“Health carrier" means an entity subject to the insurance laws and rules 23
of this state, or subject to the jurisdiction of the commissioner, that contracts or offers 24
to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of 25
health care services, including a sickness and accident insurance company, a health
maintenance organization, a nonprofit hospital and health service corporation, or 2
any other entity providing a plan of health insurance, health benefits, or health 3
“Minimum essential coverage" has the meaning given in 26 USC 5000A 5
“Qualified dental plan" means a limited scope dental plan that has been 7
certified in accordance with s. 636.42 (5).
“Qualified employer" means a small employer that elects to make its 9
full-time employees eligible for one or more qualified health plans offered through 10
the SHOP Exchange and, at the option of the employer, some or all of its part-time 11
employees, provided that the employer satisfies any of the following:
(a) The employer has its principal place of business in this state and elects to 13
provide coverage through the SHOP Exchange to all of its eligible employees, 14
(b) The employer elects to provide coverage through the SHOP Exchange to all 16
of its eligible employees who are principally employed in this state.
“Qualified health plan" means a health benefit plan that has in effect a 18
certification that the plan meets the criteria for certification described in section 19
1311 (c) of the federal act and s. 636.42.
“Qualified individual" means an individual, including a minor, who satisfies 21
all of the following:
(a) The individual is seeking to enroll in a qualified health plan offered to 23
individuals through the exchange under subch. II.
(b) The individual resides in this state.
(c) At the time of enrollment, the individual is not incarcerated in a correctional 2
facility, other than incarceration pending the disposition of charges.
(d) The individual is, and is reasonably expected to be for the entire period for 4
which enrollment is sought, a citizen or national of the United States or an alien 5
lawfully present in the United States.
“Secretary" means the secretary of the federal department of health and 7
“SHOP Exchange" means a small business health options program 9
established under s. 636.30 (1) (q).
(a) “Small employer" means an employer that employed an average of not 11
more than 100 employees during the preceding calendar year.
(b) For purposes of this subsection, all of the following apply:
1. All persons treated as a single employer under section 414
(b), (c), (m), or (o) 14
of the Internal Revenue Code shall be treated as a single employer.
2. An employer and any predecessor employer shall be treated as a single 16
3. All employees shall be counted, including part-time employees and 18
employees who are not eligible for coverage through the employer.
4. If an employer was not in existence during the entire preceding calendar 20
year, the determination of whether that employer is a small employer shall be based 21
on the average number of employees that it is reasonably expected that employer will 22
employ on business days in the current calendar year.
5. An employer that makes enrollment in qualified health plans available to 24
its employees through the SHOP Exchange and that would cease to be a small 25
employer by reason of an increase in the number of its employees shall continue to
be treated as a small employer for purposes of this chapter as long as it continuously 2
makes enrollment through the SHOP Exchange available to its employees.
operation of exchange
5636.25 General matters. (1)
The authority shall establish and operate a 6
Wisconsin Health Benefit Exchange and shall make qualified health plans, with 7
effective dates on or before January 1, 2018, available to qualified individuals and 8
(a) The authority may not make available any health benefit plan that is 10
not a qualified health plan.
(b) The authority shall allow a health carrier to offer a plan that provides 12
limited scope dental benefits meeting the requirements of section 9832
(c) (2) (A) of 13
the Internal Revenue Code through the exchange under sub. (1), either separately 14
or in conjunction with a qualified health plan, if the plan provides pediatric dental 15
benefits meeting the requirements of section 1302 (b) (1) (J) of the federal act.
Neither the authority nor a health carrier offering health benefit plans 17
through the exchange under sub. (1) may charge an individual a fee or penalty for 18
termination of coverage if the individual enrolls in another type of minimum 19
essential coverage because the individual has become newly eligible for that 20
coverage or because the individual's employer-sponsored coverage has become 21
affordable under the standards of section 36B
(c) (2) (C) of the Internal Revenue 22
The authority may enter into information-sharing agreements with federal 24
and state agencies and entities operating exchanges in other states to carry out its 25
responsibilities under this chapter, provided that such agreements include adequate
protections with respect to the confidentiality of the information to be shared and 2
comply with all state and federal laws and rules and regulations.
3636.30 Exchange duties and powers. (1)
In addition to all other duties 4
imposed under this chapter, the authority shall do all of the following relating to the 5
exchange under s. 636.25 (1):
(a) Implement procedures for the certification, recertification, and 7
decertification, consistent with guidelines developed by the secretary under section 8
1311 (c) of the federal act and s. 636.42, of health benefit plans as qualified health 9
(b) Provide for the operation of a toll-free telephone hotline to respond to 11
requests for assistance.
(c) Provide for enrollment periods, as provided under section 1311 (c) (6) of the 13
(d) Maintain an Internet site through which enrollees and prospective 15
enrollees of qualified health plans may obtain standardized comparative 16
information on such plans.
(e) Assign a rating to each qualified health plan offered through the exchange 18
in accordance with the criteria developed by the secretary under section 1311 (c) (3) 19
of the federal act, and determine each qualified health plan's level of coverage in 20
accordance with regulations issued by the secretary under section 1302 (d) (2) (A) of 21
the federal act.
(f) Use a standardized format for presenting health benefit options in the 23
exchange, including the use of the uniform outline of coverage established under 42
(g) Establish quality improvement standards for health benefit plans offered 2
through the exchange.
(h) Establish a system for enrolling eligible groups and individuals, using a 4
standard application form developed by the commissioner under s. 636.46 (2).
(i) Establish procedures for collecting premiums and remitting premium 6
payments and providing enrollment information to health carriers.
(j) Establish, in consultation with the commissioner, the method for 8
determining the amount of the surcharge under s. 636.45 (1) and establish the 9
procedure for imposing and collecting the surcharge.
(k) Establish a plan for publicizing the exchange and the eligibility 11
requirements and enrollment procedures.
(L) Establish and operate a service center to provide information to small 13
employers, individuals, enrollees, and insurance intermediaries about the exchange.
(m) Establish a mechanism for regular communication and cooperation with 15
(n) Establish an independent and binding appeals process for resolving 17
disputes over eligibility and other determinations made by the authority.
(o) In accordance with section 1413 of the federal act, inform individuals of 19
eligibility requirements for Medical Assistance under subch. IV of ch. 49 or any other 20
applicable state or local public program and if, through screening of the application 21
by the authority, the authority determines that any individual is eligible for any such 22
program, assist that individual to enroll in that program.
(p) Establish and make available by electronic means a calculator to determine 24
the actual cost of coverage after application of any premium tax credit under section
of the Internal Revenue Code and any cost-sharing reduction under section 2
1402 of the federal act.
(q) Establish a SHOP Exchange through which qualified employers may access 4
health care coverage for their employees and that shall enable any qualified 5
employer to specify the level of coverage at which its employees may enroll in any 6
qualified health plan offered through the SHOP Exchange.
(r) Perform duties required of the authority by the secretary or the federal 8
secretary of the treasury related to determining eligibility for premium tax credits, 9
reduced cost sharing, or individual responsibility requirement exemptions.
(s) Select entities, which may include insurance intermediaries, that are 11
qualified to serve as navigators in accordance with section 1311 (i) of the federal act 12
and standards developed by the secretary, and award grants to enable navigators to 13
do all of the following:
1. Conduct public education activities to raise awareness of the availability of 15
qualified health plans.
2. Distribute fair and impartial information concerning enrollment in qualified 17
health plans and concerning the availability of premium tax credits under section 1836B
of the Internal Revenue Code and cost-sharing reductions under section 1402 19
of the federal act.
3. Facilitate enrollment in qualified health plans.
4. Provide referrals to any applicable office of health insurance consumer 22
assistance or health insurance ombudsman established under 42 USC 300gg-93
, or 23
to any other appropriate state agency or agencies, for any enrollee with a grievance, 24
complaint, or question regarding the enrollee's health benefit plan, coverage, or 25
determination under that plan or coverage.
5. Provide information in a manner that is culturally and linguistically 2
appropriate to the needs of the population being served by the exchange.
(t) Assist in the coordination of any necessary administrative operations 4
between the department of corrections and the department of health services to 5
ensure all of the following:
1. That an individual, upon placement in a correctional facility, is disenrolled 7
for the duration of his or her incarceration from any health care coverage in which 8
he or she is enrolled.
2. That an individual who is incarcerated in a correctional facility, but 10
scheduled to be released from incarceration in the near future, is enrolled prior to 11
release, through the exchange and effective upon the date of his or her release, in 12
Medical Assistance, a qualified health plan, or some other form of minimum 13
essential coverage on the date of his or her release from incarceration.
(u) For those persons whose alcohol or other drug abuse or mental health 15
treatment is not covered by a federally administered program, coordinate the 16
relationships among the Medical Assistance program, the exchange, and the county 17
departments under s. 51.42 or 51.437 to provide outpatient and inpatient mental 18
health and alcohol or other drug abuse treatment with all of the following goals for 19
1. Maximizing coverage and improving access through the exchange for 21
outpatient and inpatient treatment of mental illness and alcohol or other drug abuse.
2. Improving the quality of treatment for persons with alcohol or other drug 23
dependence or a mental illness.
3. Fully integrating the treatment for physical conditions, alcohol or other drug 25
abuse, and mental illness.
4. Reducing the cost of the county departments under ss. 51.42 and 51.437 to 2
taxpayers by avoiding unnecessary overlap between the improved coverage of 3
alcohol or other drug abuse treatment or mental illness treatment by health plans 4
offered through the exchange and the services provided by county departments 5
under s. 51.42 or 51.437.
(v) Review the rate of premium growth within the exchange and outside the 7
exchange, and consider the information in developing recommendations on whether 8
to continue limiting qualified employer status to small employers.
(w) Credit the amount of any free choice voucher to the monthly premium of 10
the plan in which a qualified employee is enrolled, in accordance with section 10108 11
of the federal act, and collect the amount credited from the offering employer.
(x) Consult with stakeholders relevant to carrying out the activities required 13
under this chapter, including any of the following:
1. Educated health care consumers who are enrollees in qualified health plans.
2. Individuals and entities with experience in facilitating enrollment in 16
qualified health plans.
3. Representatives of small businesses and self-employed individuals.
4. The department of health services.
5. Advocates for enrolling hard-to-reach populations.
(y) Meet all of the following financial integrity requirements:
1. Keep an accurate accounting of all activities, receipts, and expenditures and 22
annually submit to the secretary, the governor, the commissioner, and the legislature 23
a report concerning such accountings.
2. Fully cooperate with any investigation conducted by the secretary under the 25
secretary's authority under the federal act and allow the secretary, in coordination
with the inspector general of the federal department of health and human services, 2
to do all of the following:
a. Investigate the affairs of the authority.
b. Examine the properties and records of the authority.
c. Require periodic reports in relation to the activities undertaken by the 6
3. In carrying out its activities under this chapter, not use any funds intended 8
for the administrative and operational expenses of the authority for staff retreats, 9
promotional giveaways, excessive executive compensation, or promotion of federal 10
or state legislative or regulatory modifications, except that this subdivision does not 11
prohibit the authority from advocating, as part of administering the exchange, for 12
policies that the authority determines are in the best interest of the exchange or of 13
individuals and employees receiving coverage through the exchange.
The authority may do all of the following relating to the exchange under s. 15
(a) Contract with a 3rd-party administrator for the provision of services on 17
behalf of the exchange.
(b) Establish risk adjustment mechanisms for the exchange.
(c) Enter into agreements with or establish sub-exchanges.
(d) Create any other exchange, or component of the exchange, that is provided 21
for under federal law.
The authority shall seek grants to the fullest extent to which it is eligible, 23
including amounts under section 1311 (a) (1) and (4) of the federal act, or other 24
funding from the federal or state government for which it may be eligible and from 25
private foundations for the purpose of the exchange under s. 636.25 (1).
1636.42 Health benefit plan certification. (1)
The authority may certify a 2
health benefit plan as a qualified health plan if all of the following are true:
(a) The plan provides the essential health benefits package described in section 4
1302 (a) of the federal act, except that the plan is not required to provide essential 5
benefits that duplicate the minimum benefits of qualified dental plans, as provided 6
in sub. (5), if all of the following are satisfied:
1. The authority has determined that at least one qualified dental plan is 8
available to supplement the plan's coverage.
2. The health carrier makes prominent disclosure at the time it offers the plan, 10
in a form approved by the authority, that the plan does not provide the full range of 11
essential pediatric benefits and that qualified dental plans providing those benefits 12
and other dental benefits not covered by the plan are offered through the exchange 13
under s. 636.25 (1).
(b) The premium rates and contract language have been filed with and not 15
disapproved by the commissioner.
(c) The plan provides at least a bronze level of coverage, as determined under 17
s. 636.30 (1) (e), unless the plan is certified as a qualified catastrophic plan, meets 18
the requirements of the federal act for catastrophic plans, and will only be offered to 19
individuals eligible for catastrophic coverage.
(d) The plan's cost-sharing requirements do not exceed the limits established 21
under section 1302 (c) (1) of the federal act and, if the plan is offered through the 22
SHOP Exchange, the plan's deductible does not exceed the limits established under 23
section 1302 (c) (2) of the federal act.
(e) The health carrier offering the plan satisfies all of the following: