AB 1224

This bill requires the Department of Health Services to seek any waiver of federal law necessary to administer a health plan that provides coverage to every resident of this state, as well as nonresidents employed in this state, to receive medically necessary health services for which DHS provides reimbursement. If all necessary waivers are granted, the bill requires DHS to implement the health plan in accordance with the requirements under the bill. If a necessary waiver is not granted, the bill prohibits DHS from implementing the health plan.

The bill also requires DHS to seek federal approval to do all of the following:

1. Fund a portion of the health plan with federal payments the state currently receives to fund health care services and tax credits provided under the federal Affordable Care Act to assist individuals with the cost of premiums on certain insurance policies.

2. Collect the assessment imposed under the ACA for employers of residents of this state that do not provide insurance for their employees or that have employees who qualify for premium assistance tax credits.

3. Bill another state for health care services provided to a nonresident of this state who receives long-term care or other costly treatment in this state.

Under the bill, every resident of this state and every nonresident who is employed in this state is eligible for coverage under the health plan under the bill. Coverage under the health plan generally includes any medically necessary health service, including a medically necessary health service provided to a resident while the resident is temporarily visiting another state. The bill generally prohibits coverage under the health plan for services that have no medical benefit, services that are primarily for a cosmetic purpose, and prescription drugs that are directly marketed to consumers in this state.

The bill prohibits cost-sharing for covered services under the health plan, except for the costs of room and board in a skilled nursing facility or assisted living facility. The bill provides DHS with the authority to assess and collect premiums from enrollees and directs DHS to establish an equitable and affordable premium structure based upon enrollee income and ability to pay. The bill also directs DHS, in consultation with the Department of Revenue, to develop measures to ensure the efficient collection of premiums. The bill requires DHS to seek reimbursement for the health care cost of services provided to an individual under the health plan if the health care costs are, or may be, the responsibility of a third party, as in the case of a health care cost covered by the medical components of an automobile insurance policy or a judgment for damages for personal injury. Under the bill, a nonresident visiting this state is liable for any reimbursement paid under the health plan for services provided to the nonresident, unless DHS has the authority to bill the nonresident’s state of residence for the services or has an agreement with the other state to provide reciprocal health care coverage for visitors.

The bill requires DHS to negotiate and establish payment rates for health care providers that participate in the health plan and pay claims for covered benefits in accordance with those payment rates. The bill requires DHS to pay claims within 30 days for health care providers that do not provide overnight care. The bill requires DHS to establish, for each health care provider that provides overnight care, an annual budget for anticipated services under the health plan for the next year; DHS must provide, in periodic installments, payments to the health care provider in an amount that equals the budget, rather than providing payment on a fee-for-service basis. The bill also requires health care providers that participate in the health plan to obtain approval from DHS before making capital expenditures greater than $500,000.

The bill requires health care providers to presume that an individual is covered by the health plan and provide care accordingly if the individual is unable due to their physical or mental condition to provide documentation of their coverage; is a minor; arrives at the health care facility for emergency detention; or is admitted for an involuntary civil commitment. The bill requires DHS to ensure individuals covered by the health plan have a primary care provider and access to care coordination. The bill provides that an individual may choose to receive services under the health plan from any provider and prohibits DHS from requiring referrals for specialist services. The bill also requires DHS to establish an online registry to assist covered individuals in identifying appropriate health care providers.

The bill directs DHS to take various actions related to the health plan, including implementing cost control and quality assurance procedures; assessing the adequacy of the plan’s reserves; implementing fraud prevention measures; providing public education about the plan and monitoring feedback from the public; and establishing conflict of interest standards for providers. The bill also directs DHS to prepare an annual report about the plan for the governor and legislature.

The bill creates the office of the ombudsman for patient advocacy within DHS to assist Wisconsin residents with securing health care services and benefits and to advocate on behalf of and represent the interests of enrollees. Among other duties, the office must establish and maintain a system to receive and resolve complaints from enrollees.

Under the bill, once the health plan becomes operational, the commercial sale of health benefits plans for services provide under the health plan is prohibited in this state.

Finally, the bill directs DHS and DOR to issue a report on imposing a business health tax to assist with financing the health plan and creating a sufficient reserve and directs DHS and the Office of the Commissioner of Insurance to issue a report on the feasibility and costs of self-insuring health care providers for malpractice, including the creation of a special fund for payment of losses incurred.