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AB445,24,76 (a) The individual is seeking to enroll in a qualified health plan offered to
7individuals through the exchange under subch. II.
AB445,24,88 (b) The individual resides in this state.
AB445,24,109 (c) At the time of enrollment, the individual is not incarcerated in a correctional
10facility, other than incarceration pending the disposition of charges.
AB445,24,1311 (d) The individual is, and is reasonably expected to be for the entire period for
12which enrollment is sought, a citizen or national of the United States or an alien
13lawfully present in the United States.
AB445,24,15 14(10) “Secretary" means the secretary of the federal department of health and
15human services.
AB445,24,17 16(11) “SHOP Exchange" means a small business health options program
17established under s. 636.30 (1) (q).
AB445,24,19 18(12) (a) “Small employer" means an employer that employed an average of not
19more than 100 employees during the preceding calendar year.
AB445,24,2020 (b) For purposes of this subsection, all of the following apply:
AB445,24,22211. All persons treated as a single employer under section 414 (b), (c), (m), or (o)
22of the Internal Revenue Code shall be treated as a single employer.
AB445,24,2423 2. An employer and any predecessor employer shall be treated as a single
13. All employees shall be counted, including part-time employees and
2employees who are not eligible for coverage through the employer.
AB445,25,63 4. If an employer was not in existence during the entire preceding calendar
4year, the determination of whether that employer is a small employer shall be based
5on the average number of employees that it is reasonably expected that employer will
6employ on business days in the current calendar year.
AB445,25,117 5. An employer that makes enrollment in qualified health plans available to
8its employees through the SHOP Exchange and that would cease to be a small
9employer by reason of an increase in the number of its employees shall continue to
10be treated as a small employer for purposes of this chapter as long as it continuously
11makes enrollment through the SHOP Exchange available to its employees.
AB445,25,1312 subchapter II
13 operation of exchange
AB445,25,17 14636.25 General matters. (1) The authority shall establish and operate a
15Wisconsin Health Benefit Exchange and shall make qualified health plans, with
16effective dates on or before January 1, 2018, available to qualified individuals and
17qualified employers.
AB445,25,19 18(2) (a) The authority may not make available any health benefit plan that is
19not a qualified health plan.
AB445,25,2420 (b) The authority shall allow a health carrier to offer a plan that provides
21limited scope dental benefits meeting the requirements of section 9832 (c) (2) (A) of
22the Internal Revenue Code through the exchange under sub. (1), either separately
23or in conjunction with a qualified health plan, if the plan provides pediatric dental
24benefits meeting the requirements of section 1302 (b) (1) (J) of the federal act.
1(3) Neither the authority nor a health carrier offering health benefit plans
2through the exchange under sub. (1) may charge an individual a fee or penalty for
3termination of coverage if the individual enrolls in another type of minimum
4essential coverage because the individual has become newly eligible for that
5coverage or because the individual's employer-sponsored coverage has become
6affordable under the standards of section 36B (c) (2) (C) of the Internal Revenue
AB445,26,12 8(4) The authority may enter into information-sharing agreements with federal
9and state agencies and entities operating exchanges in other states to carry out its
10responsibilities under this chapter, provided that such agreements include adequate
11protections with respect to the confidentiality of the information to be shared and
12comply with all state and federal laws and rules and regulations.
AB445,26,15 13636.30 Exchange duties and powers. (1) In addition to all other duties
14imposed under this chapter, the authority shall do all of the following relating to the
15exchange under s. 636.25 (1):
AB445,26,1916 (a) Implement procedures for the certification, recertification, and
17decertification, consistent with guidelines developed by the secretary under section
181311 (c) of the federal act and s. 636.42, of health benefit plans as qualified health
AB445,26,2120 (b) Provide for the operation of a toll-free telephone hotline to respond to
21requests for assistance.
AB445,26,2322 (c) Provide for enrollment periods, as provided under section 1311 (c) (6) of the
23federal act.
1(d) Maintain an Internet site through which enrollees and prospective
2enrollees of qualified health plans may obtain standardized comparative
3information on such plans.
AB445,27,84 (e) Assign a rating to each qualified health plan offered through the exchange
5in accordance with the criteria developed by the secretary under section 1311 (c) (3)
6of the federal act, and determine each qualified health plan's level of coverage in
7accordance with regulations issued by the secretary under section 1302 (d) (2) (A) of
8the federal act.
AB445,27,119 (f) Use a standardized format for presenting health benefit options in the
10exchange, including the use of the uniform outline of coverage established under 42
11USC 300gg-15
AB445,27,1312 (g) Establish quality improvement standards for health benefit plans offered
13through the exchange.
AB445,27,1514 (h) Establish a system for enrolling eligible groups and individuals, using a
15standard application form developed by the commissioner under s. 636.46 (2).
AB445,27,1716 (i) Establish procedures for collecting premiums and remitting premium
17payments and providing enrollment information to health carriers.
AB445,27,2018 (j) Establish, in consultation with the commissioner, the method for
19determining the amount of the surcharge under s. 636.45 (1) and establish the
20procedure for imposing and collecting the surcharge.
AB445,27,2221 (k) Establish a plan for publicizing the exchange and the eligibility
22requirements and enrollment procedures.
AB445,27,2423 (L) Establish and operate a service center to provide information to small
24employers, individuals, enrollees, and insurance intermediaries about the exchange.
1(m) Establish a mechanism for regular communication and cooperation with
2insurance intermediaries.
AB445,28,43 (n) Establish an independent and binding appeals process for resolving
4disputes over eligibility and other determinations made by the authority.
AB445,28,95 (o) In accordance with section 1413 of the federal act, inform individuals of
6eligibility requirements for Medical Assistance under subch. IV of ch. 49 or any other
7applicable state or local public program and if, through screening of the application
8by the authority, the authority determines that any individual is eligible for any such
9program, assist that individual to enroll in that program.
AB445,28,1310 (p) Establish and make available by electronic means a calculator to determine
11the 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
131402 of the federal act.
AB445,28,1714 (q) Establish a SHOP Exchange through which qualified employers may access
15health care coverage for their employees and that shall enable any qualified
16employer to specify the level of coverage at which its employees may enroll in any
17qualified health plan offered through the SHOP Exchange.
AB445,28,2018 (r) Perform duties required of the authority by the secretary or the federal
19secretary of the treasury related to determining eligibility for premium tax credits,
20reduced cost sharing, or individual responsibility requirement exemptions.
AB445,28,2421 (s) Select entities, which may include insurance intermediaries, that are
22qualified to serve as navigators in accordance with section 1311 (i) of the federal act
23and standards developed by the secretary, and award grants to enable navigators to
24do all of the following:
11. Conduct public education activities to raise awareness of the availability of
2qualified health plans.
AB445,29,63 2. Distribute fair and impartial information concerning enrollment in qualified
4health plans and concerning the availability of premium tax credits under section
536B of the Internal Revenue Code and cost-sharing reductions under section 1402
6of the federal act.
AB445,29,77 3. Facilitate enrollment in qualified health plans.
AB445,29,128 4. Provide referrals to any applicable office of health insurance consumer
9assistance or health insurance ombudsman established under 42 USC 300gg-93, or
10to any other appropriate state agency or agencies, for any enrollee with a grievance,
11complaint, or question regarding the enrollee's health benefit plan, coverage, or
12determination under that plan or coverage.
AB445,29,1413 5. Provide information in a manner that is culturally and linguistically
14appropriate to the needs of the population being served by the exchange.
AB445,29,1715 (t) Assist in the coordination of any necessary administrative operations
16between the department of corrections and the department of health services to
17ensure all of the following:
AB445,29,2018 1. That an individual, upon placement in a correctional facility, is disenrolled
19for the duration of his or her incarceration from any health care coverage in which
20he or she is enrolled.
AB445,29,2521 2. That an individual who is incarcerated in a correctional facility, but
22scheduled to be released from incarceration in the near future, is enrolled prior to
23release, through the exchange and effective upon the date of his or her release, in
24Medical Assistance, a qualified health plan, or some other form of minimum
25essential coverage on the date of his or her release from incarceration.
1(u) For those persons whose alcohol or other drug abuse or mental health
2treatment is not covered by a federally administered program, coordinate the
3relationships among the Medical Assistance program, the exchange, and the county
4departments under s. 51.42 or 51.437 to provide outpatient and inpatient mental
5health and alcohol or other drug abuse treatment with all of the following goals for
6the coordination:
AB445,30,87 1. Maximizing coverage and improving access through the exchange for
8outpatient and inpatient treatment of mental illness and alcohol or other drug abuse.
AB445,30,109 2. Improving the quality of treatment for persons with alcohol or other drug
10dependence or a mental illness.
AB445,30,1211 3. Fully integrating the treatment for physical conditions, alcohol or other drug
12abuse, and mental illness.
AB445,30,1713 4. Reducing the cost of the county departments under ss. 51.42 and 51.437 to
14taxpayers by avoiding unnecessary overlap between the improved coverage of
15alcohol or other drug abuse treatment or mental illness treatment by health plans
16offered through the exchange and the services provided by county departments
17under s. 51.42 or 51.437.
AB445,30,2018 (v) Review the rate of premium growth within the exchange and outside the
19exchange, and consider the information in developing recommendations on whether
20to continue limiting qualified employer status to small employers.
AB445,30,2321 (w) Credit the amount of any free choice voucher to the monthly premium of
22the plan in which a qualified employee is enrolled, in accordance with section 10108
23of the federal act, and collect the amount credited from the offering employer.
AB445,30,2524 (x) Consult with stakeholders relevant to carrying out the activities required
25under this chapter, including any of the following:
11. Educated health care consumers who are enrollees in qualified health plans.
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: