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1(3) “Federal act" means the federal Patient Protection and Affordable Care Act,
2P.L. 111-148, as amended by the federal Health Care and Education Reconciliation
3Act of 2010, P.L. 111-152, and any amendments to, or regulations or guidance issued
4under, those acts.
AB445,21,7 5(4) (a) Except as provided in pars. (b) to (e), “health benefit plan" means a policy,
6contract, certificate, or agreement offered or issued by a health carrier to provide,
7deliver, arrange for, pay for, or reimburse any of the costs of health care services.
AB445,21,88 (b) “Health benefit plan" does not include any of the following:
AB445,21,109 1. Coverage only for accident, or disability income insurance, or any
10combination of those.
AB445,21,1111 2. Coverage issued as a supplement to liability insurance.
AB445,21,1312 3. Liability insurance, including general liability insurance and automobile
13liability insurance.
AB445,21,1414 4. Worker's compensation or similar insurance.
AB445,21,1515 5. Automobile medical payment insurance.
AB445,21,1616 6. Credit-only insurance.
AB445,21,1717 7. Coverage for on-site medical clinics.
AB445,21,2018 8. Other similar insurance coverage, specified in federal regulations issued
19under P.L. 104-191, under which benefits for health care services are secondary or
20incidental to other insurance benefits.
AB445,21,2321 (c) “Health benefit plan" does not include any of the following benefits if they
22are provided under a separate policy, certificate, or contract of insurance or otherwise
23not an integral part of the plan:
AB445,21,2424 1. Limited scope dental or vision benefits.
12. Benefits for long-term care, nursing home care, home health care,
2community-based care, or any combination of those.
AB445,22,43 3. Other similar, limited benefits specified in federal regulations issued under
4P.L. 104-191.
AB445,22,115 (d) “Health benefit plan" does not include any of the following benefits if the
6benefits are provided under a separate policy, certificate, or contract of insurance,
7there is no coordination between the provision of the benefits and any exclusion of
8benefits under any group health plan maintained by the same plan sponsor, and the
9benefits are paid with respect to an event without regard to whether benefits are
10provided with respect to such an event under any group health plan maintained by
11the same plan sponsor:
AB445,22,1212 1. Coverage only for a specified disease or illness.
AB445,22,1313 2. Hospital indemnity or other fixed indemnity insurance.
AB445,22,1514 (e) “Health benefit plan" does not include any of the following if offered as a
15separate policy, certificate, or contract of insurance:
AB445,22,1716 1. Medicare supplemental health insurance as defined under section 1882 (g)
17(1) of the federal Social Security Act.
AB445,22,1918 2. Coverage supplemental to the coverage provided under the Civilian Health
19and Medical Program of the Uniformed Services 10 USC ch. 55.
AB445,22,2120 3. Similar coverage supplemental to coverage provided under a group health
AB445,23,3 22(5) “Health carrier" means an entity subject to the insurance laws and rules
23of this state, or subject to the jurisdiction of the commissioner, that contracts or offers
24to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of
25health care services, including a sickness and accident insurance company, a health

1maintenance organization, a nonprofit hospital and health service corporation, or
2any other entity providing a plan of health insurance, health benefits, or health
AB445,23,5 4(5m) “Minimum essential coverage" has the meaning given in 26 USC 5000A
5(f) (1).
AB445,23,7 6(6) “Qualified dental plan" means a limited scope dental plan that has been
7certified in accordance with s. 636.42 (5).
AB445,23,11 8(7) “Qualified employer" means a small employer that elects to make its
9full-time employees eligible for one or more qualified health plans offered through
10the SHOP Exchange and, at the option of the employer, some or all of its part-time
11employees, provided that the employer satisfies any of the following:
AB445,23,1412 (a) The employer has its principal place of business in this state and elects to
13provide coverage through the SHOP Exchange to all of its eligible employees,
14wherever employed.
AB445,23,1615 (b) The employer elects to provide coverage through the SHOP Exchange to all
16of its eligible employees who are principally employed in this state.
AB445,23,19 17(8) “Qualified health plan" means a health benefit plan that has in effect a
18certification that the plan meets the criteria for certification described in section
191311 (c) of the federal act and s. 636.42.
AB445,23,21 20(9) “Qualified individual" means an individual, including a minor, who satisfies
21all of the following:
AB445,23,2322 (a) The individual is seeking to enroll in a qualified health plan offered to
23individuals through the exchange under subch. II.
AB445,23,2424 (b) The individual resides in this state.
1(c) At the time of enrollment, the individual is not incarcerated in a correctional
2facility, other than incarceration pending the disposition of charges.
AB445,24,53 (d) The individual is, and is reasonably expected to be for the entire period for
4which enrollment is sought, a citizen or national of the United States or an alien
5lawfully present in the United States.
AB445,24,7 6(10) “Secretary" means the secretary of the federal department of health and
7human services.
AB445,24,9 8(11) “SHOP Exchange" means a small business health options program
9established under s. 636.30 (1) (q).
AB445,24,11 10(12) (a) “Small employer" means an employer that employed an average of not
11more than 100 employees during the preceding calendar year.
AB445,24,1212 (b) For purposes of this subsection, all of the following apply:
AB445,24,14131. All persons treated as a single employer under section 414 (b), (c), (m), or (o)
14of the Internal Revenue Code shall be treated as a single employer.
AB445,24,1615 2. An employer and any predecessor employer shall be treated as a single
AB445,24,1817 3. All employees shall be counted, including part-time employees and
18employees who are not eligible for coverage through the employer.
AB445,24,2219 4. If an employer was not in existence during the entire preceding calendar
20year, the determination of whether that employer is a small employer shall be based
21on the average number of employees that it is reasonably expected that employer will
22employ on business days in the current calendar year.
AB445,25,223 5. An employer that makes enrollment in qualified health plans available to
24its employees through the SHOP Exchange and that would cease to be a small
25employer by reason of an increase in the number of its employees shall continue to

1be treated as a small employer for purposes of this chapter as long as it continuously
2makes enrollment through the SHOP Exchange available to its employees.
AB445,25,43 subchapter II
4 operation of exchange
AB445,25,8 5636.25 General matters. (1) The authority shall establish and operate a
6Wisconsin Health Benefit Exchange and shall make qualified health plans, with
7effective dates on or before January 1, 2018, available to qualified individuals and
8qualified employers.
AB445,25,10 9(2) (a) The authority may not make available any health benefit plan that is
10not a qualified health plan.
AB445,25,1511 (b) The authority shall allow a health carrier to offer a plan that provides
12limited scope dental benefits meeting the requirements of section 9832 (c) (2) (A) of
13the Internal Revenue Code through the exchange under sub. (1), either separately
14or in conjunction with a qualified health plan, if the plan provides pediatric dental
15benefits meeting the requirements of section 1302 (b) (1) (J) of the federal act.
AB445,25,22 16(3) Neither the authority nor a health carrier offering health benefit plans
17through the exchange under sub. (1) may charge an individual a fee or penalty for
18termination of coverage if the individual enrolls in another type of minimum
19essential coverage because the individual has become newly eligible for that
20coverage or because the individual's employer-sponsored coverage has become
21affordable under the standards of section 36B (c) (2) (C) of the Internal Revenue
AB445,26,2 23(4) The authority may enter into information-sharing agreements with federal
24and state agencies and entities operating exchanges in other states to carry out its
25responsibilities under this chapter, provided that such agreements include adequate

1protections with respect to the confidentiality of the information to be shared and
2comply with all state and federal laws and rules and regulations.
AB445,26,5 3636.30 Exchange duties and powers. (1) In addition to all other duties
4imposed under this chapter, the authority shall do all of the following relating to the
5exchange under s. 636.25 (1):
AB445,26,96 (a) Implement procedures for the certification, recertification, and
7decertification, consistent with guidelines developed by the secretary under section
81311 (c) of the federal act and s. 636.42, of health benefit plans as qualified health
AB445,26,1110 (b) Provide for the operation of a toll-free telephone hotline to respond to
11requests for assistance.
AB445,26,1312 (c) Provide for enrollment periods, as provided under section 1311 (c) (6) of the
13federal act.
AB445,26,1614 (d) Maintain an Internet site through which enrollees and prospective
15enrollees of qualified health plans may obtain standardized comparative
16information on such plans.
AB445,26,2117 (e) Assign a rating to each qualified health plan offered through the exchange
18in accordance with the criteria developed by the secretary under section 1311 (c) (3)
19of the federal act, and determine each qualified health plan's level of coverage in
20accordance with regulations issued by the secretary under section 1302 (d) (2) (A) of
21the federal act.
AB445,26,2422 (f) Use a standardized format for presenting health benefit options in the
23exchange, including the use of the uniform outline of coverage established under 42
24USC 300gg-15
1(g) Establish quality improvement standards for health benefit plans offered
2through the exchange.
AB445,27,43 (h) Establish a system for enrolling eligible groups and individuals, using a
4standard application form developed by the commissioner under s. 636.46 (2).
AB445,27,65 (i) Establish procedures for collecting premiums and remitting premium
6payments and providing enrollment information to health carriers.
AB445,27,97 (j) Establish, in consultation with the commissioner, the method for
8determining the amount of the surcharge under s. 636.45 (1) and establish the
9procedure for imposing and collecting the surcharge.
AB445,27,1110 (k) Establish a plan for publicizing the exchange and the eligibility
11requirements and enrollment procedures.
AB445,27,1312 (L) Establish and operate a service center to provide information to small
13employers, individuals, enrollees, and insurance intermediaries about the exchange.
AB445,27,1514 (m) Establish a mechanism for regular communication and cooperation with
15insurance intermediaries.
AB445,27,1716 (n) Establish an independent and binding appeals process for resolving
17disputes over eligibility and other determinations made by the authority.
AB445,27,2218 (o) In accordance with section 1413 of the federal act, inform individuals of
19eligibility requirements for Medical Assistance under subch. IV of ch. 49 or any other
20applicable state or local public program and if, through screening of the application
21by the authority, the authority determines that any individual is eligible for any such
22program, assist that individual to enroll in that program.
AB445,28,223 (p) Establish and make available by electronic means a calculator to determine
24the actual cost of coverage after application of any premium tax credit under section

136B of the Internal Revenue Code and any cost-sharing reduction under section
21402 of the federal act.
AB445,28,63 (q) Establish a SHOP Exchange through which qualified employers may access
4health care coverage for their employees and that shall enable any qualified
5employer to specify the level of coverage at which its employees may enroll in any
6qualified health plan offered through the SHOP Exchange.
AB445,28,97 (r) Perform duties required of the authority by the secretary or the federal
8secretary of the treasury related to determining eligibility for premium tax credits,
9reduced cost sharing, or individual responsibility requirement exemptions.
AB445,28,1310 (s) Select entities, which may include insurance intermediaries, that are
11qualified to serve as navigators in accordance with section 1311 (i) of the federal act
12and standards developed by the secretary, and award grants to enable navigators to
13do all of the following:
AB445,28,1514 1. Conduct public education activities to raise awareness of the availability of
15qualified health plans.
AB445,28,1916 2. Distribute fair and impartial information concerning enrollment in qualified
17health plans and concerning the availability of premium tax credits under section
1836B of the Internal Revenue Code and cost-sharing reductions under section 1402
19of the federal act.
AB445,28,2020 3. Facilitate enrollment in qualified health plans.
AB445,28,2521 4. Provide referrals to any applicable office of health insurance consumer
22assistance or health insurance ombudsman established under 42 USC 300gg-93, or
23to any other appropriate state agency or agencies, for any enrollee with a grievance,
24complaint, or question regarding the enrollee's health benefit plan, coverage, or
25determination under that plan or coverage.
15. Provide information in a manner that is culturally and linguistically
2appropriate to the needs of the population being served by the exchange.
AB445,29,53 (t) Assist in the coordination of any necessary administrative operations
4between the department of corrections and the department of health services to
5ensure all of the following:
AB445,29,86 1. That an individual, upon placement in a correctional facility, is disenrolled
7for the duration of his or her incarceration from any health care coverage in which
8he or she is enrolled.
AB445,29,139 2. That an individual who is incarcerated in a correctional facility, but
10scheduled to be released from incarceration in the near future, is enrolled prior to
11release, through the exchange and effective upon the date of his or her release, in
12Medical Assistance, a qualified health plan, or some other form of minimum
13essential coverage on the date of his or her release from incarceration.
AB445,29,1914 (u) For those persons whose alcohol or other drug abuse or mental health
15treatment is not covered by a federally administered program, coordinate the
16relationships among the Medical Assistance program, the exchange, and the county
17departments under s. 51.42 or 51.437 to provide outpatient and inpatient mental
18health and alcohol or other drug abuse treatment with all of the following goals for
19the coordination:
AB445,29,2120 1. Maximizing coverage and improving access through the exchange for
21outpatient and inpatient treatment of mental illness and alcohol or other drug abuse.
AB445,29,2322 2. Improving the quality of treatment for persons with alcohol or other drug
23dependence or a mental illness.
AB445,29,2524 3. Fully integrating the treatment for physical conditions, alcohol or other drug
25abuse, and mental illness.
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.