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WISCONSIN STATUTES AND CODES

149.14 Coverage.

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149.14149.14Coverage.149.14(1)(1)Coverage offered.149.14(1)(a)(a) The plan shall offer coverage for each eligible person in an annually renewable policy. If an eligible person is also eligible for Medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by Medicare. If an eligible person is eligible for a type of medical assistance specified in s. 149.12 (2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by Medical Assistance. 149.14(1)(b)(b) If an individual terminates medical assistance coverage and applies for coverage under the plan within 45 days after the termination and is subsequently found to be eligible under s. 149.12, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage. 149.14(2)(2)Major medical expense coverage.149.14(2)(a)(a) The plan shall provide every eligible person who is not eligible for Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to deductible, copayment, and coinsurance payments, up to a lifetime limit per covered individual of $1,000,000 or a higher amount, as determined by the authority. 149.14(2)(b)(b) The plan shall provide an alternative policy for those persons eligible for medicare which reduces the benefits payable under par. (a) by the amounts paid under medicare. 149.14(2)(c)(c) In addition to the coverage under pars. (a) and (b), the plan shall offer to all eligible persons who are not eligible for Medicare a choice of coverage, as described in section 2744 (a) (1) (C), P.L. 104-191. Any such choice of coverage shall be major medical expense coverage. An eligible person who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the authority, among the coverages offered under this paragraph and par. (a). If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under the plan. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under the plan and the person remained continuously covered under the plan up to the time of electing the new coverage. 149.14(3)(3)Covered expenses.Covered expenses for coverage under the plan shall be the payment rates established by the authority for services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Covered expenses for coverage under the plan shall also be the payment rates established by the authority for, at a minimum, the following services and articles if the service or article is prescribed by a physician who is licensed under ch. 448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service or article, except for prescription drugs that are provided by a network of pharmacies approved by the board, is provided by a provider certified under s. 49.45 (2) (a) 11.: 149.14(3)(a)(a) Hospital services. 149.14(3)(b)(b) Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental. 149.14(3)(c)(c) 149.14(3)(c)1.1. Inpatient hospital services, as defined in s. 632.89 (1) (d), outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment arrangements, as defined in s. 632.89 (1) (f), at least to the extent required under s. 632.89. 149.14(3)(c)3.3. Subject to the limits under subd. 1., services for the chronically mentally ill in community support programs operated under s. 51.421. 149.14(3)(d)(d) Drugs requiring a physician's prescription. 149.14(3)(e)(e) For persons eligible for Medicare, services of a licensed skilled nursing facility, to the extent required by s. 632.895 (3) and for not more than an aggregate 120 days during a calendar year, if the services are of the type that would qualify as reimbursable services under Medicare. Coverage under this paragraph that is not required by s. 632.895 (3) is subject to any deductible and coinsurance requirements provided by the authority. 149.14(3)(em)(em) For persons not eligible for medicare, services of a licensed skilled nursing facility, only to the extent required by s. 632.895 (3). 149.14(3)(f)(f) Services of a home health agency, as defined in s. 50.49 (1) (a), only to the extent required under s. 632.895 (2). 149.14(3)(g)(g) Use of radium or other radioactive materials. 149.14(3)(h)(h) Oxygen. 149.14(3)(i)(i) Anesthetics. 149.14(3)(j)(j) Prostheses other than dental. 149.14(3)(k)(k) Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids. 149.14(3)(L)(L) Diagnostic X-rays and laboratory tests. 149.14(3)(m)(m) Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth. 149.14(3)(n)(n) Services of a physical therapist. 149.14(3)(nm)(nm) Hospice care provided by a hospice licensed under subch. IV of ch. 50. 149.14(3)(o)(o) Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat a covered condition. 149.14(3)(q)(q) Any other health insurance coverage, only to the extent required under subch. VI of ch. 632. 149.14(3)(r)(r) Processing charges for blood including, but not limited to, the cost of collecting, testing, fractionating and distributing blood. 149.14(3c)(3c)Temporary provider certification.Notwithstanding the provider licensing and certification requirements under sub. (3) (intro.), for coverage of services or articles provided to an eligible person the authority may certify on a temporary basis a provider that is not licensed under ch. 446 or 448 but that is licensed in another state to provide the service or article, or a provider that is not certified under s. 49.45 (2) (a) 11. The certification under this subsection may be retroactive. 149.14(4)(4)Plan design.Subject to subs. (1) to (3), (5), and (6), the authority shall establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state. The authority may develop additional benefit designs that are responsive to market conditions. 149.14(5)(5)Deductible and copayment subsidies.149.14(5)(a)(a) The authority shall establish and provide subsidies for deductibles paid by eligible persons with household incomes specified in s. 149.165 (2) (a) to (e). 149.14(5)(b)(b) The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in par. (a). 149.14(6)(6)Preexisting conditions.An eligible individual who obtains coverage under the plan may not be subject to any preexisting condition exclusion under the plan. 149.14(7)(7)Coordination of benefits.149.14(7)(a)(a) Covered expenses under the plan shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care insurance, medicare, medical assistance or any other governmental program, except as otherwise provided by law. 149.14(7)(b)(b) The authority has a cause of action against an eligible participant for the recovery of the amount of benefits paid that are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph. 149.14(7)(c)(c) The authority is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan. 149.14 - ANNOT.History: 1979 c. 313; 1981 c. 39 s. 22; 1981 c. 83; 1981 c. 314 ss. 117, 146; 1983 a. 27; 1985 a. 29 s. 3202 (30); 1985 a. 332 s. 253; 1987 a. 27, 239; 1989 a. 332; 1991 a. 39, 269; 1995 a. 463; 1997 a. 27 ss. 3026c, 4847 to 4859; Stats. 1997 s. 149.14; 1997 a. 237; 1999 a. 9, 165; 2001 a. 16; 2003 a. 33; 2005 a. 74 ss. 93 to 122, 130, 131; 2007 a. 39; 2009 a. 83.
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  • 149.14

    149.14 Coverage.

    149.14(1)

    (1) Coverage offered.

    149.14(1)(a)

    (a) The plan shall offer coverage for each eligible person in an annually renewable policy. If an eligible person is also eligible for Medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by Medicare. If an eligible person is eligible for a type of medical assistance specified in s. 149.12 (2) (f) 2., the plan shall not pay or reimburse the person for expenses paid for by Medical Assistance.

    149.14(1)(b)

    (b) If an individual terminates medical assistance coverage and applies for coverage under the plan within 45 days after the termination and is subsequently found to be eligible under s. 149.12, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.

    149.14(2)

    (2) Major medical expense coverage.

    149.14(2)(a)

    (a) The plan shall provide every eligible person who is not eligible for Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to deductible, copayment, and coinsurance payments, up to a lifetime limit per covered individual of $1,000,000 or a higher amount, as determined by the authority.

    149.14(2)(b)

    (b) The plan shall provide an alternative policy for those persons eligible for medicare which reduces the benefits payable under par. (a) by the amounts paid under medicare.

    149.14(2)(c)

    (c) In addition to the coverage under pars. (a) and (b), the plan shall offer to all eligible persons who are not eligible for Medicare a choice of coverage, as described in section 2744 (a) (1) (C), P.L. 104-191. Any such choice of coverage shall be major medical expense coverage. An eligible person who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the authority, among the coverages offered under this paragraph and par. (a). If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under the plan. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under the plan and the person remained continuously covered under the plan up to the time of electing the new coverage.

    149.14(3)

    (3) Covered expenses. Covered expenses for coverage under the plan shall be the payment rates established by the authority for services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Covered expenses for coverage under the plan shall also be the payment rates established by the authority for, at a minimum, the following services and articles if the service or article is prescribed by a physician who is licensed under ch. 448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service or article, except for prescription drugs that are provided by a network of pharmacies approved by the board, is provided by a provider certified under s. 49.45 (2) (a) 11.:

    149.14(3)(a)

    (a) Hospital services.

    149.14(3)(b)

    (b) Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental.

    149.14(3)(c)

    (c)

    149.14(3)(c)1.

    1. Inpatient hospital services, as defined in s. 632.89 (1) (d), outpatient services, as defined in s. 632.89 (1) (e), and transitional treatment arrangements, as defined in s. 632.89 (1) (f), at least to the extent required under s. 632.89.

    149.14(3)(c)3.

    3. Subject to the limits under subd. 1., services for the chronically mentally ill in community support programs operated under s. 51.421.

    149.14(3)(d)

    (d) Drugs requiring a physician's prescription.

    149.14(3)(e)

    (e) For persons eligible for Medicare, services of a licensed skilled nursing facility, to the extent required by s. 632.895 (3) and for not more than an aggregate 120 days during a calendar year, if the services are of the type that would qualify as reimbursable services under Medicare. Coverage under this paragraph that is not required by s. 632.895 (3) is subject to any deductible and coinsurance requirements provided by the authority.

    149.14(3)(em)

    (em) For persons not eligible for medicare, services of a licensed skilled nursing facility, only to the extent required by s. 632.895 (3).

    149.14(3)(f)

    (f) Services of a home health agency, as defined in s. 50.49 (1) (a), only to the extent required under s. 632.895 (2).

    149.14(3)(g)

    (g) Use of radium or other radioactive materials.

    149.14(3)(h)

    (h) Oxygen.

    149.14(3)(i)

    (i) Anesthetics.

    149.14(3)(j)

    (j) Prostheses other than dental.

    149.14(3)(k)

    (k) Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids.

    149.14(3)(L)

    (L) Diagnostic X-rays and laboratory tests.

    149.14(3)(m)

    (m) Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth.

    149.14(3)(n)

    (n) Services of a physical therapist.

    149.14(3)(nm)

    (nm) Hospice care provided by a hospice licensed under subch. IV of ch. 50.

    149.14(3)(o)

    (o) Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat a covered condition.

    149.14(3)(q)

    (q) Any other health insurance coverage, only to the extent required under subch. VI of ch. 632.

    149.14(3)(r)

    (r) Processing charges for blood including, but not limited to, the cost of collecting, testing, fractionating and distributing blood.

    149.14(3c)

    (3c) Temporary provider certification. Notwithstanding the provider licensing and certification requirements under sub. (3) (intro.), for coverage of services or articles provided to an eligible person the authority may certify on a temporary basis a provider that is not licensed under ch. 446 or 448 but that is licensed in another state to provide the service or article, or a provider that is not certified under s. 49.45 (2) (a) 11. The certification under this subsection may be retroactive.

    149.14(4)

    (4) Plan design. Subject to subs. (1) to (3), (5), and (6), the authority shall establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate. Subject to subs. (1) to (3), (5), and (6), the authority shall provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state. The authority may develop additional benefit designs that are responsive to market conditions.

    149.14(5)

    (5) Deductible and copayment subsidies.

    149.14(5)(a)

    (a) The authority shall establish and provide subsidies for deductibles paid by eligible persons with household incomes specified in s. 149.165 (2) (a) to (e).

    149.14(5)(b)

    (b) The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in par. (a).

    149.14(6)

    (6) Preexisting conditions. An eligible individual who obtains coverage under the plan may not be subject to any preexisting condition exclusion under the plan.

    149.14(7)

    (7) Coordination of benefits.

    149.14(7)(a)

    (a) Covered expenses under the plan shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care insurance, medicare, medical assistance or any other governmental program, except as otherwise provided by law.

    149.14(7)(b)

    (b) The authority has a cause of action against an eligible participant for the recovery of the amount of benefits paid that are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.

    149.14(7)(c)

    (c) The authority is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan.

    149.14 - ANNOT.

    History: 1979 c. 313; 1981 c. 39 s. 22; 1981 c. 83; 1981 c. 314 ss. 117, 146; 1983 a. 27; 1985 a. 29 s. 3202 (30); 1985 a. 332 s. 253; 1987 a. 27, 239; 1989 a. 332; 1991 a. 39, 269; 1995 a. 463; 1997 a. 27 ss. 3026c, 4847 to 4859; Stats. 1997 s. 149.14; 1997 a. 237; 1999 a. 9, 165; 2001 a. 16; 2003 a. 33; 2005 a. 74 ss. 93 to 122, 130, 131; 2007 a. 39; 2009 a. 83.

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