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AB1224: Bill Text
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2025 - 2026 LEGISLATURE
LRB-6582/1
KMS&EKL:skw
2025 ASSEMBLY BILL 1224
March 19, 2026 - Introduced by Representatives
Clancy
,
Madison
and
Phelps
. Referred to Committee on Health, Aging and Long-Term Care.
AB1224,1,5
1
An Act
to amend
15.01 (6);
to create
13.94 (1) (ew), 15.193 (2), 20.435 (10),
2
25.17 (1) (gt), 25.76, chapter 56, 73.03 (78) and 601.41 (14) of the statutes;
3
relating to:
establishing a publicly financed health care plan for residents of
4
this state, creating the office of the ombudsman for patient advocacy, granting
5
rule-making authority, and making an appropriation.
Analysis by the Legislative Reference Bureau
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.
For further information see the state fiscal estimate, which will be printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
AB1224,1
1
Section
1
.
13.94 (1) (ew) of the statutes is created to read:
AB1224,2,7
2
13.94
(1)
(ew) Annually, perform a financial audit of the health plan under ch.
3
56, including an analysis of the sufficiency of the health plan’s reserves. Within 30
4
days after completion of the audit, the legislative audit bureau shall submit a
5
detailed report of the audit to the legislature under s. 13.172 (2), the governor, the
6
department of administration, the department of health services, and the
7
department of revenue.
AB1224,2
8
Section
2
.
15.01 (6) of the statutes is amended to read:
AB1224,3,14
1
15.01
(6)
“Division,” “bureau,” “section,” and “unit” means the subunits of a
2
department or an independent agency, whether specifically created by law or
3
created by the head of the department or the independent agency for the more
4
economic and efficient administration and operation of the programs assigned to
5
the department or independent agency. The office of credit unions in the
6
department of financial institutions, the office of the inspector general in the
7
department of children and families, the office of the inspector general in the
8
department of health services,
the office of the ombudsman for patient advocacy in
9
the department of health services,
and the office of children’s mental health in the
10
department of health services have the meaning of “division” under this subsection.
11
The office of the long-term care ombudsman under the board on aging and long-
12
term care and the office of educational accountability and the office of literacy in
13
the department of public instruction have the meaning of “bureau” under this
14
subsection.
AB1224,3
15
Section
3
.
15.193 (2) of the statutes is created to read:
AB1224,3,20
16
15.193
(2)
Office of the ombudsman for patient advocacy.
There is
17
created in the department of health services an office of the ombudsman for patient
18
advocacy. The ombudsman shall be appointed by the secretary of health services
19
and may be removed only for just cause. An individual may not serve as
20
ombudsman while holding another public office.
AB1224,4
21
Section
4
.
20.005 (3) (schedule) of the statutes: at the appropriate place,
22
insert the following amounts for the purposes indicated:
-
See PDF for table
AB1224,5
10
Section
5
.
20.435 (10) of the statutes is created to read:
AB1224,4,12
11
20.435
(10)
Health plan.
(a)
General program operations.
The amounts in
12
the schedule for general program operations.
AB1224,4,14
13
(b)
Office of the ombudsman for patient advocacy
.
The amounts in the
14
schedule for the operations of the office of the ombudsman for patient advocacy.
AB1224,4,17
15
(q)
Health plan benefits; administration
. From the health plan fund, the
16
amounts in the schedule for administration, enrollment determinations, and
17
provision of benefits under the health plan administered under ch. 56.
AB1224,4,19
18
(r)
Capital expenditures.
From the health plan fund, the amounts in the
19
schedule for capital expenditures for institutional providers under s. 56.10 (4) (c).
AB1224,6
20
Section
6
.
25.17 (1) (gt) of the statutes is created to read:
AB1224,4,21
21
25.17
(1)
(gt) Health plan fund (s. 25.76);
AB1224,7
22
Section
7
.
25.76 of the statutes is created to read:
AB1224,4,24
23
25.76
Health plan fund.
There is created a separate, nonlapsible trust fund
24
designated as the health plan fund, consisting of all of the following:
AB1224,5,1
1
(1)
All amounts deposited under s. 56.12.
AB1224,5,3
2
(2)
All federal payments received by the state to fund health care services in
3
this state, subject to any federal waiver granted under s. 56.02 (2) (a) or (3).
AB1224,5,4
4
(3)
All donations, gifts, and bequests made to the fund.
AB1224,5,5
5
(4)
All moneys transferred to the fund from other funds.
AB1224,5,6
6
(5)
All income and interest earned by the fund.
AB1224,8
7
Section
8
.
Chapter 56 of the statutes is created to read:
AB1224,5,9
8
CHAPTER 56
9
HEALTH PLAN
AB1224,5,10
10
56.01 Definitions.
In this chapter:
AB1224,5,12
11
(1)
“Covered benefit” means a benefit under s. 56.05 (1) or (3) that is provided
12
to an enrollee.
AB1224,5,13
13
(2)
“Department” means the department of health services.
AB1224,5,15
14
(3)
“Enrollee” means an individual who is enrolled in the health plan under
15
this chapter.
AB1224,5,16
16
(4)
“Health plan fund” means the fund created under s. 25.76.
AB1224,5,17
17
(5)
“Health plan” means the plan described under s. 56.03.
AB1224,5,20
18
(6)
“Institutional provider” means a health care facility located in this state
19
that provides overnight care, including a hospital, nursing facility, or inpatient
20
rehabilitation facility.
AB1224,5,24
21
(7)
“Medically necessary” means necessary to promote health and to prevent,
22
diagnose, or treat a particular patient’s medical condition in a manner that meets
23
accepted standards of medical practice in a health care provider’s professional peer
24
group and geographic region.
AB1224,6,2
1
(8)
“Noninstitutional provider” means a health care facility located in this
2
state that does not provide overnight care.
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