Delaying eligibility changes to BadgerCare Plus and BadgerCare Plus Core and delaying other changes to the Medical Assistance program; and extending coverage under, and the deadline for the dissolution of, the Health Insurance Risk-Sharing Plan. (FE)

Under current law, certain individuals are eligible for benefits under the BC+ Benchmark plan including pregnant women whose family income exceeds 200 percent but does not exceed 300 percent of the FPL and children under one year of age of those women; certain other pregnant women; children whose family income exceeds 200 percent but does not exceed 300 percent of the FPL; and parents or caretaker relatives whose family income includes self-employment income and does not exceed 200 percent of the FPL under a certain calculation. Act 20, beginning on January 1, 2014, provides benefits under the standard plan to the pregnant women and children who are currently eligible for the BC+ Benchmark plan. Under Act 20, parents and caretaker relatives are covered only under the standard plan. Certain individuals, under current law, may pay the full member per month cost of coverage to receive benefits under the Benchmark plan. On January 1, 2014, Act 20 eliminates the ability of children whose family incomes exceed 300 percent of the FPL to receive Benchmark plan benefits. This bill delays the effective date of these changes enacted in Act 20 from January 1, 2014, to April 1, 2014.

Under current law, BC+ Core provides basic primary and preventive care to eligible individuals. Adults who are under age 65, who have family incomes that do not exceed 200 percent of the FPL, and who are not otherwise eligible for MA, including BC+, are eligible for benefits under BC+ Core. Beginning January 1, 2014, Act 20 allows only those individuals whose family incomes do not exceed 100 percent of the FPL, before a 5 percent income disregard is applied, to be eligible for BC+ Core.

Act 20 removes limitations on the benefits provided to individuals in BC+ Core and, thus, allows DHS to provide standard plan benefits to these individuals. This bill delays the effective date of these changes enacted in Act 20 from January 1, 2014, to April 1, 2014.

Under current law, family income is the total gross earned and unearned income received by all members of a family. Beginning on January 1, 2014, under Act 20, for purposes of determining eligibility for BC+ and BC+ Core, family income has the meaning given for household income under a federal regulation, which uses an income calculation based on modified adjusted gross income. Act 20 also requires DHS, beginning on January 1, 2014, to apply the definition of household in federal regulations to determinations of income. Act 20 also makes other changes to the calculation of income and family size for BC+ and BC+ Core on January 1, 2014. This bill delays the effective date of these changes enacted in Act 20 from January 1, 2014, to April 1, 2014.

DHS also currently administers the BadgerCare Plus Basic (BC+ Basic) plan, which is not an MA program but is funded by premiums paid by plan participants.

To be eligible for the BC+ Basic plan, an individual must be on the waiting list for BC+ Core. BC+ Basic provides health care benefits that do not exceed those benefits provided by BC+ Core. Under current law, BC+ Basic terminates on January 1, 2014, and Act 20 repeals the BC+ Basic statutory language on that same date. The bill eliminates the statutory termination date and delays the repeal of BC+ Basic enacted in Act 20 until April 1, 2014.

Under current law, DHS is required to develop a purchasing pool, known as Badger Rx Gold, for pharmacy benefits and set eligibility requirements to obtain prescription drug coverage through the purchasing pool. Current law allows DHS to contract with an entity to operate the purchasing pool, which is not an MA program. Act 20 eliminates the purchasing pool, Badger Rx Gold, on January 1, 2014. The bill delays the elimination of Badger Rx Gold until April 1, 2014.

Dissolution of the Health Insurance Risk-Sharing Plan The Health Insurance Risk-Sharing Plan (HIRSP), which is administered by the Health Insurance Risk-Sharing Plan Authority (authority), provides health insurance coverage in individual policies for persons who are covered under Medicare because they are disabled, persons who have tested positive for human immunodeficiency virus (HIV), persons who have been refused coverage, or coverage at an affordable price, in the private health insurance market because of their mental or physical health condition, and persons (called "eligible individuals" in the statutes) who do not currently have health insurance coverage, but who were covered under certain types of health insurance coverage (creditable coverage) for at least 18 months in the past. HIRSP is funded by premiums paid by covered persons, insurer assessments, and provider payment discounts.

Current law provides for the dissolution of HIRSP and the authority. Generally, coverage under HIRSP may not be issued to any person after December 1, 2013, existing coverage under HIRSP will end on January 1, 2014, or on the date that any health insurance coverage that is accessed through an American health benefit exchange in this state is effective, if that is later than January 1, 2014, and the authority must pay the costs of HIRSP that are incurred before administrative responsibility for HIRSP and HIRSP's remaining cash assets, tangible personal property, contracts and agreements, and all other matters, including grievances and independent reviews, are transferred to the Office of the Commissioner of Insurance (OCI). Thereafter, OCI must take any action necessary or advisable to wind up the affairs of HIRSP.

Extension of coverage under the Health Insurance Risk-Sharing Plan The bill makes various modifications to the timetable for the dissolution of HIRSP, including the following:

1. Under the bill, all coverage under HIRSP terminates at 11:59 p.m. on December 31, 2013, but an individual who has coverage on December 1, 2013, and who has paid the December premium may elect to obtain a policy under HIRSP by making a timely payment of the January 2014 premium. Any such new policy must have the same benefits, including the deductible amount, that were in effect on December 1, 2013, and may not extend beyond March 31, 2014. An individual who is eligible for Medicare has the same option to extend coverage under a HIRSP policy until March 31, 2014, if the individual was covered under HIRSP on December 1, 2013, has paid the December premium, did not enroll in Medicare Advantage during the federal open enrollment period in 2013, and, for individuals whose coverage is funded under a contract with the federal Department of Health and Human Services, the federal Department of Health and Human Services takes certain actions.

2. Under current law, provider claims for payment for medical services provided to individuals with coverage under HIRSP must be filed no later than 90 days after coverage terminates or they will not be paid. Under the bill, all provider claims for services provided to HIRSP enrollees must be filed no later than June 1, 2014, or they will not be paid. All provider claims must be adjudicated by September 30, 2014.

3. Under current law, a grievance must be submitted no later than 180 days after coverage terminates or be barred, and an independent review must be requested no later than 60 days after the individual receives notice of the disposition of his or her grievance. The bill provides that a grievance must be received no later than July 1, 2014, or be barred, and that an individual who submits a grievance after March 31, 2014, must request an independent review with respect to the grievance no later than August 1, 2014, or be barred from requesting an independent review.

4. Under current law, the transfer from the authority to OCI of administrative responsibility for HIRSP and HIRSP's remaining cash assets, tangible personal property, contracts and agreements, and all other matters takes place 60 days after coverage under HIRSP terminates. Under the bill, the transfer takes place on February 28, 2014.

5. Under current law, the authority must pay HIRSP's costs incurred in 2013 and those that are incurred before the transfer to OCI. The authority must make every effort to pay costs in accordance with the manner provided in the statutes, which is that costs are to be paid 60 percent from premiums, 20 percent from insurer assessments, and 20 percent from adjustments to provider payments. Under the bill, the authority before March 1, 2014, and OCI on and after March 1, 2014, must pay all of HIRSP's costs in accordance with the manner provided in the statutes, except that any available surplus may be used before an assessment is imposed against insurers. OCI must determine no later than July 1, 2014, whether an insurer assessment is necessary.

Time-limited guaranteed issue under Medicare supplement and replacement policies Under current law, an insurer that offers a Medicare supplement or replacement policy must provide coverage to any individual who is eligible for Medicare, who had coverage under HIRSP, whose coverage terminates on January 1, 2014, or on the date that any health insurance coverage that is accessed through an American health benefit exchange in this state is effective, if that is later than January 1, 2014, who applies for coverage before 63 days after their coverage terminated, and who pays the premium. Coverage may not be denied on the basis of health status, receipt of health care, claims experience, or medical condition.

Under the bill, the requirement to provide coverage applies if the individual's coverage under HIRSP terminated on December 31, 2014, which is the new date for coverage termination under the bill. In addition, the bill imposes the same requirement on an insurer that offers a Medicare supplement or replacement policy to provide coverage under such a policy to an individual who is eligible for Medicare, whose coverage under HIRSP terminates on March 31, 2014, who applies for coverage under the Medicare supplement or replacement policy before 63 days after their coverage terminated, and who pays the premium.