AB697,3,1817 (a) "Certified provider" means a provider that is certified by the department
18under s. 49.45 (2) (a) 11. as a provider of medical assistance.
AB697,3,2119 (b) "Enrollment year" means a 12-month period during which an individual
20has coverage under the plan under this section beginning with the effective date of
21the individual's coverage or with the anniversary of that date.
AB697,4,7
1(2) Establishment and operation. The department may establish and, no
2sooner than March 1, 2010, begin operating a plan providing coverage of limited
3primary and preventive health care benefits to individuals who satisfy the eligibility
4criteria under sub. (3). The department shall pay for its administrative costs and for
5the cost of benefits provided under the plan under this section from the appropriation
6under s. 20.435 (4) (hm) and, if needed, may pay the costs of incurred program
7benefits from the appropriation under s. 20.435 (4) (ma).
AB697,4,10 8(3) Eligibility. (a) Criteria. Subject to pars. (b) and (c) and sub. (4) (a) 2., an
9individual may receive coverage for benefits under the plan under this section if the
10individual satisfies all of the following criteria:
AB697,4,1211 1. The individual is on the waiting list established for the health care benefit
12plan under s. 49.45 (23).
AB697,4,1413 2. The individual applies for coverage for benefits under the plan under this
14section in the manner prescribed by the department.
AB697,4,1615 (b) No entitlement. Notwithstanding satisfaction of the criteria under par. (a),
16no individual is entitled to benefits under the plan under this section.
AB697,4,2217 (c) After termination of coverage. An individual whose coverage under the plan
18under this section ends for any reason, including for failure to pay a premium when
19due, is ineligible for coverage under the plan for 12 calendar months, beginning with
20the first calendar month after the last calendar month, which need not be a full
21month, in which he or she had coverage. This paragraph does not apply if the
22department determines that the individual's coverage ended for a good cause reason.
AB697,5,3 23(4) Cost sharing. (a) Premiums. 1. The plan under this section shall be funded
24through premiums paid by individuals with coverage under the plan. The
25department shall set premiums at a level necessary to pay for the benefits covered

1and to maintain the fiscal soundness of the plan. The department, or its agent, shall
2credit premiums received from individuals to the appropriation account under s.
320.435 (4) (hm).
AB697,5,74 2. Premiums shall be due in the calendar month before the calendar month of
5coverage. An individual may not enroll in the plan if he or she does not submit the
6first month's premium with the application and may not continue coverage under the
7plan if he or she does not pay a premium when due.
AB697,5,158 3. If an individual with coverage under the plan under this section is removed
9from the waiting list for the health care benefit plan under s. 49.45 (23) and begins
10receiving coverage under that health care benefit plan, the department shall not
11refund any portion of a premium paid by the individual for coverage under the plan
12under this section for the calendar month in which the individual's coverage under
13the health care benefit plan under s. 49.45 (23) commences. The department shall,
14however, waive any enrollment fee that would be payable by the individual for
15enrolling in the health care benefit plan under s. 49.45 (23).
AB697,5,1816 (b) Deductible. The department may set a deductible that applies to inpatient
17and nonemergency outpatient hospital services and that does not exceed $7,500 in
18an enrollment year.
AB697,5,2019 (c) Other. The department may set other cost-sharing requirements that the
20department determines are necessary to keep the plan actuarily sound.
AB697,5,23 21(5) Provider requirements. (a) Certification. Only a certified provider may
22receive payment from the department for services provided to individuals under the
23plan under this section.
AB697,6,624 (b) Payments and charges. 1. The department shall pay a certified provider
25for a service that is covered under the plan under this section an amount that is no

1higher than the amount that is payable for the same service under the Medical
2Assistance program under subch. IV. A certified provider that provides a covered
3service to an individual with coverage under the plan under this section shall accept
4the department's payment as payment in full and, subject to subd. 2., may not bill
5the individual to whom the service was provided for any amount other than any cost
6sharing required under sub. (4).
AB697,6,117 2. A certified provider that provides to an individual with coverage under the
8plan under this section inpatient or nonemergency outpatient hospital services to
9which a deductible under sub. (4) (b) applies may not charge for those services an
10amount that is higher than the amount that would be payable to the provider under
11subd. 1. for those services.
AB697,6,14 12(6) Benefits. (a) May not exceed benefits under other plan. The benefits
13covered under the plan under this section may not exceed the benefits covered under
14the health care benefit plan under s. 49.45 (23).
AB697,6,2415 (b) Coordination of benefits. 1. Benefits under the plan under this section shall
16not include any charge for care for injury or disease for which benefits are payable
17without regard to fault under coverage statutorily required to be contained in any
18motor vehicle or other liability insurance policy or equivalent self-insurance, for
19which benefits are payable under a worker's compensation or similar law, or for
20which benefits are payable under another policy of health care coverage, Medicare,
21or any other governmental program, except as otherwise provided by law. If an
22individual who has coverage under the plan under this section also has coverage
23under the plan under subch. II of ch. 149, benefits under the plan under this section
24are secondary to the benefits provided under the plan under subch. II of ch. 149.
AB697,7,4
12. The department is subrogated to the rights of an individual with coverage
2under the plan under this section to recover special damages for illness or injury to
3the individual caused by the act of a 3rd person to the extent that benefits are
4provided under the plan.
AB697,7,75 (c) Recovery of incorrectly paid benefits. 1. The department may recover a
6payment made incorrectly for benefits provided under this section on behalf of an
7individual if the incorrect payment was made as a result of any of the following:
AB697,7,118 a. At the time the individual obtained coverage under the plan under this
9section, the individual was on the waiting list established for the health care benefit
10plan under s. 49.45 (23) because of a misstatement or omission of fact by the
11individual.
AB697,7,1312 b. The individual's coverage under the plan under this section was continued
13because of a misstatement or omission of fact by the individual.
AB697,7,1614 2. The department's right of recovery is against the individual with coverage
15under the plan under this section on whose behalf the incorrect payment was made.
16The extent of the recovery is limited to the amount of the benefits actually paid.
AB697,7,24 17(7) Review of coverage denial or discontinuation. Any individual who is
18denied enrollment in the plan under this section or whose coverage is discontinued
19may request that the department review the action by filing with the department a
20written request that includes the reasons why the individual disagrees with the
21denial or discontinuation of coverage. The written request must be filed within 60
22days after the coverage denial or discontinuation. An individual must exhaust the
23process under this subsection before commencing any action in court relating to the
24coverage denial or discontinuation.
AB697,8,2
1(8) Inapplicable provisions. All of the following apply to the plan under this
2section:
AB697,8,33 (a) It is not medical assistance under subch. IV.
AB697,8,44 (b) It is exempt from chs. 600 to 646.
AB697, s. 5 5Section 5. 227.01 (13) (ur) of the statutes is created to read:
AB697,8,76 227.01 (13) (ur) Relates to the benefit design, cost-sharing requirements, or
7administration of the health care benefits plan under s. 49.67.
AB697, s. 6 8Section 6. 227.42 (7) of the statutes is created to read:
AB697,8,119 227.42 (7) This section does not apply to a decision denying enrollment or
10discontinuing coverage under s. 49.67, to a decision about benefits covered under s.
1149.67, or to a payment made under s. 49.67.
AB697,8,1212 (End)
Loading...
Loading...