3. A copy of the Attestation and Discrepancy Reporting Summary confirmation page as reported to CMS. If the Attestation and Discrepancy Reporting Summary contained a dispute, the eligible health carrier shall provide documentation of the disputed data and identify the claims in dispute with the enrolled individual’s unique identifier.
4. An acknowledgment that the eligible health carrier will not receive a reinsurance payment in the event that WIHSP authorizing statute is amended in a manner that no reinsurance payment is due to any carriers.
5. An acknowledgment, in accordance with s. 601.83 (5) (h), Stats., that the eligible health carrier shall not bring a lawsuit over any delay in reinsurance payments or reduction in expected reinsurance payments. 6. Any additional information required by the commissioner.
(b) The eligible health carrier shall transmit the information to the commissioner by or before May 15, of each calendar year after the applicable benefit year.
19.20 Verification audit. (1) The commissioner shall conduct a verification audit of the data submitted for reinsurance payment. The commissioner shall request eligible health carriers to provide information, pursuant to s. 601.42, Stats., including all of the following: (a) Supporting claims information including the following:
1. A sample number of claims and specific claims documentation supporting the claim for reinsurance payment. The sample of underlying claims data shall demonstrate that the claims were eligible for reinsurance payment.
2. Additional documentation for a select number of claims, including proof of payment and payment invoices for certain identified claims as specified by the commissioner.
(b) The information provided shall be masked as to any enrollee and provider other than the specific claims data requested.
(c) The requested data shall use the same enrolled individual unique numeric identifier for eligible claims as contained in quarterly or annual reports provided to the commissioner.
(2) If, as a result of the commissioner’s verification audit, a discrepancy is identified the eligible health carriers shall be notified by the commissioner. The health carrier shall respond within 10 days either affirming the commissioner’s finding or providing documents to substantiate the filed data.
(3) Prior to release of the reinsurance payment, the commissioner shall review the claims data requested for verification and the quarterly and annual reports with required affirmations or attestations confirming the accuracy of the data.
(4) Eligible health carriers shall retain all supporting data in an auditable format for 6 years from the last day of the applicable benefit year.
19.21 Reinsurance payment calculation. The commissioner shall calculate the amounts eligible for reinsurance payment under s. 601.83 (4) (a), Stats., utilizing the information provided by the eligible health carriers. (1) The commissioner shall calculate the reinsurance payment by applying the payment parameters as contained in s. 601.83 (4) (a), Stats., to each eligible claim. The commissioner shall provide a preliminary estimate of the reinsurance payments by or before June 30, in the calendar year following the applicable benefit year. (2) In accordance with s. 601.83 (3) (c), Stats., the aggregate reinsurance payments shall not exceed $200,000,000, or the amount available for the applicable benefit year. If the cumulative total amount of claims across all participating eligible health carriers exceeds $200,000,000, or the amount available for the given benefit year under s. 601.83 (1) (h), Stats., the commissioner shall make reinsurance payments in accordance with s. 601.83 (3) (c), Stats., to each eligible health carrier as follows: (a) The commissioner shall calculate each carrier’s eligible claims after application of the applicable payment parameters and s. 601.83 (4), Stats. (b) The commissioner shall distribute reinsurance payments in an amount that is directly proportional to the carrier’s eligible claims.
19.22 WIHSP overpayment reconciliation. The reconciliation period in this section means the time between June 30, or the date the commissioner notifies eligible health carriers of reinsurance payments, through December 31, of the calendar year following the applicable benefit year. For example, the reconciliation period for benefit year 2019 starts June 30, 2020, and continues through December 31, 2020.
(1) Eligible health carriers that receive additional adjustments in claim payments or identify additional data corrections during the reconciliation period shall notify the commissioner within 30 days of identifying the overpayment or no later than December 31. If the adjustment or data correction resulted in a WIHSP overpayment, the eligible health carrier shall fully identify the claim and the amount of overpayment.
(a) For eligible health carriers submitting claims for reinsurance payment during the benefit year in which the reconciliation occurs, the commissioner may reduce that benefit year’s reinsurance payment by the amount of overpayment.
(b) If a health carrier does not submit claims for reinsurance payment during the benefit year in which the reconciliation occurs, the amount of overpayment shall be remitted to the commissioner at the commissioner’s request.
(2) If, after June 30, of the reconciliation period, the eligible health carrier determines it underreported eligible claims as a result of claim adjustments or data corrections, the eligible health carrier shall not be eligible for additional reinsurance payments for the applicable benefit year.
(3) If, as a result of a verification or compliance audit, the commissioner identifies an overpayment occurred because the eligible health carrier erred in its reinsurance claim submissions, the commissioner may either reduce future reinsurance payments to that carrier in the amount of the overpayment or order the health carrier to repay the amount of overpayment.
19.24. Compliance Audit. (1) The commissioner may, at the commissioner’s sole discretion, conduct an audit in accordance with s. 601.83 (5) (f), Stats., with the reasonable audit costs paid by the audited carrier pursuant to s. 601.45 (1), Stats. The commissioner shall give the carrier reasonable notice and identify the scope of the audit to be conducted. (2) Upon findings by the commissioner that an eligible health carrier provided falsified data or intentionally provided incomplete data, the commissioner may, at the commissioner’s sole discretion, determine that health carrier is ineligible for reinsurance payments for subsequent benefit years. The health carrier shall be issued an order of the commissioner with administrative hearing rights as contained in s. 227.44, Stats. SECTION 2. Initial applicability. This rule first applies to claims that are incurred on or after January 1, 2019, by an eligible health carrier.
SECTION 3. Effective date. These proposed rule changes will take effect on the date of publication as provided in s. 227.24 (1) (c), Stats. Dated at Madison, Wisconsin, this day of , 2018.
J.P. Wieske
Deputy Commissioner of Insurance
