2. Any certificate issued under a group Medicare supplement policy or group Medicare replacement cost policy;.
3. Any individual or group policy sold in Wisconsin predominantly to individuals or groups of individuals who are 65 years of age or older which that offers hospital, medical, surgical, or other disability coverage, except for a policy which that offers solely nursing home, hospital confinement indemnity, or specified disease coverage; and.
SECTION 7. Ins 3.39 (2) (a) 4. is repealed.
SECTION 8. Ins 3.39 (2) (a) 5. and (b) are amended to read:
Ins 3.39 (2) (a) 5. Any individual or group policy or certificate sold in Wisconsin to persons under 65 years of age and eligible for medicare Medicare by reason of disability which that offers hospital, medical, surgical or other disability coverage, except for a policy or certificate which that offers solely nursing home, hospital confinement indemnity or specified disease coverage.
(b) Except as provided in pars. (d) and (e), subs. (9) and (11) apply to any individual disability policy sold to a person eligible for Medicare which that is not a Medicare supplement or a Medicare replacement cost policy as described in par. (a).
SECTION 9. Ins 3.39 (2) (c) (intro.) and 2. are consolidated and renumbered (2) (c) and, as renumbered, are amended to read:
Ins 3.39 (2) (c) Except as provided in par. (e), sub. (10) applies to:
1. Any conversion policy which is offered to a person eligible for Medicare as a replacement for prior individual or group hospital or medical coverage, other than a Medicare supplement or a Medicare cost policy described in par. (a); and
2. Any any individual or group hospital or medical policy which that continues with changed benefits after the insured becomes eligible for Medicare.
SECTION 10. Ins 3.39 (2) (c) 1. is repealed.
SECTION 11. Ins 3.39 (2) (d) (intro.) is amended to read:
Ins 3.39 (2) (d) (intro.) Except as provided in subs. (10) and (13), this section does not apply to any of the following:
SECTION 12. Ins 3.39 (2) (d) 4. is repealed.
SECTION 13. Ins 3.39 (2) (e) (intro.) and 1., are amended to read:
Ins 3.39 (2) (e) (intro.) This section does not apply to either of the following:
1. A policy providing solely accident, dental, vision, disability income, or credit disability income coverage; or.
SECTION 14. Ins 3.39 (3) (c) (intro.) and 1., (ce), and (e) are amended to read:
Ins 3.39 (3) (c) “Applicant" means either of the following:
1. In the case of an individual Medicare supplement or Medicare replacement cost policy, the person who seeks to contract for insurance benefits.
(ce) “Balance bill" means seeking: to bill, charge, or collect a deposit, remuneration or compensation from; to file or threaten to file with a credit reporting agency; or to have any recourse against an enrollee insured or any person acting on the enrollee’s insured’s behalf for health care costs for which the enrollee insured is not liable. The prohibition on recovery does not affect the liability of an enrollee insured for any deductibles, coinsurance or copayments, or for premiums owed under the policy or certificate.
(e) “CMS” means the Centers for Medicare & Medicaid Services within the department of health and human services.
SECTION 15. Ins 3.39 (3) (gm), (jm), and (pm) are created to read:
Ins 3.39 (3) (gm) “Complaint" means any dissatisfaction expressed by an individual concerning a Medicare select issuer or its network providers.
(jm) “Grievance" means dissatisfaction expressed in writing by an individual insured under a Medicare select policy or certificate with the administration, claims practices or provision of services concerning a Medicare select issuer or its network providers.
(pm) “MACRA” means the Medicare Access and CHIP Reauthorization Act of 2015, PL 114-10, signed April 16, 2015. SECTION 16. Ins 3.39 (3) (r) (intro.) is renumbered (3) (r) and amended to read:
Ins 3.39 (3) (r) “Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in 42 USC 1395w-28 (b) (1), as amended, and includes any of the following:. SECTION 17. Ins 3.39 (3) (r) 1. to 3. are repealed.
SECTION 18. Ins 3.39 (3) (v) is amended to read:
Ins 3.39 (3) (v) “Medicare replacement coverage" means coverage that meets the definition in s. 600.03 (28p), Stats., as interpreted by sub. (2) (a), and that conforms to subs. (4), (4m), (4s) (4t), and (7) “Medicare replacement coverage" includes Medicare cost and Medicare Advantage plans policies. SECTION 19. Ins 3.39 (3) (ve), (vm), and (vs) are created to read:
Ins 3.39 (3) (ve) “Medicare cost policy” means insurance that is offered by an issuer that has a contract with CMS to provide coverage when services are provided within the issuer’s geographic service area and through network medical providers selected by the issuer that is issued to as an individual policy.
(vm) “Medicare select certificate" means a Medicare supplement policy that provides coverage when services are obtained through network medical providers selected by the issuer that is issued to a group and individuals in the group receive a certificate.
(vs) “Medicare select policy" means a Medicare supplement policy that provides coverage when services are obtained through network medical providers selected by the issuer that is issued to an individual as a policy.
SECTION 20. Ins 3.39 (3) (w) is amended to read:
Ins 3.39 (3) (w) “Medicare supplement coverage" means coverage that meets the definition in s. 600.03 (28r), Stats., as interpreted by sub. (2) (a), and that conforms to subs. (4), (4m), (4s)(4t), (5), (5m), (5t), (6), (30), and (30m), and (30t). “Medicare supplement coverage" includes Medicare supplement and Medicare select plans policies but does not include coverage under Medicare Advantage plans established under Medicare Part C or Outpatient Prescription Drug plans established under Medicare Part D. SECTION 21. Ins 3.39 (3) (wg), and (wr) are created to read:
Ins 3.39 (3) (wg) “Network provider," means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare select policy or certificate.
(wr) “Newly eligible” means a Medicare eligible person who attains age 65 on or after January 1, 2020, who has not participated in Medicare Part B prior to attaining age 65, or by reason of entitlement to benefits under part A pursuant to Section 226(b) or 226A of the Social Security Act, or who is deemed to be eligible for benefits under Section 226(a) of the Social Security Act on or after January 1, 2020.
SECTION 22. Ins 3.39 (3) (zb) is amended to read:
Ins 3.39 (3) (zb) “Replacement” means any transaction, other than when used to refer to an authorized Medicare Advantage policy, wherein where new Medicare supplement or Medicare cost insurance is to be purchased, and it is known to the agent or issuer at the time of application that, as part of the transaction, existing accident and sickness insurance has been or is to be lapsed, cancelled or terminated or the benefits thereof are substantially reduced. “Replacement” includes transactions replacing a Medicare supplemental policy within the same insurer or affiliates of the insurer.
SECTION 23. Ins 3.39 (3) (zbm), (zcm), (zf) and (3g) are created to read:
Ins 3.39 (3) (zbm) “Restricted network provision," means any provision that conditions the payment of benefits, in whole or in part, on the use of network providers.
(zcm) “Service area" means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare select policy or certificate.
(zf) “Type” means, when used in reference to a plan, certificate or policy, is a Medicare supplement individual policy and group certificate, a Medicare cost individual policy, and a Medicare select individual policy and group certificate.
(3g) Medicare eligible person. (a) Generally, an individual who attains age 65 or older, an individual under the age of 65 with certain disabilities, or an individual with end-stage renal disease is eligible to enroll in Medicare. The date a person is first eligible for Medicare Part B or first elected Medicare Part A establishes the benefits available regardless of the date of election provided the benefit is offered in the market. In addition to the provisions that apply to all Medicare supplement and Medicare cost policies, the following identify the benefits and coverage subsections that have provisions tied to the date and year when a person is first eligible for Medicare Parts A and B:
1. For persons first eligible for Medicare Part A and B before June 1, 2010, subs. (4), (5), (7) (a), and (30) describe benefits and coverage available as contained in Appendix 1, and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.
2. For persons first eligible for Medicare Part A and B on or after June 1, 2010 and prior to January 1, 2020, subs. (4m), (5m), (7) (dm), (14m), and (30m) describe benefits and coverage available as contained in Appendices 2m, 3m, 4m, 5m and 6m and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.
3. For persons first eligible for Medicare Part A and B on or after January 1, 2020, MACRA designated Medicare eligible persons as “newly eligible” to distinguish from person eligible prior to January 1, 2020. For these newly eligible persons, subs. (4t), (5t), (7) (dt), (14t), and (30t) describe benefits and coverage available as contained in Appendices 2t, 3t, 4t, 5t, and 6t and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.
