This is the preview version of the Wisconsin State Legislature site.
Please see for the production version.
AB445,31,32 2. Individuals and entities with experience in facilitating enrollment in
3qualified health plans.
AB445,31,44 3. Representatives of small businesses and self-employed individuals.
AB445,31,55 4. The department of health services.
AB445,31,66 5. Advocates for enrolling hard-to-reach populations.
AB445,31,77 (y) Meet all of the following financial integrity requirements:
AB445,31,108 1. Keep an accurate accounting of all activities, receipts, and expenditures and
9annually submit to the secretary, the governor, the commissioner, and the legislature
10a report concerning such accountings.
AB445,31,1411 2. Fully cooperate with any investigation conducted by the secretary under the
12secretary's authority under the federal act and allow the secretary, in coordination
13with the inspector general of the federal department of health and human services,
14to do all of the following:
AB445,31,1515 a. Investigate the affairs of the authority.
AB445,31,1616 b. Examine the properties and records of the authority.
AB445,31,1817 c. Require periodic reports in relation to the activities undertaken by the
AB445,31,2519 3. In carrying out its activities under this chapter, not use any funds intended
20for the administrative and operational expenses of the authority for staff retreats,
21promotional giveaways, excessive executive compensation, or promotion of federal
22or state legislative or regulatory modifications, except that this subdivision does not
23prohibit the authority from advocating, as part of administering the exchange, for
24policies that the authority determines are in the best interest of the exchange or of
25individuals and employees receiving coverage through the exchange.
1(2) The authority may do all of the following relating to the exchange under s.
2636.25 (1):
AB445,32,43 (a) Contract with a 3rd-party administrator for the provision of services on
4behalf of the exchange.
AB445,32,55 (b) Establish risk adjustment mechanisms for the exchange.
AB445,32,66 (c) Enter into agreements with or establish sub-exchanges.
AB445,32,87 (d) Create any other exchange, or component of the exchange, that is provided
8for under federal law.
AB445,32,12 9(3) The authority shall seek grants to the fullest extent to which it is eligible,
10including amounts under section 1311 (a) (1) and (4) of the federal act, or other
11funding from the federal or state government for which it may be eligible and from
12private foundations for the purpose of the exchange under s. 636.25 (1).
AB445,32,14 13636.42 Health benefit plan certification. (1) The authority may certify a
14health benefit plan as a qualified health plan if all of the following are true:
AB445,32,1815 (a) The plan provides the essential health benefits package described in section
161302 (a) of the federal act, except that the plan is not required to provide essential
17benefits that duplicate the minimum benefits of qualified dental plans, as provided
18in sub. (5), if all of the following are satisfied:
AB445,32,2019 1. The authority has determined that at least one qualified dental plan is
20available to supplement the plan's coverage.
AB445,32,2521 2. The health carrier makes prominent disclosure at the time it offers the plan,
22in a form approved by the authority, that the plan does not provide the full range of
23essential pediatric benefits and that qualified dental plans providing those benefits
24and other dental benefits not covered by the plan are offered through the exchange
25under s. 636.25 (1).
1(b) The premium rates and contract language have been filed with and not
2disapproved by the commissioner.
AB445,33,63 (c) The plan provides at least a bronze level of coverage, as determined under
4s. 636.30 (1) (e), unless the plan is certified as a qualified catastrophic plan, meets
5the requirements of the federal act for catastrophic plans, and will only be offered to
6individuals eligible for catastrophic coverage.
AB445,33,107 (d) The plan's cost-sharing requirements do not exceed the limits established
8under section 1302 (c) (1) of the federal act and, if the plan is offered through the
9SHOP Exchange, the plan's deductible does not exceed the limits established under
10section 1302 (c) (2) of the federal act.
AB445,33,1111 (e) The health carrier offering the plan satisfies all of the following:
AB445,33,1312 1. Is licensed and in good standing to offer health insurance coverage in this
AB445,33,1714 2. Offers at least one qualified health plan in the silver level and at least one
15qualified health plan in the gold level through each component of the exchange in
16which the health carrier participates. In this subdivision, “component" refers to the
17SHOP Exchange or the exchange under s. 636.25 for individual coverage.
AB445,33,2018 3. Charges the same premium rate for each qualified health plan without
19regard to whether the plan is offered directly from the health carrier or through an
20insurance intermediary.
AB445,33,2221 4. Does not charge any cancellation fees or penalties in violation of s. 636.25
AB445,33,2423 5. Complies with the regulations developed by the secretary under section 1311
24(d) of the federal act and such other requirements as the authority may establish.
1(f) The plan meets the requirements of certification as required by any rules
2promulgated under s. 636.46 (1) and by the secretary under section 1311 (c) of the
3federal act, including minimum standards in the areas of marketing practices,
4network adequacy, essential community providers in underserved areas,
5accreditation, quality improvement, uniform enrollment forms, and descriptions of
6coverage and information on quality measures for health benefit plan performance.
AB445,34,97 (g) The authority determines that making the plan available through the
8exchange under s. 636.25 (1) is in the interest of qualified individuals and qualified
9employers in this state.
AB445,34,11 10(2) The authority shall not exclude a health benefit plan for any of the following
11reasons or in any of the following ways:
AB445,34,1212 (a) On the basis that the plan is a fee-for-service plan.
AB445,34,1313 (b) Through the imposition of premium price controls by the authority.
AB445,34,1614 (c) On the basis that the plan provides treatments necessary to prevent
15patients' deaths in circumstances the authority determines are inappropriate or too
AB445,34,18 17(3) The authority shall require each health carrier seeking certification of a
18health benefit plan as a qualified health plan to do all of the following:
AB445,34,2419 (a) Submit a justification for any premium increase before implementation of
20that increase. The health carrier shall prominently post the information on its
21Internet site. The authority shall take this information, along with the information
22and the recommendations provided to the authority by the commissioner under 42
23USC 300gg-94
(b), into consideration when determining whether to allow the health
24carrier to make the plan available through the exchange under s. 636.25 (1).
1(b) 1. Make available to the public, in the format described in subd. 2., and
2submit to the authority, the secretary, and the commissioner, accurate and timely
3disclosure of all of the following:
AB445,35,44 a. Claims payment policies and practices.
AB445,35,55 b. Periodic financial disclosures.
AB445,35,66 c. Data on enrollment.
AB445,35,77 d. Data on disenrollment.
AB445,35,88 e. Data on the number of claims that are denied.
AB445,35,99 f. Data on rating practices.
AB445,35,1110 g. Information on cost sharing and payments with respect to any
11out-of-network coverage.
AB445,35,1212 h. Information on enrollee and participant rights under title I of the federal act.
AB445,35,1313 i. Other information as determined appropriate by the secretary.
AB445,35,1514 2. The information required in subd. 1. shall be provided in plain language, as
15that term is defined in section 1311 (e) (3) (B) of the federal act.
AB445,35,2216 (c) Permit individuals to learn, in a timely manner upon the request of the
17individual, the amount of cost sharing, including deductibles, copayments, and
18coinsurance, under the individual's plan or coverage that the individual would be
19responsible for paying with respect to the furnishing of a specific item or service by
20a participating provider. At a minimum, this information shall be made available
21to the individual through an Internet site and through other means for individuals
22without access to the Internet.
AB445,36,2 23(4) The authority may not exempt any health carrier seeking certification of
24a health benefit plan as a qualified health plan, regardless of the type or size of the
25health carrier, from state licensure or solvency requirements and shall apply the

1criteria of this section in a manner that assures equitable treatment of all health
2carriers participating in the exchange under s. 636.25 (1).
AB445,36,6 3(5) (a) The provisions of this chapter that are applicable to qualified health
4plans shall also apply to the extent relevant to qualified dental plans, except as
5modified in accordance with pars. (b), (c), and (d) or by regulations adopted by the
AB445,36,87 (b) The health carrier shall be licensed to offer dental coverage, but need not
8be licensed to offer other health benefits.
AB445,36,149 (c) The plan shall be limited to dental and oral health benefits, without
10substantially duplicating the benefits typically offered by health benefit plans
11without dental coverage, and shall include, at a minimum, the essential pediatric
12dental benefits prescribed by the secretary under section 1302 (b) (1) (J) of the federal
13act and such other dental benefits as the authority or the secretary may specify by
AB445,36,1915 (d) Health carriers may jointly offer a comprehensive plan through the
16exchange under s. 636.25 (1) in which the dental benefits are provided by a health
17carrier through a qualified dental plan and the other benefits are provided by a
18health carrier through a qualified health plan, provided that the plans are priced
19separately and are also made available for purchase separately at the same price.
AB445,36,25 20636.43 Insurer requirements. (1) Any health carrier that is authorized to
21do business in this state in one or more lines of insurance that includes health
22insurance may offer health benefit plans through the exchange under s. 636.25 (1).
23After the exchange becomes operational, no health carrier may offer or issue a health
24benefit plan in this state to an individual or to a small employer except through the
1(2) For the purpose of determining premiums, a health carrier may pool
2together all individuals and employees who have coverage under all of the qualified
3health plans issued by the health carrier through the exchange under s. 636.25 (1).
AB445,37,7 4(3) A health carrier that offers qualified health plans through the exchange
5under s. 636.25 (1) shall establish a toll-free hotline for providing information to
6enrollees and other individuals and shall furnish such reasonable reports as the
7authority determines necessary for the administration of the exchange.
AB445,37,11 8(4) The authority may audit any health carrier that provides coverage under
9a qualified health plan through the exchange under s. 636.25 (1) for the purpose of
10ensuring that the health carrier is providing covered individuals with the benefits
11provided for under this subchapter in a manner that does all of the following:
AB445,37,1212 (a) Complies with the provisions of this chapter.
AB445,37,1313 (b) Promotes positive health outcomes.
AB445,37,1414 (c) Advances value-based and evidence-based medical practices.
AB445,37,1715 (d) Avoids unnecessary operating and capital costs arising from inappropriate
16utilization or inefficient delivery of health care services, unwarranted duplication of
17services and infrastructure, or creation of excess care delivery capacity.
AB445,37,1818 (e) Holds down the growth of health care costs.
AB445,38,2 19636.44 Intermediaries. An insurance intermediary that enrolls a qualified
20individual in a qualified health plan through the exchange under s. 636.25 (1) shall
21be paid a commission by the health carrier offering the qualified health plan. An
22insurance intermediary that enrolls the employees of a qualified employer in one or
23more qualified health plans through the exchange shall be paid a commission by each
24health carrier offering a qualified health plan selected by an employee of the

1qualified employer. The authority shall determine the commission amounts that
2must be paid to intermediaries under this section.
AB445,38,7 3636.45 Funding; publication of costs. (1) For payment of administrative
4expenses, the authority may impose a surcharge on each health carrier offering
5qualified health plans through the exchange under s. 636.25 (1). The surcharge shall
6be based on the health carrier's total premium or flat dollar amount per enrollee
7collected through the exchange.
AB445,38,11 8(2) The authority shall publish the average costs of licensing, regulatory fees,
9and any other payments required by the authority, and the administrative costs of
10the authority, on an Internet site to educate consumers on such costs. This
11information shall include information on moneys lost to waste, fraud, and abuse.
AB445,38,15 12636.46 Rules; application form. (1) The commissioner may promulgate
13rules to implement the provisions of this chapter. Rules promulgated under this
14section may not conflict with or prevent the application of regulations promulgated
15by the secretary under the federal act.
AB445,38,17 16(2) The commissioner shall develop a standard application form for use in the
AB445,38,24 18636.48 Relation to other laws. Nothing in this chapter, and no action taken
19by the authority under this chapter, shall be construed to preempt or supersede the
20authority of the commissioner to regulate the business of insurance within this state.
21Except as expressly provided to the contrary in this chapter, all health carriers
22offering qualified health plans in this state shall comply fully with all applicable
23health insurance laws of this state and rules promulgated and orders issued by the
1Subchapter III
2 badger Health benefit authority
AB445,39,13 3636.70 Creation and organization of authority. (1) There is created a
4public body corporate and politic to be known as the “Badger Health Benefit
5Authority." The board of directors of the authority shall consist of the commissioner,
6or his or her designee; the secretary of employee trust funds, or his or her designee;
7the person who is appointed by the secretary of health services to be the director of
8the Medical Assistance program, or his or her designee; the executive director, or his
9or her designee, of the Wisconsin Collaborative for Healthcare Quality, if that
10organization exists; the executive director, or his or her designee, of the Wisconsin
11Health Information Organization, if that organization exists; and all of the following
12members, who shall be nominated by the governor and, with the advice and consent
13of the senate, appointed for 3-year terms except as provided in sub. (2):
AB445,39,1414 (a) A member in good standing of the American Academy of Actuaries.
AB445,39,1515 (b) A health economist.
AB445,39,1616 (c) An employee benefits specialist.
AB445,39,1717 (d) A representative of small employers.
AB445,39,1818 (e) A representative of an organization that represents consumer interests.
AB445,39,1919 (f) A representative of organized labor.
AB445,39,2020 (g) An individual with experience in health care administration.
AB445,39,24 21(2) No member of the board appointed under sub. (1) (a) to (g) may be a health
22care provider, as defined in s. 146.81 (1) (a) to (hp); an employee of a health care
23provider, as defined in s. 146.81 (1) (i) to (p); an employee of an insurer that is
24authorized to do business in the state; or an insurance intermediary.
1(3) A vacancy on the board under sub. (1) shall be filled in the same manner
2as the original appointment to the board for the remainder of the unexpired term,
3if any.
AB445,40,7 4(4) A member of the board under sub. (1) shall receive no compensation for
5services under this chapter but shall be reimbursed for actual and necessary
6expenses, including travel expenses, incurred in the discharge of the member's
7duties under this chapter.
AB445,40,13 8(5) The commissioner or the commissioner's designee shall be the chairperson
9of the board under sub. (1). Seven members of the board constitute a quorum for the
10purpose of conducting the business and exercising the powers of the authority,
11notwithstanding the existence of any vacancy. The board may take action upon a vote
12of a majority of the members present, unless the bylaws of the authority require a
13larger number.
AB445,40,25 14(6) The board under sub. (1) shall appoint an executive director who shall not
15be a member of the board and who shall serve at the pleasure of the board. The
16executive director shall receive compensation commensurate with the duties of the
17office, as determined by the board. The executive director shall serve as secretary
18of the authority and shall keep a record of the proceedings of the authority and shall
19be custodian of all books, documents, and papers filed with the authority, the minute
20book or journal of the authority, and its official seal. The executive director or other
21person may cause copies to be made of all minutes and other records and documents
22of the authority and may give certificates under the official seal of the authority to
23the effect that such copies are true copies, and all persons dealing with the authority
24may rely upon such certificates. The executive director shall have all of the following
1(a) Supervising the administrative affairs and the general management and
2operation of the authority.
AB445,41,43 (b) Planning, directing, coordinating, and executing administrative functions
4in conformity with the policies and directives of the board.
AB445,41,55 (c) Employing professional and clerical staff, as necessary.
AB445,41,76 (d) Reporting to the board on all operations under his or her control and
AB445,41,98 (e) Preparing an annual budget and managing the administrative expenses of
9the authority.