4. Does not charge any cancellation fees or penalties in violation of s. 636.25 11
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.
(f) The plan meets the requirements of certification as required by any rules 15
promulgated under s. 636.46 (1) and by the secretary under section 1311 (c) of the 16
federal act, including minimum standards in the areas of marketing practices, 17
network adequacy, essential community providers in underserved areas, 18
accreditation, quality improvement, uniform enrollment forms, and descriptions of 19
coverage and information on quality measures for health benefit plan performance.
(g) The authority determines that making the plan available through the 21
exchange under s. 636.25 (1) is in the interest of qualified individuals and qualified 22
employers in this state.
The authority shall not exclude a health benefit plan for any of the following 24
reasons or in any of the following ways:
(a) On the basis that the plan is a fee-for-service plan.
(b) Through the imposition of premium price controls by the authority.
(c) On the basis that the plan provides treatments necessary to prevent 3
patients' deaths in circumstances the authority determines are inappropriate or too 4
The authority shall require each health carrier seeking certification of a 6
health benefit plan as a qualified health plan to do all of the following:
(a) Submit a justification for any premium increase before implementation of 8
that increase. The health carrier shall prominently post the information on its 9
Internet site. The authority shall take this information, along with the information 10
and the recommendations provided to the authority by the commissioner under 42
(b), into consideration when determining whether to allow the health 12
carrier to make the plan available through the exchange under s. 636.25 (1).
(b) 1. Make available to the public, in the format described in subd. 2., and 14
submit to the authority, the secretary, and the commissioner, accurate and timely 15
disclosure of all of the following:
a. Claims payment policies and practices.
b. Periodic financial disclosures.
c. Data on enrollment.
d. Data on disenrollment.
e. Data on the number of claims that are denied.
f. Data on rating practices.
g. Information on cost sharing and payments with respect to any 23
h. Information on enrollee and participant rights under title I of the federal act.
i. Other information as determined appropriate by the secretary.
2. The information required in subd. 1. shall be provided in plain language, as 2
that term is defined in section 1311 (e) (3) (B) of the federal act.
(c) Permit individuals to learn, in a timely manner upon the request of the 4
individual, the amount of cost sharing, including deductibles, copayments, and 5
coinsurance, under the individual's plan or coverage that the individual would be 6
responsible for paying with respect to the furnishing of a specific item or service by 7
a participating provider. At a minimum, this information shall be made available 8
to the individual through an Internet site and through other means for individuals 9
without access to the Internet.
The authority may not exempt any health carrier seeking certification of 11
a health benefit plan as a qualified health plan, regardless of the type or size of the 12
health carrier, from state licensure or solvency requirements and shall apply the 13
criteria of this section in a manner that assures equitable treatment of all health 14
carriers participating in the exchange under s. 636.25 (1).
(a) The provisions of this chapter that are applicable to qualified health 16
plans shall also apply to the extent relevant to qualified dental plans, except as 17
modified in accordance with pars. (b), (c), and (d) or by regulations adopted by the 18
(b) The health carrier shall be licensed to offer dental coverage, but need not 20
be licensed to offer other health benefits.
(c) The plan shall be limited to dental and oral health benefits, without 22
substantially duplicating the benefits typically offered by health benefit plans 23
without dental coverage, and shall include, at a minimum, the essential pediatric 24
dental benefits prescribed by the secretary under section 1302 (b) (1) (J) of the federal
act and such other dental benefits as the authority or the secretary may specify by 2
(d) Health carriers may jointly offer a comprehensive plan through the 4
exchange under s. 636.25 (1) in which the dental benefits are provided by a health 5
carrier through a qualified dental plan and the other benefits are provided by a 6
health carrier through a qualified health plan, provided that the plans are priced 7
separately and are also made available for purchase separately at the same price.
8636.43 Insurer requirements.
Any health carrier that is authorized to 9
do business in this state in one or more lines of insurance that includes health 10
insurance may offer health benefit plans through the exchange under s. 636.25 (1). 11
After the exchange becomes operational, no health carrier may offer or issue a health 12
benefit plan in this state to an individual or to a small employer except through the 13
For the purpose of determining premiums, a health carrier may pool 15
together all individuals and employees who have coverage under all of the qualified 16
health plans issued by the health carrier through the exchange under s. 636.25 (1).
A health carrier that offers qualified health plans through the exchange 18
under s. 636.25 (1) shall establish a toll-free hotline for providing information to 19
enrollees and other individuals and shall furnish such reasonable reports as the 20
authority determines necessary for the administration of the exchange.
The authority may audit any health carrier that provides coverage under 22
a qualified health plan through the exchange under s. 636.25 (1) for the purpose of 23
ensuring that the health carrier is providing covered individuals with the benefits 24
provided for under this subchapter in a manner that does all of the following:
(a) Complies with the provisions of this chapter.
(b) Promotes positive health outcomes.
(c) Advances value-based and evidence-based medical practices.
(d) Avoids unnecessary operating and capital costs arising from inappropriate 4
utilization or inefficient delivery of health care services, unwarranted duplication of 5
services and infrastructure, or creation of excess care delivery capacity.
(e) Holds down the growth of health care costs.
An insurance intermediary that enrolls a qualified 8
individual in a qualified health plan through the exchange under s. 636.25 (1) shall 9
be paid a commission by the health carrier offering the qualified health plan. An 10
insurance intermediary that enrolls the employees of a qualified employer in one or 11
more qualified health plans through the exchange shall be paid a commission by each 12
health carrier offering a qualified health plan selected by an employee of the 13
qualified employer. The authority shall determine the commission amounts that 14
must be paid to intermediaries under this section.
15636.45 Funding; publication of costs. (1)
For payment of administrative 16
expenses, the authority may impose a surcharge on each health carrier offering 17
qualified health plans through the exchange under s. 636.25 (1). The surcharge shall 18
be based on the health carrier's total premium or flat dollar amount per enrollee 19
collected through the exchange.
The authority shall publish the average costs of licensing, regulatory fees, 21
and any other payments required by the authority, and the administrative costs of 22
the authority, on an Internet site to educate consumers on such costs. This 23
information shall include information on moneys lost to waste, fraud, and abuse.
24636.46 Rules; application form.
The commissioner may promulgate 25
rules to implement the provisions of this chapter. Rules promulgated under this
section may not conflict with or prevent the application of regulations promulgated 2
by the secretary under the federal act.
The commissioner shall develop a standard application form for use in the 4
5636.48 Relation to other laws.
Nothing in this chapter, and no action taken 6
by the authority under this chapter, shall be construed to preempt or supersede the 7
authority of the commissioner to regulate the business of insurance within this state. 8
Except as expressly provided to the contrary in this chapter, all health carriers 9
offering qualified health plans in this state shall comply fully with all applicable 10
health insurance laws of this state and rules promulgated and orders issued by the 11
badger Health benefit authority
14636.70 Creation and organization of authority. (1)
There is created a 15
public body corporate and politic to be known as the “Badger Health Benefit 16
Authority." The board of directors of the authority shall consist of the commissioner, 17
or his or her designee; the secretary of employee trust funds, or his or her designee; 18
the person who is appointed by the secretary of health services to be the director of 19
the Medical Assistance program, or his or her designee; the executive director, or his 20
or her designee, of the Wisconsin Collaborative for Healthcare Quality, if that 21
organization exists; the executive director, or his or her designee, of the Wisconsin 22
Health Information Organization, if that organization exists; and all of the following 23
members, who shall be nominated by the governor and, with the advice and consent 24
of the senate, appointed for 3-year terms except as provided in sub. (2):
(a) A member in good standing of the American Academy of Actuaries.
(b) A health economist.
(c) An employee benefits specialist.
(d) A representative of small employers.
(e) A representative of an organization that represents consumer interests.
(f) A representative of organized labor.
(g) An individual with experience in health care administration.
No member of the board appointed under sub. (1) (a) to (g) may be a health 8
care provider, as defined in s. 146.81 (1) (a) to (hp); an employee of a health care 9
provider, as defined in s. 146.81 (1) (i) to (p); an employee of an insurer that is 10
authorized to do business in the state; or an insurance intermediary.
A vacancy on the board under sub. (1) shall be filled in the same manner 12
as the original appointment to the board for the remainder of the unexpired term, 13
A member of the board under sub. (1) shall receive no compensation for 15
services under this chapter but shall be reimbursed for actual and necessary 16
expenses, including travel expenses, incurred in the discharge of the member's 17
duties under this chapter.
The commissioner or the commissioner's designee shall be the chairperson 19
of the board under sub. (1). Seven members of the board constitute a quorum for the 20
purpose of conducting the business and exercising the powers of the authority, 21
notwithstanding the existence of any vacancy. The board may take action upon a vote 22
of a majority of the members present, unless the bylaws of the authority require a 23
The board under sub. (1) shall appoint an executive director who shall not 25
be a member of the board and who shall serve at the pleasure of the board. The
executive director shall receive compensation commensurate with the duties of the 2
office, as determined by the board. The executive director shall serve as secretary 3
of the authority and shall keep a record of the proceedings of the authority and shall 4
be custodian of all books, documents, and papers filed with the authority, the minute 5
book or journal of the authority, and its official seal. The executive director or other 6
person may cause copies to be made of all minutes and other records and documents 7
of the authority and may give certificates under the official seal of the authority to 8
the effect that such copies are true copies, and all persons dealing with the authority 9
may rely upon such certificates. The executive director shall have all of the following 10
(a) Supervising the administrative affairs and the general management and 12
operation of the authority.
