.13 (1) Every insurer shall participate in the cost of administering the plan,
3except that the commissioner may by rule exempt as a class those insurers whose
4share as determined under sub. (2) would be so minimal as to not to exceed the
5estimated cost of levying the assessment. The commissioner shall advise the
6department board of the insurers participating in the cost of administering the plan.

AB840,7,128 149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be
9determined annually by the commissioner based on annual statements and other
10reports filed by the insurer with the commissioner. The commissioner shall assess
11an insurer for the insurer's proportion of participation based on the total
12assessments estimated by the department board under s. 149.143 (2) (a) 3.

AB840,7,1913 (b) If the department or the, commissioner, or board finds that the
14commissioner's authority to require insurers to report under chs. 600 to 646 and 655
15is not adequate to permit the department, the commissioner, or the board to carry out
16the department's, commissioner's, or board's responsibilities under this chapter, the
17commissioner shall promulgate rules requiring insurers to report the information
18necessary for the department, commissioner, and board to make the determinations
19required under this chapter.

AB840,7,2421 149.13 (4) Notwithstanding subs. (1) to (3), the department, with the
22agreement of the commissioner and the board, may perform various administrative
23functions related to the assessment of insurers participating in the cost of
24administering the plan.

AB840,8,8

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1149.132 Participation of manufacturers and labelers. (1) As a condition
2of coverage under the plan of the prescription drugs of a manufacturer or labeler, the
3manufacturer or labeler shall pay an assessment on the total claims that the plan
4paid, in the previous calendar year, to pharmacists and pharmacies for the
5prescription drugs of the manufacturer or labeler. The assessment amount per claim
6shall be equal to the rebate paid under the Medical Assistance program by the
7manufacturer or labeler for the prescription drug that is the subject of the claim, not
8including any rebate under s. 49.45 (49m) (c) 2.

AB840,8,13 9(2) The plan administrator shall notify each manufacturer and each labeler of
10the amount paid by the plan in claims for the prescription drugs of each
11manufacturer and labeler and shall advise the board and the department of the
12amounts. The department shall levy and collect the assessments and deposit the
13amounts collected in the health insurance risk-sharing plan fund.

AB840,9,316 149.14 (3) Covered expenses. Except as provided in sub. (4), except as
17restricted by cost containment provisions under s. 149.17 (4) and except as reduced
18by the department board under ss. 149.143 and 149.144, covered expenses for the
19coverage under this section shall be the payment rates established by the
20department under s. 149.142 for the services provided by persons licensed under ch.
21446 and certified under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as
22restricted by cost containment provisions under s. 149.17 (4) and except as reduced
23by the department board under ss. 149.143 and 149.144, covered expenses for the
24coverage under this section shall also be the payment rates established by the
25department under s. 149.142 for the following services and articles specified by the

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1board if the service or article is prescribed by a physician who is licensed under ch.
2448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service
3or article is provided by a provider certified under s. 49.45 (2) (a) 11.:

AB840,9,128 149.14 (5) (d) Notwithstanding pars. (a) to (c), the department board may
9establish different deductible amounts, a different coinsurance percentage, and
10different covered costs and deductible aggregate amounts from those specified in
11pars. (a) to (c) in accordance with cost containment provisions established by the
12department board under s. 149.17 (4).

AB840,9,2515 149.14 (5) (e) Subject to sub. (8) (b), the department board may, by rule under
16s. 149.17 (4), establish for prescription drug coverage under sub. (3) (d) this section
17copayment amounts, coinsurance rates, and copayment and coinsurance
18out-of-pocket limits over which the plan will pay 100% 100 percent of covered costs
19under sub. (3) (d) for prescription drugs. The department board may provide
20subsidies for prescription drug copayment amounts paid by eligible persons under
21s. 149.165 (2) (a) 1. to 5. Any copayment amount, coinsurance rate, or out-of-pocket
22limit established under this paragraph is subject to the approval of the board.
23Copayments and coinsurance paid by an eligible person under this paragraph are
24separate from and do not count toward the deductible and covered costs not paid by
25the plan under pars. (a) to (c).

AB840,10,32 149.14 (5m) (c) Other economic factors that the department and the board
3consider considers relevant.

AB840,10,85 149.14 (7) (b) The department board has a cause of action against an eligible
6participant person for the recovery of the amount of benefits paid which that are not
7for covered expenses under the plan. Benefits under the plan may be reduced or
8refused as a setoff against any amount recoverable under this paragraph.

AB840,10,129 (c) The department board is subrogated to the rights of an eligible person to
10recover special damages for illness or injury to the person caused by the act of a 3rd
11person to the extent that benefits are provided under the plan. Section 814.03 (3)
12applies to the department board under this paragraph.

AB840,10,1914 149.14 (8) Applicability of medical assistance provisions. (a) Except as
15provided in par. (b), the department board may, by rule under s. 149.17 (4), apply to
16the plan the same utilization and cost control procedures that apply under rules
17promulgated by the department to medical assistance under subch. IV of ch. 49. The
18board shall consult with the department as necessary in the application of the
19utilization and cost control procedures specified in this paragraph.

AB840,10,2220 (b) The department board may not apply to eligible persons for covered services
21or articles the same copayments that apply to recipients of medical assistance under
22subch. IV of ch. 49 for services or articles covered under that program.

AB840,11,824 149.142 (1) (a) Except as provided in par. (b), the department board shall
25establish payment rates for covered expenses that consist of the allowable charges

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1paid under s. 49.46 (2) for the services and articles provided plus an enhancement
2determined by the department board. The rates shall be based on the allowable
3charges paid under s. 49.46 (2), projected plan costs, and trend factors. Using the
4same methodology that applies to medical assistance under subch. IV of ch. 49, the
5department board shall establish hospital outpatient per visit reimbursement rates
6and hospital inpatient reimbursement rates that are specific to diagnostically
7related groups of eligible persons. The board shall consult with the department in
8establishing the payment and reimbursement rates under this paragraph.

AB840,11,139 (b) The payment rate for a prescription drug shall be the allowable charge paid
10under s. 49.46 (2) (b) 6. h. for the prescription drug. Notwithstanding s. 149.17 (4),
11the department board may not reduce the payment rate for prescription drugs below
12the rate specified in this paragraph, and the rate may not be adjusted under s.
13149.143 or 149.144.

AB840,11,1915 149.142 (3) Whenever a claim is processed for payment, the adjustment of a
16provider's payment rate under sub. (1) and any adjustment under s. 149.143 or
17149.144 shall be calculated and applied on a per-claim basis. The adjustment shall
18be disclosed on the explanation-of-benefits form provided to the eligible person and
19to the provider.

AB840,12,221 149.143 (1) (intro.) The department shall pay or recover the operating costs of
22the plan from the appropriation under s. 20.435 (4) (v) and administrative costs of
23the plan from the appropriation under s. 20.435 (4) (u). For purposes of determining
24premiums, insurer assessments, and provider payment rate adjustments, the

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1department board shall apportion and prioritize responsibility for payment or
2recovery of plan costs from among the moneys constituting the fund as follows:

AB840,12,65 149.143 (1) (am) A total of 60% 60 percent from the following sources,
6calculated as follows:

AB840,12,157 1. First, from premiums from eligible persons with coverage under s. 149.14 (2)
8(a) set at a rate that is 140% 140 percent to 150% 150 percent of the rate that a
9standard risk would be charged under an individual policy providing substantially
10the same coverage and deductibles cost-sharing provisions as are provided under
11the plan and from eligible persons with coverage under s. 149.14 (2) (b) set in
12accordance with s. 149.14 (5m), including amounts received for premium, deductible,
13and prescription drug copayment subsidies under s. 149.144, and from premiums
14collected from eligible persons with coverage under s. 149.146 set in accordance with
15s. 149.146 (2) (b).

AB840,12,1716 2. Second, from moneys specified under sub. (2m), to the extent that the
17amounts under subd. 1. are insufficient to pay 60% 60 percent of plan costs.

