Ins 19.01Ins 19.01 Purpose. The commissioner implements 2017 Wis. Act 138 for the purposes of establishing the Wisconsin Healthcare Stability Plan. The commissioner will seek to maximize federal funding for the Wisconsin Healthcare Stability Plan. The commissioner shall design and adjust the payment parameters with the goal to stabilize or reduce premium rates, increase participation by health insurers, improve access to health care providers and services, and mitigate the impact of high-risk individuals participating in the individual health insurance market.

Ins 19.02Ins 19.02 Definitions. In addition to definitions contained in s. 601.80, Stats., the following definitions shall apply in this chapter:

Ins 19.02(1)(1) “Audit” has the meaning provided under s. 601.83 (5) (f), Stats., and includes a verification and compliance audit conducted by OCI.

Ins 19.02(2)(2) “CMS” means the Centers for Medicare & Medicaid Services within the U.S. department of health and human services.

Ins 19.02(4)(4) “Compliant plan” means an individual health benefit plan offered by an eligible health carrier that conforms with regulations set forth in the Affordable Care Act, as applicable, or an individual health benefit plan that provides substantially similar benefits as required by the Affordable Care Act effective July 1, 2018, as defined by the office.

Ins 19.02(5)(5) “Eligible health carrier” means an insurer offering a compliant plan either on or off the federally facilitated marketplace that was issued after January 1, 2014, and is not a grandfathered plan or transitional plan. A transitional plan is a health plan in effect on October 1, 2013, and is in compliance with CMS and guidance issued by the office. A grandfathered plan is a health plan that has been continuously offered since March 23, 2010, and in compliance with CMS.

Ins 19.02(6)(6) “Enrolled individual” means an insured member of an eligible health carrier during the applicable benefit year for at least one day and who has paid all premium owed for the period in which claims eligible for reinsurance payment were incurred or the eligible health carrier is obligated to pay under law.

Ins 19.02(7)(7) “External Data Gathering Environment” or “EDGE server” means the server developed by the CMS in conjunction with the federally facilitated marketplace for health care insurers to submit claims information on enrolled individuals for claims paid for covered services or treatments.

Ins 19.02(8)(8) “Secure file transfer portal” or “FTP” means a manner of securely transferring requested information from the eligible health carrier to the commissioner in a manner specified by the commissioner.

Ins 19.02(10)(10) “Wisconsin Healthcare Stability Plan” or “WIHSP” means the Wisconsin healthcare stability plan created under s. 601.83, Stats.

Ins 19.02 HistoryHistory: CR 19-088: cr. Register November 2021 No. 791, eff. 12-1-21; correction in (5) made under s. 35.17, Stats., and correction in numbering of (7m) made under s. 13.92 (4) (b) 1., Stats., Register November 2021 No. 791.

Ins 19.03Ins 19.03 Payment parameters. The commissioner shall annually establish the payment parameters for future benefit years through an established procedure that includes all of the following components:

Ins 19.03(1)(1) The commissioner shall request, under s. 601.42, Stats., all eligible health carriers to submit data and information from prior and current benefit years including: compliant plan membership, premium experience at a metal and federally facilitated marketplace status level, advanced premium tax credit enrollee information, and other information as requested by the commissioner.

Ins 19.03(2)(2) The commissioner shall publish the preliminary payment parameters and a public hearing notice in the Wisconsin Administrative Register and to the OCI website. The commissioner shall hold a public hearing seeking public comment regarding the preliminary payment parameters for the subsequent benefit year.

Ins 19.03(3)(3) The commissioner shall set the final payment parameters after consultation with an actuarial firm, consideration of comments received from the public hearing, the goals established in s. 601.83 (2), Stats., and any additional information as appropriate.

Ins 19.03(4)(4) The commissioner shall publish the final payment parameters in the Wisconsin Administrative Register and to the OCI website by May 15 of the calendar year prior to the applicable benefit year.

Ins 19.03 HistoryHistory: CR 19-088: cr. Register November 2021 No. 791, eff. 12-1-21; correction in (4) made under s. 35.17, Stats., Register November 2021 No. 791.

Ins 19.07Ins 19.07 Eligible claims. For claims to be eligible for reinsurance payment, the eligible health carrier shall comply with s. 601.83, Stats., and submit claims that comply with the following criteria:

Ins 19.07(1)(1) The claims that were paid for as covered benefits by the eligible health carrier under the terms and conditions of the carrier’s compliant plan for the applicable benefit year including but not limited to medical, surgical, and prescription drug services and treatments.

Ins 19.07(2)(2) The claims that were paid by the eligible health carrier after January 1, of the applicable benefit year and before April 30, of the following calendar year, or a date established by the commissioner.

Ins 19.07(3)(3) The cumulative amount of the claims paid that exceeds the applicable attachment point. Claims reported shall not include any amount of cost sharing required to be paid by the enrolled individual or the person responsible for the payment of the enrolled individual’s cost sharing. Cost sharing may include any of the following; deductibles, co-insurance, co-payment, visit fees, or similar costs.

Ins 19.07(4)(4) The cumulative amount of paid claims shall be reduced by any reimbursement received by the eligible health carrier for the enrolled individual through subrogation, recoupment of overpayments from providers, application of negotiated rates reductions with providers, or recoupment of third-party payment including workers compensation or civil litigation.

Ins 19.10Ins 19.10 Reporting requirements. All eligible health carriers shall provide all requested information as ordered by the commissioner pursuant to s. 601.42, Stats. Information collected under ss. Ins 19.07 and 19.11 may be used on an aggregate basis by the commissioner to satisfy federal and state reporting requirements. Additional data may be requested to inform federal and state reports including: second lowest cost silver rates by rating area demonstrating rates with and without reinsurance payments, actual average premium rates for compliant plans, and actual enrollment for compliant plans.

Ins 19.10 HistoryHistory: CR 19-088: cr. Register November 2021 No. 791, eff. 12-1-21; correction made under s. 35.17, Stats., Register November 2021 No. 791.