(b) Planning, directing, coordinating, and executing administrative functions 14
in conformity with the policies and directives of the board.
(c) Employing professional and clerical staff, as necessary.
(d) Reporting to the board on all operations under his or her control and 17
(e) Preparing an annual budget and managing the administrative expenses of 19
(f) Undertaking any activities necessary to implement the powers and duties 21
set forth in this chapter.
22636.72 Authority duties.
In addition to all other duties imposed under this 23
chapter, the authority shall do all of the following:
Establish its annual budget and monitor its fiscal management.
No later than 2 years after an exchange under subch. II begins operation, 2
and annually thereafter, submit a report to the legislature under s. 13.172 (2) and 3
to the governor on the operation of any exchange under subch. II, including a review 4
of all of the following:
(a) Progress toward the goals of the exchange.
(b) The operations and administration of the exchange.
(c) The types of health insurance plans available to eligible individuals and 8
groups and the percentage of the total exchange enrollees served by each plan.
(d) Surveys and reports on the insurers' experiences with different plans, 10
including aggregated data on enrollees, claims, statistics, complaint data, and 11
enrollee satisfaction data.
(e) Significant observations regarding utilization and adoption of the 13
Annually submit to the governor and the legislative audit bureau a 15
statement of its activities and financial condition.
Approve the use of any trademarks, seals, or logos by participating insurers 17
and small employers.
Comply with the requirements of s. 16.413 as if the authority is a state 19
20636.74 Authority powers.
The authority has all of the powers necessary or 21
convenient to carry out its duties under this chapter, except that it may not acquire 22
or hold title to real estate or issue bonds. In addition, the authority may do any of 23
Adopt bylaws and policies and procedures for the regulation of its affairs 25
and the conduct of its business.
Have a seal and alter the seal at pleasure, have perpetual existence, and 2
maintain an office.
Hire employees, define their duties, and fix their rate of compensation.
Delegate by resolution to one or more of its members any powers and duties 5
that it considers proper.
Appoint any technical or professional advisory committee that the 8
authority finds necessary to assist the authority in exercising its duties and powers. 9
If the authority appoints a committee, the authority shall define the duties of the 10
committee and provide reimbursement for the expenses of the committee.
Accept gifts, grants, loans, or other contributions from private or public 12
Procure liability insurance.
Sue and be sued in its own name and plead and be impleaded.
Execute contracts and other instruments, including contracts for 16
professional or technical services required for the authority or the operation of an 17
exchange under subch. II.
18636.76 Contracting for professional services. (1)
Whenever contracting 19
for professional services, the authority shall solicit competitive sealed bids or 20
competitive sealed proposals, whichever is appropriate. Each request for 21
competitive sealed proposals shall state the relative importance of price and other 22
(a) When the estimated cost exceeds $25,000, the authority may invite 24
competitive sealed bids or proposals by publishing a class 2 notice under ch. 985 or 25
by posting notice on the Internet at a site determined or approved by the authority.
The notice shall describe the contractual services to be purchased, the intent to make 2
the procurement by solicitation of bids or proposals, any requirement for surety, and 3
the date the bids or proposals will be opened, which shall be at least 7 days after the 4
date of the last insertion of the notice or at least 7 days after the date of posting on 5
(b) When the estimated cost is $25,000 or less, the authority may award the 7
contract in accordance with simplified procedures established by the authority for 8
(c) For purposes of clarification, the authority may discuss the requirements 10
of the proposed contract with any person who submits a bid or proposal and shall 11
permit any offerer to revise his or her bid or proposal to ensure its responsiveness to 12
(a) The authority shall determine which bids or proposals are reasonably 14
likely to be awarded the contract and shall provide each offerer of such a bid or 15
proposal a fair and equal opportunity to discuss the bid or proposal. The authority 16
may negotiate with each offerer in order to obtain terms that are advantageous to 17
the authority. Prior to the award of the contract, any offerer may revise his or her 18
bid or proposal. The authority shall keep a written record of all meetings, 19
conferences, oral presentations, discussions, negotiations, and evaluations of bids or 20
proposals under this section.