2019 - 2020 LEGISLATURE
ASSEMBLY AMENDMENT 2,
TO ASSEMBLY BILL 1
January 16, 2019 - Offered by Representative Rohrkaste.
“(ag) “Defined network plan” has the meaning given in s. 609.01 (1b).”.
“(ar) “Preexisting condition exclusion” means, with respect to coverage, a 7
limitation or exclusion of benefits relating to a condition based on the fact that the 8
condition was present before the date of enrollment for the coverage, whether or not 9
any medical advice, diagnosis, care, or treatment was recommended or received 10
before the date of enrollment for coverage.”.
“(b) A health benefit plan that is a defined network plan may do any of the 3
1. Limit the employers that may apply for group health benefit plan coverage 5
to those employers whose employees live, work, or reside in the service area for the 6
defined network plan.
2. Deny coverage to employers and individuals in the service area of the defined 8
network plan if the defined network plan has demonstrated to the commissioner all 9
of the following:
a. The defined network plan does not have the capacity to deliver services 11
adequately to enrollees of any additional groups or additional individuals because 12
of its obligations to existing defined network plan enrollees.
b. The defined network plan is denying coverage uniformly to all employers and 14
individuals without regard to the claims experience or health status-related factor, 15
as described under s. 632.748 (1) (a) 1. to 8., of the individuals, employers, employees, 16
or dependents of individuals or employees.
(c) A group or individual health benefit plan may deny coverage if the plan has 18
demonstrated to the commissioner all of the following:
1. The issuer of the health benefit plan does not have the financial reserves 20
necessary to underwrite additional coverage.
2. The group or individual health benefit plan is denying coverage uniformly 22
to all employers and individuals without regard to the claims experience or health 23
status-related factor, as described under s. 632.748 (1) (a) 1. to 8., of the individuals, 24
employers, employees, or dependents of individuals or employees.
(d) A defined network plan that denies coverage under par. (b) 2. may not offer 2
coverage within the service area of the defined network plan within 180 days after 3
the date coverage is denied under par. (b) 2. An issuer of a health benefit plan that 4
denies coverage under par. (c) may not offer coverage under a group or individual 5
health benefit plan in this state within 180 days after the date coverage is denied 6
under par. (c) or until the date the issuer of the health benefit plan demonstrates to 7
the commissioner that the issuer has sufficient financial reserves to underwrite 8
additional coverage, whichever is later.”.
1714. Page 5, line 12
: after “Applicability.
" insert “(a) A health benefit plan that 18
is considered a grandfathered health plan under 42 USC 18011
as of January 1, 2019, 19
or has transitional status as of January 1, 2019, granted by the federal department 20
of health and human services and the commissioner is not required to comply with 21
sub. (2) or (3). An individual health benefit plan that is considered a grandfathered 22
health plan under 42 USC 18011
as of January 1, 2019, or has transitional status as
of January 1, 2019, granted by the federal department of health and human services 2
and the commissioner is not required to comply with sub. (5).