4. Worker's compensation or similar insurance.
5. Automobile medical payment insurance.
6. Credit-only insurance.
7. Coverage for on-site medical clinics.
8. Other similar insurance coverage, specified in federal regulations issued 2
under P.L. 104-191
, under which benefits for health care services are secondary or 3
incidental to other insurance benefits.
(c) “Health benefit plan" does not include any of the following benefits if they 5
are provided under a separate policy, certificate, or contract of insurance or otherwise 6
not an integral part of the plan:
1. Limited scope dental or vision benefits.
2. Benefits for long-term care, nursing home care, home health care, 9
community-based care, or any combination of those.
3. Other similar, limited benefits specified in federal regulations issued under 11
(d) “Health benefit plan" does not include any of the following benefits if the 13
benefits are provided under a separate policy, certificate, or contract of insurance, 14
there is no coordination between the provision of the benefits and any exclusion of 15
benefits under any group health plan maintained by the same plan sponsor, and the 16
benefits are paid with respect to an event without regard to whether benefits are 17
provided with respect to such an event under any group health plan maintained by 18
the same plan sponsor:
1. Coverage only for a specified disease or illness.
2. Hospital indemnity or other fixed indemnity insurance.
(e) “Health benefit plan" does not include any of the following if offered as a 22
separate policy, certificate, or contract of insurance:
1. Medicare supplemental health insurance as defined under section 1882 (g) 24
(1) of the federal Social Security Act.
2. Coverage supplemental to the coverage provided under the Civilian Health 2
and Medical Program of the Uniformed Services 10 USC ch. 55
3. Similar coverage supplemental to coverage provided under a group health 4
“Health carrier" means an entity subject to the insurance laws and rules 6
of this state, or subject to the jurisdiction of the commissioner, that contracts or offers 7
to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of 8
health care services, including a sickness and accident insurance company, a health 9
maintenance organization, a nonprofit hospital and health service corporation, or 10
any other entity providing a plan of health insurance, health benefits, or health 11
“Minimum essential coverage" has the meaning given in 26 USC 5000A 13
“Qualified dental plan" means a limited scope dental plan that has been 15
certified in accordance with s. 636.42 (5).
“Qualified employer" means a small employer that elects to make its 17
full-time employees eligible for one or more qualified health plans offered through 18
the SHOP Exchange and, at the option of the employer, some or all of its part-time 19
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 21
provide coverage through the SHOP Exchange to all of its eligible employees, 22
(b) The employer elects to provide coverage through the SHOP Exchange to all 24
of its eligible employees who are principally employed in this state.
“Qualified health plan" means a health benefit plan that has in effect a 2
certification that the plan meets the criteria for certification described in section 3
1311 (c) of the federal act and s. 636.42.
“Qualified individual" means an individual, including a minor, who satisfies 5
all of the following:
(a) The individual is seeking to enroll in a qualified health plan offered to 7
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 10
facility, other than incarceration pending the disposition of charges.
(d) The individual is, and is reasonably expected to be for the entire period for 12
which enrollment is sought, a citizen or national of the United States or an alien 13
lawfully present in the United States.
“Secretary" means the secretary of the federal department of health and 15
“SHOP Exchange" means a small business health options program 17
established under s. 636.30 (1) (q).
(a) “Small employer" means an employer that employed an average of not 19
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) 22
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 24
3. All employees shall be counted, including part-time employees and 2
employees who are not eligible for coverage through the employer.
4. If an employer was not in existence during the entire preceding calendar 4
year, the determination of whether that employer is a small employer shall be based 5
on the average number of employees that it is reasonably expected that employer will 6
employ on business days in the current calendar year.
5. An employer that makes enrollment in qualified health plans available to 8
its employees through the SHOP Exchange and that would cease to be a small 9
employer by reason of an increase in the number of its employees shall continue to 10
be treated as a small employer for purposes of this chapter as long as it continuously 11
makes enrollment through the SHOP Exchange available to its employees.
operation of exchange
14636.25 General matters. (1)
The authority shall establish and operate a 15
Wisconsin Health Benefit Exchange and shall make qualified health plans, with 16
effective dates on or before January 1, 2018, available to qualified individuals and 17
(a) The authority may not make available any health benefit plan that is 19
not a qualified health plan.
(b) The authority shall allow a health carrier to offer a plan that provides 21
limited scope dental benefits meeting the requirements of section 9832
(c) (2) (A) of 22
the Internal Revenue Code through the exchange under sub. (1), either separately 23
or in conjunction with a qualified health plan, if the plan provides pediatric dental 24
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 2
through the exchange under sub. (1) may charge an individual a fee or penalty for 3
termination of coverage if the individual enrolls in another type of minimum 4
essential coverage because the individual has become newly eligible for that 5
coverage or because the individual's employer-sponsored coverage has become 6
affordable under the standards of section 36B
(c) (2) (C) of the Internal Revenue 7
The authority may enter into information-sharing agreements with federal 9
and state agencies and entities operating exchanges in other states to carry out its 10
responsibilities under this chapter, provided that such agreements include adequate 11
protections with respect to the confidentiality of the information to be shared and 12
comply with all state and federal laws and rules and regulations.
13636.30 Exchange duties and powers. (1)
In addition to all other duties 14
imposed under this chapter, the authority shall do all of the following relating to the 15
exchange under s. 636.25 (1):
(a) Implement procedures for the certification, recertification, and 17
decertification, consistent with guidelines developed by the secretary under section 18
1311 (c) of the federal act and s. 636.42, of health benefit plans as qualified health 19
(b) Provide for the operation of a toll-free telephone hotline to respond to 21
requests for assistance.
(c) Provide for enrollment periods, as provided under section 1311 (c) (6) of the 23
(d) Maintain an Internet site through which enrollees and prospective 2
enrollees of qualified health plans may obtain standardized comparative 3
information on such plans.
(e) Assign a rating to each qualified health plan offered through the exchange 5
in accordance with the criteria developed by the secretary under section 1311 (c) (3) 6
of the federal act, and determine each qualified health plan's level of coverage in 7
accordance with regulations issued by the secretary under section 1302 (d) (2) (A) of 8
the federal act.
(f) Use a standardized format for presenting health benefit options in the 10
exchange, including the use of the uniform outline of coverage established under 42
(g) Establish quality improvement standards for health benefit plans offered 13
through the exchange.
(h) Establish a system for enrolling eligible groups and individuals, using a 15
standard application form developed by the commissioner under s. 636.46 (2).
(i) Establish procedures for collecting premiums and remitting premium 17
payments and providing enrollment information to health carriers.
(j) Establish, in consultation with the commissioner, the method for 19
determining the amount of the surcharge under s. 636.45 (1) and establish the 20
procedure for imposing and collecting the surcharge.
(k) Establish a plan for publicizing the exchange and the eligibility 22
requirements and enrollment procedures.
(L) Establish and operate a service center to provide information to small 24
employers, individuals, enrollees, and insurance intermediaries about the exchange.
(m) Establish a mechanism for regular communication and cooperation with 2
(n) Establish an independent and binding appeals process for resolving 4
disputes over eligibility and other determinations made by the authority.
(o) In accordance with section 1413 of the federal act, inform individuals of 6
eligibility requirements for Medical Assistance under subch. IV of ch. 49 or any other 7
applicable state or local public program and if, through screening of the application 8
by the authority, the authority determines that any individual is eligible for any such 9
program, assist that individual to enroll in that program.
(p) Establish and make available by electronic means a calculator to determine 11
the actual cost of coverage after application of any premium tax credit under section 1236B
of the Internal Revenue Code and any cost-sharing reduction under section 13
1402 of the federal act.
(q) Establish a SHOP Exchange through which qualified employers may access 15
health care coverage for their employees and that shall enable any qualified 16
employer to specify the level of coverage at which its employees may enroll in any 17
qualified health plan offered through the SHOP Exchange.
(r) Perform duties required of the authority by the secretary or the federal 19
secretary of the treasury related to determining eligibility for premium tax credits, 20
reduced cost sharing, or individual responsibility requirement exemptions.
(s) Select entities, which may include insurance intermediaries, that are 22
qualified to serve as navigators in accordance with section 1311 (i) of the federal act 23
and standards developed by the secretary, and award grants to enable navigators to 24
do all of the following:
1. Conduct public education activities to raise awareness of the availability of 2
qualified health plans.
2. Distribute fair and impartial information concerning enrollment in qualified 4
health plans and concerning the availability of premium tax credits under section 536B
of the Internal Revenue Code and cost-sharing reductions under section 1402 6
of the federal act.
3. Facilitate enrollment in qualified health plans.
4. Provide referrals to any applicable office of health insurance consumer 9
assistance or health insurance ombudsman established under 42 USC 300gg-93
, or 10
to any other appropriate state agency or agencies, for any enrollee with a grievance, 11
complaint, or question regarding the enrollee's health benefit plan, coverage, or 12
determination under that plan or coverage.
5. Provide information in a manner that is culturally and linguistically 14
appropriate to the needs of the population being served by the exchange.
(t) Assist in the coordination of any necessary administrative operations 16
between the department of corrections and the department of health services to 17
ensure all of the following:
1. That an individual, upon placement in a correctional facility, is disenrolled 19
for the duration of his or her incarceration from any health care coverage in which 20
he or she is enrolled.
2. That an individual who is incarcerated in a correctional facility, but 22
scheduled to be released from incarceration in the near future, is enrolled prior to 23
release, through the exchange and effective upon the date of his or her release, in 24
Medical Assistance, a qualified health plan, or some other form of minimum 25
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 2
treatment is not covered by a federally administered program, coordinate the 3
relationships among the Medical Assistance program, the exchange, and the county 4
departments under s. 51.42 or 51.437 to provide outpatient and inpatient mental 5
health and alcohol or other drug abuse treatment with all of the following goals for 6
1. Maximizing coverage and improving access through the exchange for 8
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 10
dependence or a mental illness.
3. Fully integrating the treatment for physical conditions, alcohol or other drug 12
abuse, and mental illness.
4. Reducing the cost of the county departments under ss. 51.42 and 51.437 to 14
taxpayers by avoiding unnecessary overlap between the improved coverage of 15
alcohol or other drug abuse treatment or mental illness treatment by health plans 16
offered through the exchange and the services provided by county departments 17
under s. 51.42 or 51.437.
(v) Review the rate of premium growth within the exchange and outside the 19
exchange, and consider the information in developing recommendations on whether 20
to continue limiting qualified employer status to small employers.
(w) Credit the amount of any free choice voucher to the monthly premium of 22
the plan in which a qualified employee is enrolled, in accordance with section 10108 23
of the federal act, and collect the amount credited from the offering employer.
(x) Consult with stakeholders relevant to carrying out the activities required 25
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 3
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 9
annually submit to the secretary, the governor, the commissioner, and the legislature 10
a report concerning such accountings.
2. Fully cooperate with any investigation conducted by the secretary under the 12
secretary's authority under the federal act and allow the secretary, in coordination 13
with the inspector general of the federal department of health and human services, 14
to do all of the following:
a. Investigate the affairs of the authority.
b. Examine the properties and records of the authority.