AB94, s. 14 5Section 14. Chapter 152 of the statutes is created to read:
AB94,8,76 Chapter 152
7 health plan
AB94,8,8 8152.01 Definitions. In this chapter:
AB94,8,9 9(1) "Block grant" has the meaning given in s. 16.54 (2) (a) 3.
AB94,8,10 10(2) "Board" means the health policy board.
AB94,8,11 11(3) "Department" means the department of health planning and finance.
AB94,8,12 12(4) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a).
AB94,8,21 13(5) "Health care facility" means a facility, as defined in s. 647.01 (4), or any
14hospital, nursing home, community-based residential facility, county home, county
15infirmary, county hospital, county mental health center, community health center,
16primary health center, tuberculosis sanatorium, adult family home, assisted living
17facility, rural medical center, hospice, or other place licensed, certified, or approved
18by the department of health and family services under s. 49.70, 49.71, 49.72, 50.02,
1950.03, 50.032, 50.033, 50.034, 50.35, 50.52, 50.92 (2), 51.08, or 51.09 or a facility
20under s. 45.50, 51.05, 51.06, or 252.10 or ch. 233, or licensed or certified by a county
21department under s. 50.032 or 50.033.
AB94,8,23 22(6) "Health care provider" means a provider of health care services or other
23benefits in this state that are specified under s. 152.10 (4).
AB94,8,25 24(7) "Medicare" means coverage under part A or part B of Title XVIII of the
25federal Social Security Act, 42 USC 1395 to 1395hhh.
AB94,9,2
1(8) "Reimbursement" means payment for the provision of services and other
2benefits that are specified under s. 152.10 (4).
AB94,9,3 3(9) "Secretary" means the secretary of health planning and finance.
AB94,9,5 4(10) "Veteran", except as otherwise provided, has the meaning given in 38 USC
5101
(2).
AB94,9,13 6152.10 Health plan. (1) There is created a health plan in this state, under
7which, beginning on July 1, 2010, each eligible person, regardless of any preexisting
8condition, shall receive reasonable medical service necessary to maintain health,
9enable diagnosis, or provide treatment or rehabilitation for an injury, condition,
10disability, or disease, for which reimbursement shall be made by the department.
11Coverage is provided under the health plan for orthodontia or for the performance
12of reconstructive or cosmetic surgery that is determined to be necessary under
13criteria that are promulgated as rules by the department.
AB94,9,17 14(2) Each individual in this state who is not excluded from residency, as specified
15in sub. (3) (c), is eligible for coverage under the health plan, except as provided in sub.
16(5), and except that all of the following may be phased in for eligibility under this
17subsection, beginning no later than July 1, 2011:
AB94,9,1918 (a) Individuals, other than those specified in par. (b), who have no coverage
19under disability insurance policies.
AB94,9,2320 (b) Individuals who have no coverage under disability insurance policies and
21who receive health care, treatment for nervous or mental disorders, or treatment or
22prevention services for alcohol and other drug abuse that are funded by state or local
23funding.
AB94,9,2524 (c) Individuals who are employees of the state or any county, city, village, or
25town, and who, as a benefit of the employment, have coverage for themselves and

1family members under provisions of group disability insurance policies or under
2self-insured health plans.
AB94,10,53 (d) Individuals, other than those specified in par. (c) or (h), who, by reason of
4their employment or as family members of individuals who are employed, have
5coverage under group disability insurance policies.
AB94,10,76 (e) Individuals who have coverage under individual disability insurance
7policies.
AB94,10,98 (f) Individuals who have coverage under the health insurance risk-sharing
9plan under subch. II of ch. 149.
AB94,10,1210 (g) Individuals who are eligible for benefits or services under s. 49.46, 49.468,
1149.47, 49.473, or 49.665, waiver programs under medical assistance, Medicare, or
12block grants that provide health care services.
AB94,10,1513 (h) Individuals who are employees of self-insured employers, other than those
14specified in par. (c), and who receive health care benefits for themselves and family
15members under self-insured health plans.
AB94,10,1616 (i) Individuals who receive medical benefits under worker's compensation.
AB94,10,2117(j) Veterans who receive medical benefits under 38 USC 1701 to 1754 and
18certain spouses and dependents of veterans who receive benefits under 38 USC 1781
19to 1785 or 38 USC 1802 to 1834; and veterans, as defined in s. 45.01 (12), who receive
20medical benefits under s. 45.40 (2) and certain spouses and dependents of these
21veterans who receive medical benefits under s. 45.40 (2m).
AB94,10,2322 (k) Members of federally-recognized American Indian tribes or bands who
23receive health and other services under 25 USC 1621 to 1683.
AB94,11,3 24(3) (a) Any individual who is eligible under sub. (2) may receive services that
25are available under the health plan from any participating health care provider in

1this state. Services that correspond to those that are available under the health plan
2and that are provided to the individual in another state are reimbursable at rates
3under the health plan that are current at the time of service provision.
AB94,11,64 (b) No individual who is eligible under sub. (2) may under this section be
5required to pay an amount as a deductible or copayment as a condition for receipt of
6services under this section from a health care facility or health care provider.
AB94,11,107 (c) An individual who has a fixed habitation outside the state but not inside the
8state is not a resident for purposes of this chapter. Any reimbursement paid under
9the health plan for health care services rendered to an individual who is determined
10not to be a resident is a liability of the individual.
AB94,11,12 11(4) Health care services and other benefits provided under the health plan shall
12include all of the following:
AB94,11,1413 (a) Services of all persons licensed, certified, registered, or permitted to treat
14the sick under chs. 441, 446, 447, 448, 449, 450, 451, 455, 457, and 459.
AB94,11,1615 (b) Health care services that are provided by health care facilities and the
16offices and clinics of persons under par. (a).
AB94,11,1817 (c) Preventive health care services and health promotional programs, including
18well-child care, immunizations, screening, outreach, and education.
AB94,11,2119 (d) Medical or surgical supplies and durable medical or surgical equipment,
20supplies and appliances, including valves, pacemakers, prostheses, eyeglasses, and
21hearing aids.
AB94,11,2422 (e) Prescription drugs specified in the listing of approved medicinal substances
23and formulae under s. 152.40 (5) (n) and any other drugs specified by the department
24by rule.
AB94,11,2525 (f) Blood and blood products.
AB94,12,5
1(g) Long-term care services that are necessary for the physical health, mental
2and emotional well-being, and social and personal needs of individuals who have
3limited self-care capabilities, including services of health care facilities; home
4health care; hospice care; home-based and community-based services, including
5personal assistance and attendant care; and periodic needs assessments.
AB94,12,76 (h) Mental health treatment and services, including substance abuse and brain
7injury treatment.
AB94,12,88 (i) Dental services, as specified under s. 49.46 (2) (b) 1.
AB94,12,11 9(5) The health plan is the payer of last resort, and coverage under the health
10plan is supplemental to any health care coverage in force that is held by an
11individual.
AB94,12,15 12(6) As a condition of participation by a health care provider in the health plan,
13the health care provider shall accept reimbursement only under the health plan for
14all services or other benefits that the health care provider provides under the health
15plan.
AB94,12,18 16152.20 Health policy board; powers and duties. (1) The board shall
17approve and continually evaluate the listing of approved medicinal substances and
18formulae that is required under s. 152.40 (5) (n).
AB94,12,21 19(2) The board shall biennially evaluate and oversee cost containment
20guidelines and policies, including the evaluation of mechanisms used to contain costs
21of providing services, and shall revise the guidelines and policies as necessary.
AB94,12,23 22(3) The board shall review all of the following issues and formulate or revise
23policies, as appropriate, with respect to the issues:
AB94,12,2424 (a) Duties of the department that require policy determinations.
AB94,13,3
1(b) The sources and amounts of revenues for the administration of the
2department and the board and for financing the payment of health care services that
3are provided to residents under the health plan.
AB94,13,44 (c) Information provided by the regional consumer health councils.
AB94,13,85 (d) Development of a system for determination and periodic review of areas in
6this state, and specific populations within those areas, that are medically
7underserved; and development of plans for providing health care services to those
8areas and populations, including the establishment of community health centers.
AB94,13,129 (e) Development of a system for periodic reviews and evaluations of all aspects
10of the operation of the health plan, including the adequacy, cost, effectiveness, and
11quality of health care services provided. These reviews and evaluations shall be
12made available to the public by the board.
AB94,13,1413 (f) Development of a notice and hearing procedure for review of complaints of
14residents about the health plan, in accordance with the requirements of ch. 227.
AB94,13,1515 (g) Other issues that the board determines are relevant to the health plan.
AB94,13,1616 (h) State statutory changes that may be necessary to effect pars. (a) to (g).
AB94,13,20 17(4) By January 1, April 1, July 1, and October 1 of each year, the board shall
18report to the governor on the revenues and expenditures of the health plan for the
19calendar quarter immediately preceding the most recently completed calendar
20quarter.
AB94,14,2 21(5) (a) The board may appoint up to 2 advisory committees, each with not more
22than 12 members, that shall be advisory to the secretary. Appointees shall reflect
23as much as possible a balance of gender, race, age, sexual orientation, ethnicity,
24religion, disability, and geographic area. The board may determine the length of

1terms of advisory committee members and the frequency of meetings, and may
2terminate the committees.
AB94,14,33 (b) If appointed under par. (a), all of the following apply:
AB94,14,64 1. Only one advisory committee shall reflect the interests and concerns of
5consumer advocacy and may not include a health care provider or representative of
6a health care provider or the agency or organization of a health care provider.
AB94,14,97 2. Only one advisory committee shall reflect the interests and concerns of
8health care providers and agencies and organizations of health care providers and
9may not include a representative of a consumer advocacy agency or organization.
AB94,14,1310 3. An advisory committee shall report annually to the board and the secretary
11concerning the committee's activities in the immediately preceding fiscal year, shall
12provide advice relative to health policy issues, and shall make recommendations
13concerning departmental policies and procedures.
AB94,14,15 14152.30 Regional consumer health councils. (1) Each regional consumer
15health council shall do all of the following:
AB94,14,2016 (a) Elect one member of the regional consumer health council to serve as a
17member of the board under s. 15.20 (1). If the term of the member who is so elected
18expires with respect to the regional consumer health council or with respect to the
19board under s. 15.20 (1), the regional consumer health council shall elect a current
20member of the council to serve as a member of the board in his or her stead.
AB94,14,2421 (b) Study and continuously monitor the delivery and quality of and access to
22health care services in the region of the regional consumer health council and
23recommend to the board and regional office ways to improve the quality of and help
24ensure access to health care services.
AB94,15,3
1(c) Recommend to the board payment rates and conditions appropriate to
2specific regional needs and advise on regional health care policy issues and
3administrative policies and procedures.
AB94,15,64 (d) Study and continuously monitor the unmet health care service needs in the
5region of the regional consumer health council and recommend to the board ways by
6which the needs may be met.
AB94,15,107 (e) Report at least annually to the board with respect to the health care needs,
8problems, and concerns of the region, including any issues elicited at public hearings
9under par. (g), and provide to the board recommendations to alleviate these needs,
10problems, and concerns.
AB94,15,1311 (f) Require reports from and advise the member of the staff of the appropriate
12regional office whose duties are specified under s. 152.40 (1), concerning issues that
13arise under pars. (b) to (e).
AB94,15,1714 (g) In at least 2 localities of the region, hold public hearings at least annually
15to elicit public opinion concerning the health plan under this chapter. The council
16shall give notice of each hearing by publishing a class 1 notice, under ch. 985, at least
1715 days before the hearing in a newspaper covering the affected area.
AB94,15,1818 (h) Perform other duties as required by the board.
AB94,15,21 19(2) Each regional consumer health council may, for cause, recall the member
20elected under sub. (1) (a) and may elect another member to fulfill that term on the
21board if all of the following are done:
AB94,15,2422 (a) The elected member of the board for whom recall is sought receives notice
23of the recall at least 10 working days before the meeting at which the recall is voted
24upon.
AB94,16,3
1(b) Notice of the vote to recall the elected member is made on the agenda of the
2meeting of the regional consumer health council that is immediately prior to the
3meeting at which recall is voted upon.
AB94,16,9 4(2m) The regional consumer health council may appoint a regional advisory
5committee. If appointed, the regional advisory committee shall consist of 18
6members who reflect as much as possible a balance of gender, race, age, sexual
7orientation, ethnicity, religion, geographic area, and the interests of management,
8labor, and individuals with disabilities, and may consist of consumer advocates and
9health care providers.
AB94,16,12 10(3) The staff of the appropriate regional office shall provide services to each
11regional consumer health council to deal with issues of health consumer advocacy
12and health ombudsman functions.
AB94,16,17 13152.40 Department of health planning and finance. (1) The department
14shall administer the health plan under this chapter, including establishing a
15regional office in each of the regions specified under s. 15.207 (1) (a) 1. to 6. Each
16regional office shall have at least one staff member who acts in a full-time capacity
17as a regional consumer advocate and health care ombudsman.
AB94,16,20 18(2) The department shall establish provider payment rates, taking into
19consideration regional, rural, and urban differences, and conditions of payment for
20the provision of health care services under the health plan.
AB94,16,22 21(3) The department shall, after review and approval by the board, promulgate
22as rules all of the following:
AB94,16,2423 (a) Guidelines for cost containment under the health plan, including the
24purchasing and distribution of major diagnostic, medical, and surgical equipment.
AB94,17,4
1(b) Criteria, as recommended by the medical advisory committee appointed by
2the secretary under sub. (7), for determining necessity for orthodontia and for the
3performance of reconstructive or cosmetic surgery for coverage under the health
4plan.
AB94,17,6 5(4) The department shall biennially evaluate and recommend to the board cost
6control measures for the health plan.
AB94,17,9 7(5) The department shall, by July 1, 2009, begin implementation of processes,
8in light of policies formulated or revised under s. 152.20 (3), to effect all of the
9following:
AB94,17,1310 (a) Specification of the amounts and sources of revenues to finance payment to
11providers under the health plan, which may not include any premiums, copayments,
12deductibles, and other forms of direct payment by patients, and which shall include
13all of the following:
AB94,17,1914 1. Use of federal, state, and local moneys that fund, as of July 1, 2010, health
15care services, including medicare, medical assistance, health care services funded by
16a relief block grant under s. 49.02, 49.025, or 49.029; health care services under s.
1749.665; veterans medical benefits; services specified in s. 152.10 (2) (k); services
18provided under federal block grants; alcohol and other drug abuse services; and
19services provided by local health departments.
AB94,17,2420 2. Use of revenues from a tax on employers, based on the amount of wages that
21they pay, that generates, in the aggregate, revenues that are at least equal to
22amounts that employers contribute, as of the effective date of this subdivision ....
23[revisor inserts date], for employee health care benefit costs, including the costs of
24worker's compensation attributable to health care for injured employees.
AB94,18,4
13. Use of revenues from a graduated income tax on individuals that generates,
2in the aggregate, revenues that are not greater than expenditures that individuals
3make, as of July 1, 2010, for health care costs for which coverage under disability
4insurance policies is not obtained.
AB94,18,75 4. An indexing of the sources of revenues under this paragraph that provides
6for revenue growth that is equivalent to the anticipated growth of health care costs
7under the health plan.
AB94,18,108(b) Application for waivers to 42 USC 1396 to 1396v or consideration of the
9feasibility of statutory changes to 42 USC 1396 to 1396v in order to effect all of the
10following:
AB94,18,1211 1. Administration of the Medical Assistance program in this state by the
12department, rather than by the department of health and family services.
AB94,18,1413 2. Use of federal financial participation to fund a portion of the administrative
14costs, after June 30, 2010, of the department.
AB94,18,1915 3. Use of federal financial participation, after June 30, 2010, to fund, under the
16health plan, the health care services received by a percentage of the residents that
17corresponds to the percentage of the residents, as determined by the board, that is
18eligible to receive health care services under the Medical Assistance program on July
191, 2010.
AB94,18,2120 4. The formulation of criteria and procedures for payment of out-of-state
21health care costs incurred by residents specified in subd. 3.
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