AB 697

Current law authorizes the Department of Health Services (DHS) to establish

a Medical Assistance (MA) health care benefit plan providing basic primary and

preventive care for adults under age 65 who have family incomes not exceeding 200

percent of the poverty line and who are not otherwise eligible for MA or Medicare.

This plan for childless adults is commonly known as the BadgerCare Plus Core Plan

(Core Plan). Due to the volume of applications for the plan, which exceeded the plan's

ability to provide benefits for all who applied, DHS suspended enrollment on October

9, 2009, and established a waiting list.

This bill authorizes DHS to establish and operate, no sooner than March 1,

2010, another health care benefit plan for individuals who are on the waiting list for

the Core Plan. The health care benefit plan, which is not MA and which will be

known as the BadgerCare Plus Basic Plan (Basic Plan), will provide primary and

preventive care, and the benefits may not exceed those provided under the Core Plan.

The Basic Plan, including both benefits and administration, will be funded entirely

from premiums set by DHS and paid by individuals with coverage under the Basic

Plan. To enroll, an individual must submit the first month's premium along with his

or her application. Thereafter the individual must pay the premium for a month's

coverage in the preceding month. If an individual with coverage under the Basic

Plan is removed from the Core Plan waiting list and begins receiving coverage under

the Core Plan, DHS will not refund any portion of a premium that the individual paid

for coverage under the Basic Plan for the month in which his or her coverage under

the Core Plan commences, but DHS will waive any enrollment fee that the individual

would have had to pay for enrolling in the Core Plan. An individual whose coverage

under the Basic Plan terminates for any reason, including for failure to pay a

premium when due, is not again eligible for coverage under the Basic Plan for 12

months, unless the individual's coverage terminated for a good cause reason. DHS

may set a deductible not exceeding $7,500 per enrollment year for inpatient and

nonemergency outpatient hospital services, as well as other cost-sharing

requirements.

DHS will pay a provider that provides services to individuals with coverage

under the Basic Plan if the provider is certified by DHS to provide services under MA.

For those services, DHS will pay a certified provider an amount that is no higher than

the amount that is payable for the service under MA. A certified provider may not

bill the individual who received the service for any additional amount, other than

cost sharing established by DHS, and a certified provider may not charge a covered

individual an amount that is higher than the amount that DHS would pay the

provider for inpatient or nonemergency outpatient hospital services to which a

deductible applies.

Any individual who is denied coverage under the Basic Plan or whose coverage

is discontinued may file a written request for review by DHS and must exhaust that