Amendment SSA3-AB365

AB365-SSA3,75 Section 75 . 601.64 (1) of the statutes is amended to read:

AB365-SSA3,27,11 601.64 (1) Injunctions and restraining orders. The commissioner may commence an action in circuit court in the name of the state to restrain by temporary or permanent injunction or by temporary restraining order any violation of chs. 600 to 655 or s. 149.13, 2011 stats., or s. 656.15, any rule promulgated under chs. 600 to 655, or any order issued under s. 601.41 (4). The commissioner need not show irreparable harm or lack of an adequate remedy at law in an action commenced under this subsection.

AB365-SSA3,76 Section 76 . 601.64 (3) (a) of the statutes is amended to read:

AB365-SSA3,27,16 601.64 (3) (a) Restitutionary forfeiture. Whoever violates an effective order issued under s. 601.41 (4), any insurance statute or rule, or s. 149.13, 2011 stats., or s. 656.15 shall forfeit to the state twice the amount of any profit gained from the violation, in addition to any other forfeiture or penalty imposed.

AB365-SSA3,77 Section 77 . 601.64 (3) (c) of the statutes is amended to read:

AB365-SSA3,27,25 601.64 (3) (c) Forfeiture for violation of statute or rule. Whoever violates an insurance statute or rule or s. 149.13, 2011 stats., or s. 656.15 intentionally aids a person in violating an insurance statute or rule or s. 149.13, 2011 stats., or s. 656.15 or knowingly permits a person over whom he or she has authority to violate an insurance statute or rule or s. 149.13, 2011 stats., or s. 656.15 shall forfeit to the state not more than $1,000 for each violation. If the statute or rule imposes a duty to make a report to the commissioner, each week of delay in complying with the duty is a new violation.

AB365-SSA3,78 Section 78. 601.64 (4) of the statutes is amended to read:

AB365-SSA3,28,7 601.64 (4) Criminal penalty. Whoever intentionally violates or intentionally permits any person over whom he or she has authority to violate or intentionally aids any person in violating any insurance statute or rule of this state, s. 149.13, 2011 stats., or s. 656.15 or any effective order issued under s. 601.41 (4) is guilty of a Class I felony, unless a specific penalty is provided elsewhere in the statutes. Intent has the meaning expressed under s. 939.23.

AB365-SSA3,79 Section 79. 613.03 (5) of the statutes is created to read:

AB365-SSA3,28,11 613.03 (5) Health Insurance Risk-Sharing Plan. Service insurance corporations organized or operating under this chapter are subject to the requirements that apply to insurers and insurance under ch. 656.

AB365-SSA3,80 Section 80. 631.20 (1) (c) 5m. of the statutes is created to read:

AB365-SSA3,28,13 631.20 (1) (c) 5m. A form filed under ch. 656.

AB365-SSA3,81 Section 81. 631.20 (2) (g) of the statutes is created to read:

AB365-SSA3,28,16 631.20 (2) (g) In the case of a policy form under ch. 656, that any of the following applies:

AB365-SSA3,28,18 1. The benefit design is not comparable to a typical comprehensive individual health insurance policy offered in the private sector market in this state.

AB365-SSA3,28,21 2. The benefit levels are not generally reflective of and commensurate with comprehensive health insurance coverage offered in the private individual market in this state.

AB365-SSA3,28,23 3. The copayments, deductibles, and coinsurance are not actuarially equivalent to comprehensive individual plans and would create undue financial hardship.

AB365-SSA3,28,25 4. It is inconsistent with the purpose of providing health care coverage to those unable to obtain coverage in the private market.

AB365-SSA3,82 Section 82. 631.36 (7) (c) of the statutes is created to read:

AB365-SSA3,29,4 631.36 (7) (c) Notice of cancellation or nonrenewal required under sub. (2) (b) or (4) is not effective unless the notice contains the notice required under s. 632.784, if applicable.

AB365-SSA3,83 Section 83. 632.7495 (4) (c) of the statutes is amended to read:

AB365-SSA3,29,13 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods. This paragraph does not apply if provisions of the federal Patient Protection and Affordable Care Act, P.L. 111-148, under 42 USC 300gg to 300gg-4 are no longer enforceable or no longer preempt state law relating to individual health insurance policies.

AB365-SSA3,84 Section 84. 632.784 of the statutes is created to read:

AB365-SSA3,29,21 632.784 Notice of Health Insurance Risk-Sharing Plan. (1) If an insurer issues one or more of the following or takes any other action based wholly or partially on medical underwriting considerations which is likely to render any person eligible under s. 656.12 for coverage under ch. 656, the insurer shall notify all persons affected of the existence of the mandatory health insurance risk-sharing plan under ch. 656, as well as the eligibility requirements and method of applying for coverage under the plan:

AB365-SSA3,29,22 (a) A notice of rejection or cancellation of coverage.

AB365-SSA3,30,2 (b) A notice of reduction or limitation of coverage, including restrictive riders, if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.

AB365-SSA3,30,5 (c) A notice of increase in premium exceeding the premium then in effect for the insured person by 50 percent or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.

AB365-SSA3,30,8 (d) A notice of premium for a policy not yet in effect which exceeds the premium applicable to a person considered a standard risk by 50 percent or more for the types of coverage provided by the plan.

AB365-SSA3,30,10 (2) Any notice issued under sub. (1) shall also state the reasons for the rejection, termination, cancellation, or imposition of underwriting restrictions.

AB365-SSA3,85 Section 85. 646.01 (1) (a) 2. k. of the statutes is amended to read:

AB365-SSA3,30,12 646.01 (1) (a) 2. k. Risk-sharing plans under ch. chs. 619 and 656.

AB365-SSA3,86 Section 86 . Chapter 656 of the statutes is created to read:

AB365-SSA3,30,15 Chapter 656 Health insurance risk-sharing plans

AB365-SSA3,30,17 SUBCHAPTER I general provisions

AB365-SSA3,30,18 656.01 Definitions. In this chapter:

AB365-SSA3,30,19 (1) “Authority” means the Health Insurance Risk-Sharing Plan Authority.

AB365-SSA3,30,20 (2) “Board” means the board of directors of the authority.

AB365-SSA3,30,21 (3) “Church plan” has the meaning given in 29 USC 1002 (33).

AB365-SSA3,30,22 (4) “Commissioner” means the commissioner of insurance.

AB365-SSA3,30,23 (5) “Creditable coverage” has the meaning given in s. 632.745 (4).

AB365-SSA3,31,3 (6) “Eligible person” means a person who is certified as eligible under s. 656.12 (1), whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.

AB365-SSA3,31,4 (7) “Federal continuation provision” has the meaning given in s. 632.745 (8).

AB365-SSA3,31,7 (8) “Federal governmental plan” means a benefit program established or maintained for its employees by the government of the United States or by any agency or instrumentality of the government of the United States.

AB365-SSA3,31,9 (9) “Fund” means the Health Insurance Risk-Sharing Plan fund under s. 656.10 (2).

AB365-SSA3,31,10 (10) “Governmental plan” has the meaning given under 29 USC 1002 (32).

AB365-SSA3,31,11 (11) “Group health plan” has the meaning given in s. 632.745 (10).

AB365-SSA3,31,13 (12) “Health care coverage revenue” means any of the following, but does not include payments to health maintenance organizations under s. 49.45 (59) (a):

AB365-SSA3,31,14 (a) Premiums received for health care coverage.

AB365-SSA3,31,15 (b) Subscriber contract charges received for health care coverage.

AB365-SSA3,31,17 (c) Health maintenance organization, limited service health organization, or preferred provider plan charges received for health care coverage.

AB365-SSA3,31,19 (d) The sum of benefits paid and administrative costs incurred for health care coverage under a medical reimbursement plan.

AB365-SSA3,31,25 (13) “Health insurance” means surgical, medical, hospital, major medical, and other health service coverage provided on an expense-incurred basis and fixed indemnity policies. “Health insurance” does not include ancillary coverage such as income continuation, short-term, accident only, credit insurance, automobile medical payment coverage, coverage issued as a supplement to liability coverage, loss of time, or accident benefits.

AB365-SSA3,32,1 (14) “Health maintenance organization” has the meaning given in s. 609.01 (2).

AB365-SSA3,32,3 (15) “HIV” means any strain of human immunodeficiency virus, which causes acquired immunodeficiency syndrome.

AB365-SSA3,32,4 (16) “Insurance” has the meaning given in s. 600.03 (25).

AB365-SSA3,32,6 (17) “Insurer” has the meaning given in s. 600.03 (27) and does not include a plan under ch. 613 which offers only dental care.

AB365-SSA3,32,8 (18) “Limited service health organization” has the meaning given in s. 609.01 (3).

AB365-SSA3,32,10 (19) “Medical Assistance program” means the health care benefit program provided under subch. IV of ch. 49.

AB365-SSA3,32,11 (20) “Policy” has the meaning given in s. 600.03 (35).

AB365-SSA3,32,16 (21) “Preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage, whether or not the individual received any medical advice or recommendation, diagnosis, care, or treatment related to the condition before that date.

AB365-SSA3,32,17 (22) “Preferred provider plan” has the meaning given in s. 609.01 (4).

AB365-SSA3,32,18 (23) “Premium” has the meaning given in s. 600.03 (38).

AB365-SSA3,32,22 656.03 Applicability. This chapter applies only if provisions of the federal Patient Protection and Affordable Care Act, P.L. 111-148, under 42 USC 300gg to 300gg-4 are no longer enforceable or no longer preempt state law relating to individual health insurance policies.

AB365-SSA3,33,2 656.05 Immunity. No liability may be imposed on any of the following for an act or omission in the performance of any powers and duties under this chapter, unless the person asserting liability proves the act or omission constitutes willful misconduct:

AB365-SSA3,33,3 (1) The authority, plan, or board.

AB365-SSA3,33,4 (2) Any agent, employee, or director of the authority, plan, or board.

AB365-SSA3,33,5 (3) Any participating insurer.

AB365-SSA3,33,6 (4) The commissioner.

AB365-SSA3,33,7 (5) Any of the commissioner's agents, employees, or representatives.

AB365-SSA3,33,10 SUBCHAPTER II health insurance risk-sharing plan provisions

AB365-SSA3,33,13 656.10 Administration of plan. (1) Authority. The authority shall be responsible for the operation of the plan and, subject to ss. 656.43 (3) and 656.47, may enter into contracts for the plan's administration.

AB365-SSA3,33,16 (2) Fund. (a) The authority shall pay the operating administrative expenses of the plan from the fund, which shall be outside the state treasury and which shall consist of all of the following:

AB365-SSA3,33,17 1. Insurer assessments paid under s. 656.15.

AB365-SSA3,33,18 2. Premiums paid by eligible persons.

AB365-SSA3,33,19 3. Moneys received from the federal government as grants for high-risk pools.

AB365-SSA3,33,20 4. The earnings resulting from investments under par. (b).

AB365-SSA3,33,21 5. Any other moneys received by the authority.

AB365-SSA3,33,23 (b) The authority controls assets of the fund, including investment of assets of the fund.

AB365-SSA3,33,25 (c) Moneys in the fund may be expended only for the purposes specified in par. (a).

AB365-SSA3,34,5 656.11 Rules relating to creditable coverage. The commissioner shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 656.12 (1) (c) 1. and that determine the creditable coverage to which s. 656.12 (1) (c) 2. and 4. applies. The rules shall comply with any applicable federal law regarding creditable coverage.

AB365-SSA3,34,8 656.12 Eligibility determination. (1) Eligible persons. Except as provided in sub. (3) and subject to subs. (2) and (4), the authority shall certify as eligible a person who is a resident of this state and is any of the following:

AB365-SSA3,34,10 (a) A person who is covered by the Medicare program under 42 USC 1395 et seq. because he or she is disabled under 42 USC 423.

AB365-SSA3,34,12 (b) A person who submits evidence that he or she has a positive, validated HIV test result, as defined in s. 252.01 (8).

AB365-SSA3,34,13 (c) A person for whom all of the following apply:

AB365-SSA3,34,15 1. The aggregate of the individual's periods of creditable coverage is 18 months or more.

AB365-SSA3,34,18 2. The individual's most recent period of creditable coverage was under a group health plan, governmental plan, federal governmental plan, church plan, or under any health insurance offered in connection with any of those plans.

AB365-SSA3,34,22 3. The individual does not have creditable coverage and is not eligible for coverage under a group health plan; part A, B, or D of the Medicare program under 42 USC 1395 et seq.; or a state plan under the Medicaid program under 42 USC 1396 et seq.

AB365-SSA3,34,25 4. The individual's most recent period of creditable coverage was not terminated for any reason related to fraud or intentional misrepresentation of material fact or a failure to pay premiums.

AB365-SSA3,35,3 5. If the individual was offered the option of continuation coverage under a federal continuation provision or similar state program, the individual elected the continuation coverage.