2019 - 2020 LEGISLATURE
February 15, 2019 - Introduced by Senators Erpenbach, Schachtner, Bewley,
Carpenter, Hansen, Johnson, Miller, Ringhand, Risser, Shilling, Smith,
Wirch and Larson, cosponsored by Representatives Riemer,
Considine, Crowley, Hesselbein, Pope, Sinicki, Spreitzer, Shankland,
Subeck, C. Taylor and Vruwink. Referred to Committee on Health and
1An Act to repeal
632.746 (1) (b), 632.746 (2) (c), (d) and (e), 632.746 (3) (a), 2
632.746 (3) (d) 2. and 3., 632.746 (5) and 632.76 (2) (ac) 3.; to renumber
(3) (d) 1.; to renumber and amend
632.746 (1) (a);
40.51 (8), 40.51 4
(8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 625.12 (1) (a), 625.12 (1) (e), 5
625.12 (2), 625.15 (1), 628.34 (3) (a), 632.746 (2) (a), 632.746 (8) (a) (intro.), 6
632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), 7
632.895 (14) (a) 1. i. and j., 632.895 (14) (b), 632.895 (14) (c), 632.895 (14) (d) 3., 8
632.895 (16m) (b), 632.895 (17) (b) 2., 632.895 (17) (c) and 632.897 (11) (a); and 9to create
609.713, 609.847, 632.728, 632.895 (13m), 632.895 (14) (a) 1. k. to o. 10
and 632.895 (14m) of the statutes;
relating to: coverage of preventive services,
11essential health benefits, and individuals with preexisting conditions; rating;
12and benefit limits under health plans.
Analysis by the Legislative Reference Bureau
This bill requires certain health plans to guarantee access to coverage;
prohibits plans from imposing preexisting condition exclusions; prohibits plans from
setting premiums or cost-sharing amounts based on a health status-related factors;
prohibits plans from setting lifetime or annual limits on benefits; requires plans to
cover certain essential health benefits; and requires coverage of certain preventive
services by plans without a cost-sharing contribution by an enrollee.
Coverage of individuals with preexisting conditions; rating; benefit limits.
This bill requires every individual health insurance policy, known in the bill as
a health benefit plan, to accept every individual who, and every group health
insurance policy to accept every employer that, applies for coverage, regardless of
sexual orientation, gender identity, or whether an employee or individual has a
preexisting condition. The bill allows health benefit plans to restrict enrollment in
coverage to open or special enrollment periods and requires the commissioner of the
Office of the Commissioner of Insurance to establish a statewide open enrollment
period of no shorter than 30 days for every individual health benefit plan. The bill
prohibits a group health insurance policy, including a self-insured governmental
health plan, from imposing a preexisting condition exclusion. The bill also prohibits
an individual health insurance policy from reducing or denying a claim or loss
incurred or disability commencing under the policy on the ground that a disease or
physical condition existed prior to the effective date of coverage.
A health benefit plan offered on the individual or small employer market or a
self-insured governmental health plan may not vary premium rates for a specific
plan except on the basis of whether the plan covers an individual or family, area in
the state, age, and tobacco use as specified in the bill. An individual health benefit
plan or self-insured health plan is prohibited under the bill from establishing rules
for the eligibility of any individual to enroll based on health-status related factors,
which are specified in the bill. A self-insured health plan or an insurer offering an
individual health benefit plan is also prohibited from requiring an enrollee to pay a
greater premium, contribution, deductible, copayment, or coinsurance amount than
is required of a similarly situated enrollee based on a health-status related factor.
Current state law prohibits group health benefit plans from establishing rules of
eligibility or requiring greater premium or contribution amounts based on a
health-status related factor. The bill adds to these current law requirements for
group health benefit plans that the plan may not require a greater deductible,
copayment, or coinsurance amount based on a health-status related factor.
Under the bill, an individual or group health benefit plan or a self-insured
governmental health plan may not establish lifetime or annual limits on the dollar
value of benefits for an enrollee or a dependent of an enrollee under the plan.
The requirements and prohibitions in this bill related to coverage of individuals
with preexisting conditions and prohibition of lifetime and annual benefit limits also
apply to short-term, limited-duration health insurance policies.
Coverage of essential health benefits and preventive services
This bill requires certain health insurance policies, known in the bill as
disability insurance policies, and governmental self-insured health plans to cover
essential health benefits that will be specified by the commissioner of insurance by
rule. The bill specifies a list of requirements that the commissioner must follow when
establishing the essential health benefits including certain limitations on cost
sharing and the following general categories of benefits, items, or services in which
the commissioner must require coverage: ambulatory patient services, emergency
services, hospitalization, maternity and newborn care, mental health and substance
use disorder services, prescription drugs, rehabilitative and habilitative services
and devices, laboratory services, preventive and wellness services and chronic
disease management, and pediatric services. If an essential health benefit specified
by the commissioner is also subject to its own mandated coverage requirement, the
bill requires the disability insurance policy or self-insured health plan to provide
coverage under whichever requirement provides the insured or plan participant with
more comprehensive coverage.
This bill requires health insurance policies and governmental self-insured
health plans to cover certain preventive services and to provide coverage of those
preventive services without subjecting that coverage to deductibles, copayments, or
coinsurance. The preventive services for which coverage is required are specified in
the bill. The bill also specifies certain instances when cost-sharing amounts may be
charged for an office visit associated with a preventive service.