(b) Medicare supplement and Medicare select policies are guaranteed renewable for life. Therefore, a Medicare eligible person can, at his or her choice, elect to receive benefits and coverage under a policy that may have fewer riders available. An insurer cannot require the Medicare eligible person to replace existing coverage with coverage reflecting recent changes, including changes due to MACRA. This means that if a Medicare eligible person who is eligible for Medicare prior to January 1, 2020, and elects the Medicare Part B medical deductible rider prior to January 1, 2020, upon renewal of the policy that person shall be eligible to continue to receive benefits from the Medicare Part B medical deductible rider in accordance with the terms of the policy even though the insurer can no longer actively market that rider.
SECTION 24. Ins 3.39 (4) (title) and (intro.), (a) (intro.) 1. to 7., 9. to 12., and 16. are amended to read:
Ins 3.39 (4) (title) Medicare supplement and Medicare replacement cost policy and certificate requirements for policies and certificates with effective dates prior to June 1, 2010. Except as explicitly allowed by subs. (5), (7), and (30), no disability insurance policy or certificate shall relate its coverage to Medicare or be structured, advertised, solicited, delivered or issued for delivery in this state after December 31, 1990, for policies or certificates with effective dates prior to June 1, 2010, as a Medicare supplement policy or certificate or as a Medicare replacement cost policy or certificate, as defined in s. 600.03 (28p) (a) and (c), Stats., unless it the policy or certificate complies, as applicable, with all of the following : (a) The policy or certificate complies with all of the following requirements:
1. Provides only the coverage set out in sub. (5), (7), or (30) and applicable statutes and contains no exclusions or limitations other than those permitted by sub. (8). No issuer may issue a Medicare cost policy or Medicare select policy or certificate without prior approval from the commissioner and compliance with subs. (7) and (30), respectively.
2. Discloses on the first page any applicable pre-existing preexisting conditions limitation, contains no pre-existing preexisting condition waiting period longer than 6 months and shall does not define a pre-existing preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
3. Contains no definitions of terms such as “Medicare eligible expenses.” “accident,” “sickness,” “mental or nervous disorders,” “skilled nursing facility,” “hospital,” “nurse,” “physician,” “Medicare approved expenses,” “benefit period,” “convalescent nursing home,” or “outpatient prescription drugs” that are worded less favorably to the insured person than the corresponding Medicare definition or the definitions contained in sub. (3), and defines “Medicare” as in accordance with sub. (3) (q).
4. Does not indemnify against losses resulting from sickness on a different basis from losses resulting from accident;.
5. Is “guaranteed renewable" and does not provide for termination of coverage of a spouse solely because of an event specified for termination of coverage of the insured, other than the nonpayment of premium. The policy shall not be cancelled or nonrenewed by the insurer on the grounds of deterioration of health. The policy may be cancelled only for nonpayment of premium or material misrepresentation. If the policy is issued by a health maintenance organization as defined by s. 609.01 (2), Stats., the policy may, in addition to the above reasons, be cancelled or nonrenewed by the issuer if the insured moves out of the service area;. 6. Provides that termination of a Medicare supplement policy or certificate or Medicare cost policy or certificate shall be without prejudice to a continuous loss that commenced while the policy or certificate was in force, although the extension of benefits may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits shall not be considered in determining a continuous loss.
7. Contains statements on the first page and elsewhere in the policy which that satisfy the requirements of s. Ins 3.13 (2) (c), (d) or (e), and clearly states on the first page or schedule page the duration of the term of coverage for which the policy or certificate is issued and for which it may be renewed. (theThe renewal period cannot be less than the greater greatest of the following: 3 months, the period for which the insured has paid the premium, or the period specified in the policy); or certificate. 9. Prominently discloses any limitations on the choice of providers or geographical area of service;.
10. Contains on the first page the designation, printed in 18-point type, and in close conjunction the caption printed in 12-point type, prescribed in sub. (5), (7), or (30);.
11. Contains text which that is plainly printed in black or blue ink the and has a font size of which that is uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point;.
12. Contains a provision describing the review and appeal procedure for denied claims as required by s. 632.84, Stats., and a provision describing any grievance rights as required by s. 632.83, Stats., applicable to Medicare supplement policy and certificates and Medicare replacement cost policies; and. 16. Except for permitted preexisting condition clauses as described in subd. 2., no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
SECTION 25. Ins 3.39 (4) (a) 18r. is repealed.
SECTION 26. Ins 3.39 (4) (a) 18r. a. to c. are renumbered 3.39 (4) (a) 18s., 18u., and 18x. and amended to read:
Ins 3.39 (4) (a) 18s. Shall No Medicare supplement or certificate may not provide for any waiting period for resumption of coverage that was in effect before the date of suspension under subd. 18. with respect to treatment of preexisting conditions.
18u. Shall Each Medicare supplement or certificate shall provide for resumption of coverage that was in effect before the date of suspension in subd. 18. If the suspended Medicare supplement or Medicare cost policy provided coverage for outpatient prescription drugs, reinstitution resumption of the policy shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension. If the suspended Medicare supplement or Medicare cost policy provided coverage of Medicare Part B medical deductible coverage or if the insured was enrolled or Medicare eligible prior to January 1, 2020, and the insurer offers a plan with Medicare Part B medical deductible coverage. If the insurer no longer offers a plan with the Medicare Part B medial deductible coverage then the insurer shall provide the insured with substantially equivalent coverage to the coverage in effect prior to the date of suspension.
18x. Shall Each Medicare supplement or certificate shall provide for that upon the resumption of coverage that was in effect before the date of suspension in subd. 18. classification of premiums shall be on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.
SECTION 27. Ins 3.39 (4) (a) 21. is repealed.
SECTION 28. Ins 3.39 (4) (b) (intro.) and 1. to 7., (c), (e), and (g) are amended to read:
Ins 3.39 (4) (b) (intro.) The outline of coverage for the policy or certificate. shall comply with all of the following:
1. Is provided to all applicants at the time application is made and, except in the case of direct response insurance, the issuer obtains written acknowledgement from the applicant that the outline was received;.
and 4.
3. Is substituted to properly describe the policy or certificate as issued, if the outline provided at the time of application did not properly describe the coverage which was issued. The substituted outline shall accompany the policy or certificate when it is delivered and shall contain the following statement in no less than 12-point type and immediately above the company name: “NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application, and the coverage originally applied for has not been issued.";
4. Contains in close conjunction on its first page the designation, printed in a distinctly contrasting color in 24-point type, and the caption, printed in a distinctly contrasting color in 18-point type prescribed in sub. (5), (7) or (30);.
5. Is substantially in the format prescribed in Appendix 1 to this section for the appropriate category and printed in no less than 12-point type;.
6. Summarizes or refers to the coverage set out in applicable statutes;.
7. Contains a listing of the required coverage as set out in sub. (5) (c) and the optional coverages as set out in sub. (5) (i), and the annual premiums therefor, for each selected coverage, substantially in the format of sub. (11) of Appendix 1; and.
(c) Any rider or endorsement added to the policy or certificate shall comply with all of the following:
1. Shall be set forthcontained in the policy or certificate and, if a separate, additional premium is charged in connection with the rider or endorsement, the premium charge shall be set forthstated in the policy or certificate; and.
2. After Shall be agreed to in writing signed by the insured if, after the date of the policy or certificate issue, shall be agreed to in writing signed by the insured, if the rider or endorsement increases benefits or coverage with an and there is an accompanying increase in premium during the term of the policy or certificate, unless the increase in benefits or coverage is required by law.
3. Shall only provide coverage as defined in sub. (5) (i) or provide coverage to meet statutory Wisconsin mandated provisions.
(e) The anticipated loss ratio for any new policy or certificate form, that is, or the expected percentage of the aggregate amount of premiums earned that will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, that is provided under the policy or certificate form:
1. Is computed on the basis of anticipated incurred claims or incurred health care expenses where coverage is provided by a health maintenance organizations on a service rather than reimbursement basis and earned premiums for the entire period for which the policy form provides coverage, in accordance with accepted actuarial principles and practices.; and
2. Is submitted to the commissioner along with the policy or certificate form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards in under sub. (16) (d). The policy or certificate form will not be approved by the commissioner unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance with sub. (16) (d).