AB840,13,318 3. Third, by increasing premiums from eligible persons with coverage under s.
19149.14 (2) (a) to more than the rate at which premiums were set under subd. 1. but
20not more than 200% 200 percent of the rate that a standard risk would be charged
21under an individual policy providing substantially the same coverage and
22deductibles cost-sharing provisions as are provided under the plan and from eligible
23persons with coverage under s. 149.14 (2) (b) by a comparable amount in accordance
24with s. 149.14 (5m), including amounts received for premium, deductible, and
25prescription drug copayment subsidies under s. 149.144, and by increasing

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1premiums from eligible persons with coverage under s. 149.146 in accordance with
2s. 149.146 (2) (b), to the extent that the amounts under subds. 1. and 2. are
3insufficient to pay 60% 60 percent of plan costs.

AB840,13,84 4. Fourth, notwithstanding par. (bm), by increasing insurer assessments,
5excluding assessments under s. 149.144, and adjusting provider payment rates,
6subject to s. 149.142 (1) (b) and excluding adjustments to those rates under s.
7149.144, in equal proportions and to the extent that the amounts under subds. 1. to
83. are insufficient to pay 60% 60 percent of plan costs.

AB840,13,1111 149.143 (1) (bm) (intro.) A total of 40% 40 percent as follows:

AB840,13,1615 149.143 (1) (bm) 1m. First, from manufacturer and labeler assessments under
16s. 149.132.

AB840,13,2020 149.143 (1) (bm) 2m. (intro.) The remainder as follows:

AB840,14,223 149.143 (2) (a) (intro.) Prior to each plan year, the department board shall
24estimate the operating and administrative costs of the plan and the costs of the
25premium reductions under s. 149.165 (2) and (3), the deductible reductions under s.

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1149.14 (5) (a), and any prescription drug copayment reductions under s. 149.14 (5)
2(e) for the new plan year and do all of the following:

AB840,14,105 149.143 (2) (a) 1. a. Estimate the amount of enrollee premiums that would be
6received in the new plan year if the enrollee premiums were set at a level sufficient,
7when including amounts received for premium, deductible, and prescription drug
8copayment subsidies under s. 149.144 and from premiums collected from eligible
9persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to
10cover 60% 60 percent of the estimated plan costs for the new plan year.

AB840,14,1913 149.143 (2) (a) 2. After making the determinations under subd. 1., by rule set
14premium rates for the new plan year, including the rates under s. 149.146 (2) (b), in
15the manner specified in sub. (1) (am) 1. and 3. and such that a rate for coverage under
16s. 149.14 (2) (a) is approved by the board and is not less than 140% 140 percent nor
17more than 200% 200 percent of the rate that a standard risk would be charged under
18an individual policy providing substantially the same coverage and deductibles
19cost-sharing provisions as are provided under the plan.

AB840,15,222 149.143 (2) (a) 3. By rule, after estimating the amount of manufacturer and
23labeler assessments that will be received under sub. (1) (bm) 1m., set the total
24insurer assessments under s. 149.13 for the new plan year by estimating and setting

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1the assessments at the amount necessary to equal the amounts specified in sub. (1)
2(am) 4. and (bm) 1. 2m. a. and notify the commissioner of the amount.

AB840,15,105 149.143 (2) (a) 4. By the same rule as under subd. 3., after estimating the
6amount of the manufacturer and labeler assessments that will be received under
7sub. (1) (bm) 1m., adjust the provider payment rate for the new plan year, subject to
8s. 149.142 (1) (b), by estimating and setting the rate at the level necessary to equal
9the amounts specified in sub. (1) (am) 4. and (bm) 2. 2m. b. and as provided in s.
10149.145.

AB840,15,1813 149.143 (2) (b) In setting the premium rates under par. (a) 2., the insurer
14assessment amount under par. (a) 3., and the provider payment rate under par. (a)
154. for the new plan year, the department board shall include any increase or decrease
16necessary to reflect the amount, if any, by which the rates and amount set under par.
17(a) for the current plan year differed from the rates and amount which would have
18equaled the amounts specified in sub. (1) (am) and (bm) in the current plan year.