This proposal may contain a health insurance mandate requiring a social and
financial impact report under s. 601.423, stats.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
40.51 (8) of the statutes is amended to read:
Every health care coverage plan offered by the state under sub. (6) 3
shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2),
(1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 5
632.855, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 6
40.51 (8m) of the statutes is amended to read:
Every health care coverage plan offered by the group insurance 9
board under sub. (7) shall comply with ss. 631.95, 632.728,
632.746 (1) to (8) and (10), 10
632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.867, 11
632.885, 632.89, and 632.895 (11) (8) and (10)
66.0137 (4) of the statutes is amended to read:
66.0137 (4) Self-insured health plans.
If a city, including a 1st class city, or 2
a village provides health care benefits under its home rule power, or if a town 3
provides health care benefits, to its officers and employees on a self-insured basis, 4
the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 5632.728,
632.746 (1) and
(10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 6
632.855, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) (8)
to (17), 632.896, 7
and 767.513 (4).
120.13 (2) (g) of the statutes is amended to read:
(g) Every self-insured plan under par. (b) shall comply with ss. 10
49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.728,
632.746 (1) and
(10) (a) 2. and (b) 11
2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.867, 632.87 (4) to (6), 632.885, 12
632.89, 632.895 (9) (8)
to (17), 632.896, and 767.513 (4).
185.983 (1) (intro.) of the statutes is amended to read:
(intro.) Every voluntary nonprofit health care plan operated by a 15
cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 16
646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 17
601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 18
631.95, 632.72 (2), 632.728,
632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 19
632.85, 632.853, 632.855, 632.867, 632.87 (2) to (6), 632.885, 632.89, 632.895 (5) and 20
(8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but 21
the sponsoring association shall:
609.713 of the statutes is created to read:
23609.713 Essential health benefits; preventive services.
Defined network 24
plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).
609.847 of the statutes is created to read:
1609.847 Preexisting condition discrimination and certain benefit
Limited service health organizations, preferred provider plans, 3
and defined network plans are subject to s. 632.728.
625.12 (1) (a) of the statutes is amended to read:
(a) Past and prospective loss and expense experience within and 6
outside of this state, except as provided in s. 632.728
625.12 (1) (e) of the statutes is amended to read:
(e) Subject to s.
632.365 and 632.728
, all other relevant factors, 9
including the judgment of technical personnel.
625.12 (2) of the statutes is amended to read:
625.12 (2) Classification. Risks Except as provided in s. 632.728, risks
be classified in any reasonable way for the establishment of rates and minimum 13
premiums, except that no classifications may be based on race, color, creed or 14
national origin, and classifications in automobile insurance may not be based on 15
physical condition or developmental disability as defined in s. 51.01 (5). Subject to 16s. ss.
632.365 and 632.728
, rates thus produced may be modified for individual risks 17
in accordance with rating plans or schedules that establish reasonable standards for 18
measuring probable variations in hazards, expenses, or both. Rates may also be 19
modified for individual risks under s. 625.13 (2).
625.15 (1) of the statutes is amended to read:
625.15 (1) Rate making. An Except as provided in s. 632.728, an
insurer may 22
itself establish rates and supplementary rate information for one or more market 23
segments based on the factors in s. 625.12 and, if the rates are for motor vehicle 24
liability insurance, subject to s. 632.365, or the insurer may use rates and 25
supplementary rate information prepared by a rate service organization, with
average expense factors determined by the rate service organization or with such 2
modification for its own expense and loss experience as the credibility of that 3
628.34 (3) (a) of the statutes is amended to read:
(a) No insurer may unfairly discriminate among policyholders by 6
charging different premiums or by offering different terms of coverage except on the 7
basis of classifications related to the nature and the degree of the risk covered or the 8
expenses involved, subject to ss. 632.365, 632.728,
632.746 and 632.748. Rates are 9
not unfairly discriminatory if they are averaged broadly among persons insured 10
under a group, blanket or franchise policy, and terms are not unfairly discriminatory 11
merely because they are more favorable than in a similar individual policy.
632.728 of the statutes is created to read:
13632.728 Coverage of persons with preexisting conditions; guaranteed
14issue; benefit limits. (1) Definitions.
In this section:
(a) “Health benefit plan” has the meaning given in s. 632.745 (11).
(b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
17(2) Guaranteed issue.
(a) Every individual health benefit plan shall accept 18
every individual in this state who, and every group health benefit plan shall accept 19
every employer in this state that, applies for coverage, regardless of sexual 20
orientation, gender identity, or whether or not any employee or individual has a 21
preexisting condition. A health benefit plan may restrict enrollment in coverage 22
described in this paragraph to open or special enrollment periods.
(b) The commissioner shall establish a statewide open enrollment period of no 24
shorter than 30 days for every individual health benefit plan to allow individuals, 25
including individuals who do not have coverage, to enroll in coverage.
1(3) Prohibiting discrimination based on health status.
(a) An individual 2
health benefit plan or a self-insured health plan may not establish rules for the 3
eligibility of any individual to enroll, or for the continued eligibility of any individual 4
to remain enrolled, under the plan based on any of the following health 5
status-related factors in relation to the individual or a dependent of the individual: