Ins 8.11 Note Assume a school district has a self-insured employee health care benefit plan that covers 250 employees and family members. The plan offers individual specific stop-loss of \$25,000 and provides benefits with a \$500.00 deductible per person, 80% coinsurance and \$1,000.00 out-of-pocket limit per person.
Ins 8.11 Note The plan's stop-loss coverage and benefit package are the same as that used in Table 7. Therefore, use Table 7 for determining whether the plan meets the requirements in sub. (4).
Ins 8.11 Note In Table 7, use the 125 percent of mean line. Since sub. (4) (a) deals with "125% of expected claims," refer to the 125% of mean line when using any of the tables.
Ins 8.11 Note To determine whether the probability that aggregate claims will exceed 125% of expected claims is less than 5%, subtract the decimal numbers shown in the tables from the number "1". For example, for a plan offering the benefits described in Table 7 and having 25 employees, the probability that aggregate claims will exceed 125% of expected claims is 28% (1 minus .72= .28). It is 26% for 50 employees (1 minus .74), 23% for 100 employees (1 minus .77), etc.
Ins 8.11 Note In this example, the plan covers 250 employees. Table 7 shows that at 250 employees, the probability that aggregate claims will exceed 125% of expected claims is 18% (1 minus .82).
Ins 8.11 Note In order to comply with the rule, this probability must be less than 5%. In this example, the probability is 18%. Therefore, the school district or county must purchase aggregate stop-loss insurance at a level sufficient to bring this probability down to less than 5%. Stop-loss insurance is sold at various levels, including a level at which the probability that aggregate claims will exceed 125% of expected claims is less than 5%. At a minimum, the school district or county should purchase stop-loss insurance at this level. - See PDF for table - See PDF for table - See PDF for table - See PDF for table - See PDF for table - See PDF for table - See PDF for table - See PDF for table
Ins 8.11(7) (7)Actuary qualifications. The actuarial certification specified in sub. (6) shall be signed by an actuary who satisfies the requirements of s. Ins 6.12.
Ins 8.11 History History: Cr. Register, April, 1988, No. 388, eff. 5-1-88; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562.
subch. II of ch. Ins 8 Subchapter II — Employee Benefit Plan Administrators
Ins 8.20 Ins 8.20 Purpose. This subchapter interprets and implements ch. 633, Stats.
Ins 8.20 History History: Cr. Register, April, 1992, No. 436, eff. 5-1-92.
Ins 8.22 Ins 8.22 Definitions. In this subchapter:
Ins 8.22(1) (1) "Administrator" has the meaning given in s. 633.01 (1), Stats.
Ins 8.22(2) (2) "Commissioner" means the commissioner of insurance.
Ins 8.22(3) (3) "Employee" has the meaning given in s. 633.01 (2), Stats.
Ins 8.22(4) (4) "Office" means the office of the commissioner.
Ins 8.22(5) (5) "Plan" has the meaning given in s. 633.01 (4), Stats.
Ins 8.22(6) (6) "Principal" has the meaning given in s. 633.01 (5), Stats.
Ins 8.22 History History: Cr. Register, April, 1992, No. 436, eff. 5-1-92.
Ins 8.24 Ins 8.24 Exemptions.
Ins 8.24(1)(1) Each of the following is exempt from ch. 633, Stats., and this subchapter for the portion of its business subject to regulation under the specified sections:
Ins 8.24(1)(a) (a) An administrator of one or more self-insured, partially insured or divided insurance worker's compensation plans subject to or 80.61.
Ins 8.24(1)(b) (b) A warrantor or warranty plan administrator, as defined in or (e), that holds a valid certificate of authority under ch. Ins 15.
Ins 8.24(2) (2) An administrator that is partially exempt under sub. (1) (a) or (b) is subject to ch. 633, Stats., and this subchapter for any portion of its business that is outside the scope of the exemption.
Ins 8.24 History History: Cr. Register, April, 1992, No. 436, eff. 5-1-92; correction in (1) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1997, No. 498.
Ins 8.26 Ins 8.26 Licensing.
Ins 8.26(1)(1)Application. A person applying for a new or renewal license as an administrator shall submit an application to the office in the form prescribed by the office. With the application, the person shall submit all of the following:
Ins 8.26(1)(a) (a) With the initial application, a performance bond meeting the requirements of s. Ins 8.28.
Ins 8.26(1)(b) (b) With a renewal application, proof that the bond continues to meet the requirements of s. Ins 8.28, if the amount required for the bond has changed.
Ins 8.26(1)(c) (c) A financial statement for the administrator's most recently completed fiscal year, prepared according to generally accepted accounting principles. The financial statement shall report the administrator's assets, liabilities and net worth, the results of operations and the changes in net worth for the fiscal year on the accrual basis.
Ins 8.26(1)(d) (d) A statement as to whether the administrator does any of the following:
Ins 8.26(1)(d)1. 1. Collects premiums or employee contributions on behalf of any principal.
Ins 8.26(1)(d)2. 2. Maintains separate fiduciary accounts for each principal.
Ins 8.26(1)(e) (e) All of the following information about the administrator, if an individual, or about each officer, director, partner or other individual having comparable responsibilities in the organization, if a corporation or partnership:
Ins 8.26(1)(e)1. 1. Whether the individual has been fined or reprimanded or has been the subject of a consent decree in any state by any agency that regulates the business of administrators, insurance, real estate, securities or financial institutions.
Ins 8.26(1)(e)2. 2. Whether the individual has had a license to solicit insurance, real estate or securities or to act as an administrator refused, suspended, denied or revoked in any state.
Ins 8.26(1)(e)3. 3. Whether the individual has been convicted of a felony or misdemeanor, other than a misdemeanor related to the use of a motor vehicle or the violation of a fish and game regulation.
Ins 8.26(1)(e)4. 4. If the individual has ever been employed by an administrator or insurance company, or in the business of real estate, securities or financial institutions, whether his or her employment has been terminated or nonrenewed because of allegations of misconduct or wrongdoing.
Ins 8.26(1)(f) (f) If the administrator is an individual, his or her insurance intermediary agent's license number and social security number and a statement that he or she intends to act as an administrator in good faith and in compliance with all applicable laws of this state and rules and orders of the commissioner.
Ins 8.26(1)(g) (g) If the administrator is a corporation or partnership, its federal identification number, the state and year of its incorporation or year of its formation and a statement that it intends to act as an administrator in good faith and in compliance with all applicable laws of this state and rules and orders of the commissioner and that it has designated or will designate an individual with direct responsibility for each plan it administers.
Ins 8.26(1)(h) (h) If the administrator is an individual who is not a resident of this state or a corporation or partnership that is not organized under the laws of this state, a statement that the administrator agrees to be subject to the jurisdiction of the commissioner and the courts of this state with respect to all matters pertaining to activities as an administrator and to accept service of process as provided under ss. 601.72 and 601.73, Stats.
Ins 8.26(1)(i) (i) Any other information requested by the office.
Ins 8.26(1)(j) (j) The fee specified under s. 601.31 (1) (w), Stats., which shall be nonrefundable.
Ins 8.26(2) (2)Renewal application deadline. An administrator shall submit a renewal application on or before August 1 of each year.
Ins 8.26(3) (3)Application review. The office shall review and approve or disapprove each complete application within 60 days after its receipt.
Ins 8.26 Note Note: The application form, which includes a sample performance bond format, OCI 30-001, may be obtained from the Office of the Commissioner of Insurance, P.O. Box 7872, Madison, Wisconsin 53707-7872.
Ins 8.26 History History: Cr. Register, April, 1992, No. 436, eff. 5-1-92.
Ins 8.28 Ins 8.28 Performance bond requirements.
Ins 8.28(1) (1) A performance bond required under s. 633.14 (1) (b) or (2) (b), Stats., shall be continuous in form, shall be issued by an insurer authorized to do a surety business in this state and shall be in favor of the commissioner and payable to any resident of this state who is the beneficiary of an employee benefit plan administered by the administrator and to any such employee benefit plan on behalf of the residents of this state who are its beneficiaries in the event of injury caused by a failure of the administrator to fulfill its responsibilities as an administrator.
Ins 8.28(2) (2) If the administrator collects premiums or employee contributions on behalf of any principal, or commingles funds belonging to more than one principal, the performance bond shall be in the greater of the following amounts:
Ins 8.28(2)(a) (a) \$25,000.
Ins 8.28(2)(b) (b) Ten percent of the total amount of projected premiums, charges and claim funds the administrator expects to handle on behalf of residents of this state during the fiscal year following the year for which a financial statement is submitted under. A bond under this paragraph need not exceed \$500,000.
Ins 8.28(3) (3) If the administrator does not collect premiums or employee contributions on behalf of any principal, and maintains a separate fiduciary account for each principal, the performance bond shall be in the greater of the following amounts:
Ins 8.28(3)(a) (a) \$15,000.
Ins 8.28(3)(b) (b) Five percent of the total amount of projected claim funds the administrator expects to handle on behalf of residents of this state during the fiscal year following the year for which a financial statement is submitted under. A bond under this paragraph need not exceed \$250,000.
Ins 8.28(4) (4) An administrator may exclude from the calculations required under sub. (2) (b) or (3) (b) all amounts handled as administrator for any of the following:
Ins 8.28(4)(a) (a) Self-insured, partially insured or divided insurance worker's compensation plans subject to or 80.61.
Ins 8.28(4)(b) (b) Warranty plans subject to ch. Ins 15.
Ins 8.28 History History: Cr. Register, April, 1992, No. 436, eff. 5-1-92; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1997, No. 498.
Ins 8.30 Ins 8.30 Notification to office. An administrator shall notify the office in writing of any of the following within 30 days after the date of the occurrence:
Ins 8.30(1) (1) The cessation of business activities as an administrator. A notification under this subsection shall include the name and address of the custodian of the administrator's business records and the location of those records.
Ins 8.30(3) (3) Formal administrative action in this state or another state by an agency that regulates the business of administrators, insurance, real estate, securities or financial institutions against the administrator or any officer, director, partner or other individual having comparable responsibilities in the corporation or partnership.
Ins 8.30(4) (4) The conviction in this state or another state of a felony or misdemeanor, other than a misdemeanor related to the use of a motor vehicle or the violation of a fish and game regulation, of the administrator or any of the officers, directors, partners or other persons having comparable responsibilities in the corporation or partnership.
Ins 8.30 History History: Cr. Register, April, 1992, No. 436, eff. 5-1-92.
Ins 8.32 Ins 8.32 Audit. In order to determine whether the financial resources of an administrator are adequate to safeguard the interests of the public and persons covered by a plan, or to determine the appropriate bond amount under s. Ins 8.28, the office may order the administrator to submit financial statements that have been audited by a certified public accountant.
Ins 8.32 History History: Cr. Register, April, 1992, No. 436, eff. 5-1-92.
subch. III of ch. Ins 8 Subchapter III — Small Employer Health Insurance
Ins 8.40 Ins 8.40 Purpose. This subchapter interprets and implements ch. 635, Stats., and s. 149.12 (2) (e), Stats.
Ins 8.40 History History: Cr. Register, October, 1992, No. 442, eff. 11-1-92; am. Register, November, 1993, No. 455, eff. 2-1-94; correction made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562.
Ins 8.42 Ins 8.42 Definitions. In addition to the definitions in s. 635.02, Stats., which apply to this subchapter, in this subchapter:
Ins 8.42(1) (1) "Basic market share ratio" means the ratio of the number of risk characteristic basic health benefit plans in force to the total number of basic health benefit plans in force.
Ins 8.42(2) (2) "Commissioner" means the commissioner of insurance.
Ins 8.42(3) (3) "Initial enrollment period" means a period prior to issuance of a policy during which eligible employees, and dependents of eligible employees, are entitled to enroll in coverage under the policy.
Ins 8.42(4) (4) "Late enrollee" means an eligible employee, or dependent of an eligible employee, who does not request coverage under a policy during an enrollment period in which the individual is entitled to enroll in the policy, and who subsequently requests coverage under the policy, regardless of whether the enrollment period was held prior to, on or after the law's effective date."Late enrollee" does not include an individual who:
Ins 8.42(4)(a) (a) Did not request coverage during an enrollment period under a basic health benefit plan, is covered under the plan established under ch. 149, Stats., under s. 149.12 (2) (e), Stats., and has not terminated eligibility for coverage under the plan established under ch. 149, Stats.; or
Ins 8.42(4)(b) (b) Did not request coverage during an enrollment period for a policy other than a basic health benefit plan which commenced prior to February 1, 1994, and who was covered during the enrollment period under the plan established under ch. 149, Stats.; or
Ins 8.42(4)(c) (c) Is a new entrant under sub. (7) (b) or (c).
Ins 8.42(5) (5) "Law's effective date" means May 12, 1992, or the first renewal date of a policy which occurs on or after May 12, 1992, whichever is later.
Ins 8.42(6) (6) "Market share ratio" means the ratio of the number of risk characteristic basic health benefit plans in force to the total number of policies in force.
Ins 8.42(7) (7) "New entrant" means an eligible employee, or the dependent of an eligible employee, who:
Ins 8.42(7)(a) (a) Becomes part of an employer group on or after the law's effective date and after commencement of an initial enrollment period;
Ins 8.42(7)(b) (b) Is a spouse, minor or dependent under a covered employee's policy who a court orders be covered under the policy and who requests enrollment within 30 days after issuance of the court order; or
Ins 8.42(7)(c) (c) Failed to request enrollment in the policy during an enrollment period which commenced prior to, on or after the law's effective date, during which the individual was entitled to enroll in the policy, if the individual:
Ins 8.42(7)(c)1. 1. Is covered under qualifying coverage during the enrollment period and the qualifying coverage is not the plan established under ch. 149, Stats., or, if it is the plan established under ch. 149, Stats., it is obtained under s. 149.12 (2) (e), Stats.;
Ins 8.42(7)(c)2. 2. Subsequently, and on or after February 1, 1994, loses coverage under the qualifying coverage; and
Ins 8.42(7)(c)3. 3. Requests enrollment within 30 days after termination of the qualifying coverage.
Ins 8.42(8) (8) "Office" means the office of the commissioner.
Ins 8.42(9) (9) "Policy" means any of the following:
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