(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.
c. Require periodic reports in relation to the activities undertaken by the 18
3. In carrying out its activities under this chapter, not use any funds intended 20
for the administrative and operational expenses of the authority for staff retreats, 21
promotional giveaways, excessive executive compensation, or promotion of federal 22
or state legislative or regulatory modifications, except that this subdivision does not 23
prohibit the authority from advocating, as part of administering the exchange, for 24
policies that the authority determines are in the best interest of the exchange or of 25
individuals and employees receiving coverage through the exchange.
The authority may do all of the following relating to the exchange under s. 2
(a) Contract with a 3rd-party administrator for the provision of services on 4
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 8
for under federal law.
The authority shall seek grants to the fullest extent to which it is eligible, 10
including amounts under section 1311 (a) (1) and (4) of the federal act, or other 11
funding from the federal or state government for which it may be eligible and from 12
private foundations for the purpose of the exchange under s. 636.25 (1).
13636.42 Health benefit plan certification. (1)
The authority may certify a 14
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 16
1302 (a) of the federal act, except that the plan is not required to provide essential 17
benefits that duplicate the minimum benefits of qualified dental plans, as provided 18
in sub. (5), if all of the following are satisfied:
1. The authority has determined that at least one qualified dental plan is 20
available to supplement the plan's coverage.
2. The health carrier makes prominent disclosure at the time it offers the plan, 22
in a form approved by the authority, that the plan does not provide the full range of 23
essential pediatric benefits and that qualified dental plans providing those benefits 24
and other dental benefits not covered by the plan are offered through the exchange 25
under s. 636.25 (1).
(b) The premium rates and contract language have been filed with and not 2
disapproved by the commissioner.
(c) The plan provides at least a bronze level of coverage, as determined under 4
s. 636.30 (1) (e), unless the plan is certified as a qualified catastrophic plan, meets 5
the requirements of the federal act for catastrophic plans, and will only be offered to 6
individuals eligible for catastrophic coverage.
(d) The plan's cost-sharing requirements do not exceed the limits established 8
under section 1302 (c) (1) of the federal act and, if the plan is offered through the 9
SHOP Exchange, the plan's deductible does not exceed the limits established under 10
section 1302 (c) (2) of the federal act.
(e) The health carrier offering the plan satisfies all of the following:
1. Is licensed and in good standing to offer health insurance coverage in this 13
2. Offers at least one qualified health plan in the silver level and at least one 15
qualified health plan in the gold level through each component of the exchange in 16
which the health carrier participates. In this subdivision, “component" refers to the 17
SHOP Exchange or the exchange under s. 636.25 for individual coverage.
3. Charges the same premium rate for each qualified health plan without 19
regard to whether the plan is offered directly from the health carrier or through an 20
4. Does not charge any cancellation fees or penalties in violation of s. 636.25 22
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.
(f) The plan meets the requirements of certification as required by any rules 2
promulgated under s. 636.46 (1) and by the secretary under section 1311 (c) of the 3
federal act, including minimum standards in the areas of marketing practices, 4
network adequacy, essential community providers in underserved areas, 5
accreditation, quality improvement, uniform enrollment forms, and descriptions of 6
coverage and information on quality measures for health benefit plan performance.
(g) The authority determines that making the plan available through the 8
exchange under s. 636.25 (1) is in the interest of qualified individuals and qualified 9
employers in this state.
The authority shall not exclude a health benefit plan for any of the following 11
reasons or in any of the following ways:
(a) On the basis that the plan is a fee-for-service plan.
(b) Through the imposition of premium price controls by the authority.
(c) On the basis that the plan provides treatments necessary to prevent 15
patients' deaths in circumstances the authority determines are inappropriate or too 16
The authority shall require each health carrier seeking certification of a 18
health benefit plan as a qualified health plan to do all of the following:
(a) Submit a justification for any premium increase before implementation of 20
that increase. The health carrier shall prominently post the information on its 21
Internet site. The authority shall take this information, along with the information 22
and the recommendations provided to the authority by the commissioner under 42
(b), into consideration when determining whether to allow the health 24
carrier to make the plan available through the exchange under s. 636.25 (1).
(b) 1. Make available to the public, in the format described in subd. 2., and 2
submit to the authority, the secretary, and the commissioner, accurate and timely 3
disclosure of all of the following:
a. Claims payment policies and practices.
b. Periodic financial disclosures.
c. Data on enrollment.
d. Data on disenrollment.
e. Data on the number of claims that are denied.
f. Data on rating practices.
g. Information on cost sharing and payments with respect to any 11
h. Information on enrollee and participant rights under title I of the federal act.
i. Other information as determined appropriate by the secretary.