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14. Reducing the cost of the county departments under ss. 51.42 and 51.437 to
2taxpayers by avoiding unnecessary overlap between the improved coverage of
3alcohol or other drug abuse treatment or mental illness treatment by health plans
4offered through the exchange and the services provided by county departments
5under s. 51.42 or 51.437.
AB445,30,86 (v) Review the rate of premium growth within the exchange and outside the
7exchange, and consider the information in developing recommendations on whether
8to continue limiting qualified employer status to small employers.
AB445,30,119 (w) Credit the amount of any free choice voucher to the monthly premium of
10the plan in which a qualified employee is enrolled, in accordance with section 10108
11of the federal act, and collect the amount credited from the offering employer.
AB445,30,1312 (x) Consult with stakeholders relevant to carrying out the activities required
13under this chapter, including any of the following:
AB445,30,1414 1. Educated health care consumers who are enrollees in qualified health plans.
AB445,30,1615 2. Individuals and entities with experience in facilitating enrollment in
16qualified health plans.
AB445,30,1717 3. Representatives of small businesses and self-employed individuals.
AB445,30,1818 4. The department of health services.
AB445,30,1919 5. Advocates for enrolling hard-to-reach populations.
AB445,30,2020 (y) Meet all of the following financial integrity requirements:
AB445,30,2321 1. Keep an accurate accounting of all activities, receipts, and expenditures and
22annually submit to the secretary, the governor, the commissioner, and the legislature
23a report concerning such accountings.
AB445,31,224 2. Fully cooperate with any investigation conducted by the secretary under the
25secretary's authority under the federal act and allow the secretary, in coordination

1with the inspector general of the federal department of health and human services,
2to do all of the following:
AB445,31,33 a. Investigate the affairs of the authority.
AB445,31,44 b. Examine the properties and records of the authority.
AB445,31,65 c. Require periodic reports in relation to the activities undertaken by the
AB445,31,137 3. In carrying out its activities under this chapter, not use any funds intended
8for the administrative and operational expenses of the authority for staff retreats,
9promotional giveaways, excessive executive compensation, or promotion of federal
10or state legislative or regulatory modifications, except that this subdivision does not
11prohibit the authority from advocating, as part of administering the exchange, for
12policies that the authority determines are in the best interest of the exchange or of
13individuals and employees receiving coverage through the exchange.
AB445,31,15 14(2) The authority may do all of the following relating to the exchange under s.
15636.25 (1):
AB445,31,1716 (a) Contract with a 3rd-party administrator for the provision of services on
17behalf of the exchange.
AB445,31,1818 (b) Establish risk adjustment mechanisms for the exchange.
AB445,31,1919 (c) Enter into agreements with or establish sub-exchanges.
AB445,31,2120 (d) Create any other exchange, or component of the exchange, that is provided
21for under federal law.
AB445,31,25 22(3) The authority shall seek grants to the fullest extent to which it is eligible,
23including amounts under section 1311 (a) (1) and (4) of the federal act, or other
24funding from the federal or state government for which it may be eligible and from
25private foundations for the purpose of the exchange under s. 636.25 (1).
1636.42 Health benefit plan certification. (1) The authority may certify a
2health benefit plan as a qualified health plan if all of the following are true:
AB445,32,63 (a) The plan provides the essential health benefits package described in section
41302 (a) of the federal act, except that the plan is not required to provide essential
5benefits that duplicate the minimum benefits of qualified dental plans, as provided
6in sub. (5), if all of the following are satisfied:
AB445,32,87 1. The authority has determined that at least one qualified dental plan is
8available to supplement the plan's coverage.
AB445,32,139 2. The health carrier makes prominent disclosure at the time it offers the plan,
10in a form approved by the authority, that the plan does not provide the full range of
11essential pediatric benefits and that qualified dental plans providing those benefits
12and other dental benefits not covered by the plan are offered through the exchange
13under s. 636.25 (1).
AB445,32,1514 (b) The premium rates and contract language have been filed with and not
15disapproved by the commissioner.
AB445,32,1916 (c) The plan provides at least a bronze level of coverage, as determined under
17s. 636.30 (1) (e), unless the plan is certified as a qualified catastrophic plan, meets
18the requirements of the federal act for catastrophic plans, and will only be offered to
19individuals eligible for catastrophic coverage.
AB445,32,2320 (d) The plan's cost-sharing requirements do not exceed the limits established
21under section 1302 (c) (1) of the federal act and, if the plan is offered through the
22SHOP Exchange, the plan's deductible does not exceed the limits established under
23section 1302 (c) (2) of the federal act.
AB445,32,2424 (e) The health carrier offering the plan satisfies all of the following:
11. Is licensed and in good standing to offer health insurance coverage in this
AB445,33,63 2. Offers at least one qualified health plan in the silver level and at least one
4qualified health plan in the gold level through each component of the exchange in
5which the health carrier participates. In this subdivision, “component" refers to the
6SHOP Exchange or the exchange under s. 636.25 for individual coverage.
AB445,33,97 3. Charges the same premium rate for each qualified health plan without
8regard to whether the plan is offered directly from the health carrier or through an
9insurance intermediary.
AB445,33,1110 4. Does not charge any cancellation fees or penalties in violation of s. 636.25
AB445,33,1312 5. Complies with the regulations developed by the secretary under section 1311
13(d) of the federal act and such other requirements as the authority may establish.
AB445,33,1914 (f) The plan meets the requirements of certification as required by any rules
15promulgated under s. 636.46 (1) and by the secretary under section 1311 (c) of the
16federal act, including minimum standards in the areas of marketing practices,
17network adequacy, essential community providers in underserved areas,
18accreditation, quality improvement, uniform enrollment forms, and descriptions of
19coverage and information on quality measures for health benefit plan performance.
AB445,33,2220 (g) The authority determines that making the plan available through the
21exchange under s. 636.25 (1) is in the interest of qualified individuals and qualified
22employers in this state.
AB445,33,24 23(2) The authority shall not exclude a health benefit plan for any of the following
24reasons or in any of the following ways:
AB445,33,2525 (a) On the basis that the plan is a fee-for-service plan.
1(b) Through the imposition of premium price controls by the authority.
AB445,34,42 (c) On the basis that the plan provides treatments necessary to prevent
3patients' deaths in circumstances the authority determines are inappropriate or too
AB445,34,6 5(3) The authority shall require each health carrier seeking certification of a
6health benefit plan as a qualified health plan to do all of the following:
AB445,34,127 (a) Submit a justification for any premium increase before implementation of
8that increase. The health carrier shall prominently post the information on its
9Internet site. The authority shall take this information, along with the information
10and the recommendations provided to the authority by the commissioner under 42
11USC 300gg-94
(b), into consideration when determining whether to allow the health
12carrier to make the plan available through the exchange under s. 636.25 (1).
AB445,34,1513 (b) 1. Make available to the public, in the format described in subd. 2., and
14submit to the authority, the secretary, and the commissioner, accurate and timely
15disclosure of all of the following:
AB445,34,1616 a. Claims payment policies and practices.
AB445,34,1717 b. Periodic financial disclosures.
AB445,34,1818 c. Data on enrollment.
AB445,34,1919 d. Data on disenrollment.
AB445,34,2020 e. Data on the number of claims that are denied.
AB445,34,2121 f. Data on rating practices.
AB445,34,2322 g. Information on cost sharing and payments with respect to any
23out-of-network coverage.
AB445,34,2424 h. Information on enrollee and participant rights under title I of the federal act.
AB445,34,2525 i. Other information as determined appropriate by the secretary.
12. The information required in subd. 1. shall be provided in plain language, as
2that term is defined in section 1311 (e) (3) (B) of the federal act.
AB445,35,93 (c) Permit individuals to learn, in a timely manner upon the request of the
4individual, the amount of cost sharing, including deductibles, copayments, and
5coinsurance, under the individual's plan or coverage that the individual would be
6responsible for paying with respect to the furnishing of a specific item or service by
7a participating provider. At a minimum, this information shall be made available
8to the individual through an Internet site and through other means for individuals
9without access to the Internet.
AB445,35,14 10(4) The authority may not exempt any health carrier seeking certification of
11a health benefit plan as a qualified health plan, regardless of the type or size of the
12health carrier, from state licensure or solvency requirements and shall apply the
13criteria of this section in a manner that assures equitable treatment of all health
14carriers participating in the exchange under s. 636.25 (1).
AB445,35,18 15(5) (a) The provisions of this chapter that are applicable to qualified health
16plans shall also apply to the extent relevant to qualified dental plans, except as
17modified in accordance with pars. (b), (c), and (d) or by regulations adopted by the
AB445,35,2019 (b) The health carrier shall be licensed to offer dental coverage, but need not
20be licensed to offer other health benefits.
AB445,36,221 (c) The plan shall be limited to dental and oral health benefits, without
22substantially duplicating the benefits typically offered by health benefit plans
23without dental coverage, and shall include, at a minimum, the essential pediatric
24dental benefits prescribed by the secretary under section 1302 (b) (1) (J) of the federal

1act and such other dental benefits as the authority or the secretary may specify by
AB445,36,73 (d) Health carriers may jointly offer a comprehensive plan through the
4exchange under s. 636.25 (1) in which the dental benefits are provided by a health
5carrier through a qualified dental plan and the other benefits are provided by a
6health carrier through a qualified health plan, provided that the plans are priced
7separately and are also made available for purchase separately at the same price.
AB445,36,13 8636.43 Insurer requirements. (1) Any health carrier that is authorized to
9do business in this state in one or more lines of insurance that includes health
10insurance may offer health benefit plans through the exchange under s. 636.25 (1).
11After the exchange becomes operational, no health carrier may offer or issue a health
12benefit plan in this state to an individual or to a small employer except through the
AB445,36,16 14(2) For the purpose of determining premiums, a health carrier may pool
15together all individuals and employees who have coverage under all of the qualified
16health plans issued by the health carrier through the exchange under s. 636.25 (1).
AB445,36,20 17(3) A health carrier that offers qualified health plans through the exchange
18under s. 636.25 (1) shall establish a toll-free hotline for providing information to
19enrollees and other individuals and shall furnish such reasonable reports as the
20authority determines necessary for the administration of the exchange.
AB445,36,24 21(4) The authority may audit any health carrier that provides coverage under
22a qualified health plan through the exchange under s. 636.25 (1) for the purpose of
23ensuring that the health carrier is providing covered individuals with the benefits
24provided for under this subchapter in a manner that does all of the following:
AB445,36,2525 (a) Complies with the provisions of this chapter.
1(b) Promotes positive health outcomes.
AB445,37,22 (c) Advances value-based and evidence-based medical practices.
AB445,37,53 (d) Avoids unnecessary operating and capital costs arising from inappropriate
4utilization or inefficient delivery of health care services, unwarranted duplication of
5services and infrastructure, or creation of excess care delivery capacity.
AB445,37,66 (e) Holds down the growth of health care costs.
AB445,37,14 7636.44 Intermediaries. An insurance intermediary that enrolls a qualified
8individual in a qualified health plan through the exchange under s. 636.25 (1) shall
9be paid a commission by the health carrier offering the qualified health plan. An
10insurance intermediary that enrolls the employees of a qualified employer in one or
11more qualified health plans through the exchange shall be paid a commission by each
12health carrier offering a qualified health plan selected by an employee of the
13qualified employer. The authority shall determine the commission amounts that
14must be paid to intermediaries under this section.
AB445,37,19 15636.45 Funding; publication of costs. (1) For payment of administrative
16expenses, the authority may impose a surcharge on each health carrier offering
17qualified health plans through the exchange under s. 636.25 (1). The surcharge shall
18be based on the health carrier's total premium or flat dollar amount per enrollee
19collected through the exchange.
AB445,37,23 20(2) The authority shall publish the average costs of licensing, regulatory fees,
21and any other payments required by the authority, and the administrative costs of
22the authority, on an Internet site to educate consumers on such costs. This
23information shall include information on moneys lost to waste, fraud, and abuse.
AB445,38,2 24636.46 Rules; application form. (1) The commissioner may promulgate
25rules to implement the provisions of this chapter. Rules promulgated under this

1section may not conflict with or prevent the application of regulations promulgated
2by the secretary under the federal act.
AB445,38,4 3(2) The commissioner shall develop a standard application form for use in the
AB445,38,11 5636.48 Relation to other laws. Nothing in this chapter, and no action taken
6by the authority under this chapter, shall be construed to preempt or supersede the
7authority of the commissioner to regulate the business of insurance within this state.
8Except as expressly provided to the contrary in this chapter, all health carriers
9offering qualified health plans in this state shall comply fully with all applicable
10health insurance laws of this state and rules promulgated and orders issued by the
AB445,38,1312 Subchapter III
13 badger Health benefit authority
AB445,38,24 14636.70 Creation and organization of authority. (1) There is created a
15public body corporate and politic to be known as the “Badger Health Benefit
16Authority." The board of directors of the authority shall consist of the commissioner,
17or his or her designee; the secretary of employee trust funds, or his or her designee;
18the person who is appointed by the secretary of health services to be the director of
19the Medical Assistance program, or his or her designee; the executive director, or his
20or her designee, of the Wisconsin Collaborative for Healthcare Quality, if that
21organization exists; the executive director, or his or her designee, of the Wisconsin
22Health Information Organization, if that organization exists; and all of the following
23members, who shall be nominated by the governor and, with the advice and consent
24of the senate, appointed for 3-year terms except as provided in sub. (2):
AB445,38,2525 (a) A member in good standing of the American Academy of Actuaries.
1(b) A health economist.
AB445,39,22 (c) An employee benefits specialist.
AB445,39,33 (d) A representative of small employers.
AB445,39,44 (e) A representative of an organization that represents consumer interests.
AB445,39,55 (f) A representative of organized labor.
AB445,39,66 (g) An individual with experience in health care administration.
AB445,39,10 7(2) No member of the board appointed under sub. (1) (a) to (g) may be a health
8care provider, as defined in s. 146.81 (1) (a) to (hp); an employee of a health care
9provider, as defined in s. 146.81 (1) (i) to (p); an employee of an insurer that is
10authorized to do business in the state; or an insurance intermediary.
AB445,39,13 11(3) A vacancy on the board under sub. (1) shall be filled in the same manner
12as the original appointment to the board for the remainder of the unexpired term,
13if any.
AB445,39,17 14(4) A member of the board under sub. (1) shall receive no compensation for
15services under this chapter but shall be reimbursed for actual and necessary
16expenses, including travel expenses, incurred in the discharge of the member's
17duties under this chapter.
AB445,39,23 18(5) The commissioner or the commissioner's designee shall be the chairperson
19of the board under sub. (1). Seven members of the board constitute a quorum for the
20purpose of conducting the business and exercising the powers of the authority,
21notwithstanding the existence of any vacancy. The board may take action upon a vote
22of a majority of the members present, unless the bylaws of the authority require a
23larger number.
AB445,40,10 24(6) The board under sub. (1) shall appoint an executive director who shall not
25be a member of the board and who shall serve at the pleasure of the board. The

1executive director shall receive compensation commensurate with the duties of the
2office, as determined by the board. The executive director shall serve as secretary
3of the authority and shall keep a record of the proceedings of the authority and shall
4be custodian of all books, documents, and papers filed with the authority, the minute
5book or journal of the authority, and its official seal. The executive director or other
6person may cause copies to be made of all minutes and other records and documents
7of the authority and may give certificates under the official seal of the authority to
8the effect that such copies are true copies, and all persons dealing with the authority
9may rely upon such certificates. The executive director shall have all of the following