State of Wisconsin Group Health Insurance Program Agreement Issued by the State of Wisconsin Department of Employee Trust Funds On behalf of the Group Insurance Board Release Date: October 19, 2018 TABLE OF CONTENTS Table of Contents ..................................................................................................................... 2 000 Definitions ......................................................................................................................... 7 100 General .............................................................................................................................11 105 Introduction .....................................................................................................................11 110 Objectives .......................................................................................................................11 115 General Requirements ....................................................................................................12 120 Board Authority ...............................................................................................................16 125 Eligibility ..........................................................................................................................17 125A General .....................................................................................................................17 125B Dependent Coverage Eligibility ..................................................................................20 125C Change to Family Coverage ......................................................................................20 125D No Double Coverage .................................................................................................20 125E Medicare Participants ................................................................................................21 125F Notice of Qualifying Event .........................................................................................21 125G Notice of Medicare Part B Enrollment .......................................................................21 130 Premiums........................................................................................................................21 130A Medicare Participant Premiums .................................................................................22 130B Rate-Setting Process ................................................................................................23 130C Annual Rate-Setting Process for MEDICARE ADVANTAGE CONTRACTOR ...........25 130D Medicare Advantage Uniform Premium Requirements ..............................................26 135 Financial Administration ..................................................................................................26 135A Prohibited Fees .........................................................................................................26 135B Included Services ......................................................................................................27 135C Recovery of Overpayments .......................................................................................27 135D Subrogation and Other Payers ..................................................................................27 135E Amounts Owed by Contractor ....................................................................................27 135F Automated Clearinghouse (ACH) ..............................................................................27 140 Participant Materials and Marketing ................................................................................27 140A Informational / Marketing Materials ............................................................................27 140B It’s Your Choice Open Enrollment Materials ..............................................................32 145 Information Systems .......................................................................................................33 150 Data Requirements .........................................................................................................35 TABLE OF CONTENTS 2 (v. 2018-05-16) 150A Data Integration and Technical Requirements ...........................................................35 150B Eligibility/834 File Requirements ................................................................................35 150C Data Warehouse File Requirements ..........................................................................36 150D Data Integration and Use ..........................................................................................38 150E Data Submission Requirements ................................................................................38 155 Miscellaneous General Requirements .............................................................................40 155A Reporting Requirements and Deliverables ................................................................40 155B Performance Standards and Penalties ......................................................................41 155C Audit and Other Services ..........................................................................................41 155D Fraud and Abuse .......................................................................................................42 155E Department May Designate Vendor...........................................................................44 155F Contract Termination .................................................................................................44 155G Transition Plan ..........................................................................................................44 155H Insolvency .................................................................................................................45 160 Submission of New Proposals.........................................................................................45 160A Operating Experience ................................................................................................45 160B Financial Requirements .............................................................................................46 160C Comprehensive Plans ...............................................................................................46 160D Provider Agreements.................................................................................................47 160E Capital Equipment and Expenditures .........................................................................48 160F Enrollment and Reporting ..........................................................................................48 160G Rate-Making Process ................................................................................................49 160H Submission of Proposals ...........................................................................................49 160I Implementation ...........................................................................................................49 200 Program Requirements ....................................................................................................52 205 Enrollment.......................................................................................................................52 205A Identification (ID) Cards .............................................................................................52 205B Participant Information...............................................................................................52 205C Disabled Child Eligibility ............................................................................................53 205D Date of Death ............................................................................................................53 205E Coordination of Benefits (COB) .................................................................................53 210 Primary Care Provider or Primary Care Clinic .................................................................53 215 Medical Management ......................................................................................................54 215A Disease Management / Prior Authorizations / Utilization Review ...............................54 TABLE OF CONTENTS 3 (v. 2018-05-16) 215B Department Initiatives ................................................................................................56 220 Benefits ...........................................................................................................................57 220A Overview ...................................................................................................................57 220B Telehealth / Nurse Line .............................................................................................57 220C Emergency / Urgent / Catastrophic Care ...................................................................57 220D Inpatient When Changing Coverage ..........................................................................58 220E Federal / State Requirements ....................................................................................58 220F Out-of-Network Services for Preferred Provider Organization (PPO) .........................58 220G Medicare ...................................................................................................................58 220H End Stage Renal Disease - Medicare Participants