Amendment AA8-ASA1-AB64

AB64-ASA1-AA8,14,13 625.22 (1) Order in event of violation. If the commissioner finds after a hearing that a rate or proposed rate is not in compliance with s. 625.11, the commissioner shall order that its use be discontinued, or that it may not be used, for any policy issued or renewed after a date specified in the order.

AB64-ASA1-AA8,2218z Section 2218z. 625.22 (3) of the statutes is amended to read:

AB64-ASA1-AA8,14,19 625.22 (3) Approval of substituted rate. Within Except for rates for health insurance, which is subject to s. 625.25 (2) (a), within one year after the effective date of an order under sub. (1), no rate promulgated to replace a disapproved one may be used until it has been filed with the commissioner and not disapproved within 30 days thereafter.

AB64-ASA1-AA8,2219b Section 2219b. 625.23 of the statutes is amended to read:

AB64-ASA1-AA8,15,7 625.23 Special restrictions on individual insurers. The commissioner may by order require that a particular insurer file any or all of its rates and supplementary rate information 15 days prior to their effective date, if and to the extent that he or she finds, after a hearing, that the protection of the interests of its insureds and the public in this state requires closer supervision of its rates because of the insurer's financial condition or rating practices. The commissioner may extend the waiting period for any filing for not to exceed 15 additional days by written notice to the insurer before the first 15-day period expires. A filing not disapproved before the expiration of the waiting period shall be deemed to meet the requirements of this chapter, subject to the possibility of subsequent disapproval under s. 625.22. This section does not apply to an insurer with respect to rates for health insurance, which is subject to s. 625.25 (2) (a).

AB64-ASA1-AA8,2219c Section 2219c. 625.25 of the statutes is created to read:

AB64-ASA1-AA8,15,9 625.25 Rates for health insurance. (1) Definitions. In this section:

AB64-ASA1-AA8,15,10 (a) “Group health benefit plan" has the meaning given in s. 632.745 (9).

AB64-ASA1-AA8,15,11 (b) “Health benefit plan" has the meaning given in s. 632.745 (11).

AB64-ASA1-AA8,15,12 (c) “Insurer" has the meaning given in s. 632.745 (15).

AB64-ASA1-AA8,15,13 (d) “Large group market" has the meaning given in s. 632.745 (17).

AB64-ASA1-AA8,15,14 (e) “Small group market" has the meaning given in s. 632.745 (26).

AB64-ASA1-AA8,16,6 (2) Filing of rates; hearing. (a) Every insurer, and every rate service organization licensed under s. 625.31 that has been designated by any insurer for the filing of rates under s. 625.15 (2), shall file with the commissioner all proposed rates and supplementary rate information, and all proposed changes and amendments to rates and supplementary rate information, for use in this state for any health benefit plan offered by the insurer before the proposed rates or changes to rates become effective. An insurer may not use a proposed rate or change to a rate until it has been filed with and approved by the commissioner. Unless the commissioner holds a hearing on the proposed rate or change to a rate, a proposed rate or change to a rate is approved if the commissioner does not disapprove the proposed rate or change within 30 days after filing, or within a 30-day extension of that period ordered by the commissioner prior to the expiration of the first 30 days. The requirement under this paragraph applies with respect to rates and changes to rates for all health benefit plans, including individual health benefit plans, group health benefit plans offered in the small group market, and group health benefit plans offered in the large group market, that have not gone into effect by the effective date of this paragraph .... [LRB inserts date].

AB64-ASA1-AA8,16,9 (b) If any proposed change to a rate filed under par. (a) increases the existing rate by more than 10 percent of that rate, the commissioner shall hold a public hearing before approving or disapproving the proposed change to the rate.

AB64-ASA1-AA8,16,12 (c) The commissioner may disapprove a proposed rate or change to a rate filed under par. (a) that the commissioner determines is not justified based on underlying medical costs.

AB64-ASA1-AA8,16,16 (3) Publication of increases, negotiated rates. (a) The commissioner shall publish on the office's Internet site, in a format that is readily understandable by members of the public, all rate changes filed under sub. (2) (a) that increase an existing rate by any amount and that are approved.

AB64-ASA1-AA8,16,21 (b) If the commissioner approves a rate increase after holding a hearing under sub. (2) (b) and the insurer justified the rate increase based on increased medical costs, the commissioner shall publish on the office's Internet site, in a format that is readily understandable by members of the public, the discounted payment rates the insurer has negotiated with each of the insurer's provider networks.

AB64-ASA1-AA8,16,25 (4) Notice of rate increase to insureds. If the commissioner approves a rate increase filed under sub. (2) (a), the insurer shall provide notice of the rate increase to each insured under the health benefit plan at least 60 days before the rate increase goes into effect.”.

AB64-ASA1-AA8,17,1 24. Page 925, line 14: after that line insert:

AB64-ASA1-AA8,17,2 “ Section 2218u. 609.713 of the statutes is created to read:

AB64-ASA1-AA8,17,4 609.713 Essential health benefits. Defined network plans and preferred provider plans are subject to s. 632.895 (14m).

AB64-ASA1-AA8,2218y Section 2218y. 632.895 (14m) of the statutes is created to read:

AB64-ASA1-AA8,17,7 632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB64-ASA1-AA8,17,10 (b) On a date specified by the commissioner, by rule, every disability insurance policy and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).

AB64-ASA1-AA8,17,12 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB64-ASA1-AA8,17,14 1. Include benefits, items, and services in, at least, all of the following categories:

AB64-ASA1-AA8,17,15 a. Ambulatory patient services.

AB64-ASA1-AA8,17,16 b. Emergency services.

AB64-ASA1-AA8,17,17 c. Hospitalization.

AB64-ASA1-AA8,17,18 d. Maternity and newborn care.

AB64-ASA1-AA8,17,20 e. Mental health and substance use disorder services, including behavioral health treatment.

AB64-ASA1-AA8,17,21 f. Prescription drugs.

AB64-ASA1-AA8,17,22 g. Rehabilitative and habilitative services and devices.

AB64-ASA1-AA8,17,23 h. Laboratory services.

AB64-ASA1-AA8,17,24 i. Preventive and wellness services and chronic disease management.

AB64-ASA1-AA8,18,1 j. Pediatric services, including oral and vision care.

AB64-ASA1-AA8,18,6 2. Conduct a survey of employer-sponsored coverage to determine benefits typically covered by employers and ensure that the scope of essential health benefits for which coverage is required under this subsection is equal to the scope of benefits covered under a typical disability insurance policy offered by an employer to its employees.

AB64-ASA1-AA8,18,8 3. Ensure that essential health benefits reflect a balance among the categories described in subd. 1. such that benefits are not unduly weighted toward one category.

AB64-ASA1-AA8,18,10 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB64-ASA1-AA8,18,14 5. Require that disability insurance policies and self-insured health plans do not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.

AB64-ASA1-AA8,18,17 6. Establish essential health benefits in a way that takes account of the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

AB64-ASA1-AA8,18,21 7. Ensure that essential health benefits established under this subsection not be subject to a coverage denial based on an insured's or plan participant's age, expected length of life, present or predicted disability, degree of dependency on medical care, or quality of life.

AB64-ASA1-AA8,19,3 8. Require that disability insurance policies and self-insured health plans cover emergency department services that are essential health benefits without imposing any requirement to obtain prior authorization for those services and without limiting coverage for services provided by an emergency services provider that is not in the provider network of a policy or plan in a way that is more restrictive than requirements or limitations that apply to emergency services provided by a provider that is in the provider network of the policy or plan.

AB64-ASA1-AA8,19,8 9. Require a disability insurance policy or self-insured health plan to apply to emergency department services that are essential health benefits provided by an emergency department provider that is not in the provider network of the policy or plan the same copayment amount or coinsurance rate that applies if those services are provided by a provider that is in the provider network of the policy or plan.

AB64-ASA1-AA8,19,10 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB64-ASA1-AA8,19,15 (e) If an essential health benefit is also subject to mandated coverage elsewhere under this section and the coverage requirements are not identical, the disability insurance policy or self-insured health plan shall provide coverage under whichever subsection provides the insured or plan participant with more comprehensive coverage of the medical condition, item, or service.

AB64-ASA1-AA8,19,19 (f) Nothing in this subsection or rules promulgated under this subsection prohibits a disability insurance policy or a self-insured health plan from providing benefits in excess of the essential health benefit coverage required under this subsection.”.

AB64-ASA1-AA8,19,20 25. Page 925, line 14: after that line insert:

AB64-ASA1-AA8,19,21 “ Section 2218t. 609.847 of the statutes is created to read:

AB64-ASA1-AA8,19,24 609.847 Preexisting condition discrimination prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.

AB64-ASA1-AA8,2218w Section 2218w. 625.12 (1) (a) of the statutes is amended to read:

AB64-ASA1-AA8,20,3 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB64-ASA1-AA8,2218y Section 2218y. 625.12 (1) (e) of the statutes is amended to read:

AB64-ASA1-AA8,20,6 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB64-ASA1-AA8,2219b Section 2219b. 625.12 (2) of the statutes is amended to read:

AB64-ASA1-AA8,20,16 625.12 (2) Classification. Risks Except as provided in s. 632.728, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to s. ss. 632.365 and 632.728, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB64-ASA1-AA8,2219d Section 2219d. 625.15 (1) of the statutes is amended to read:

AB64-ASA1-AA8,20,25 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB64-ASA1-AA8,2219f Section 2219f. 628.34 (3) (a) of the statutes is amended to read:

AB64-ASA1-AA8,21,8 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.746 and 632.748. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB64-ASA1-AA8,2219h Section 2219h. 632.728 of the statutes is created to read:

AB64-ASA1-AA8,21,11 632.728 Premiums and cost-sharing discrimination prohibited for preexisiting conditions. (1) Definition. In this section:

AB64-ASA1-AA8,21,12 (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB64-ASA1-AA8,21,13 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB64-ASA1-AA8,21,19 (2) Prohibition. For the purpose of setting rates or premiums for coverage under a group or individual disability insurance policy or a self-insured health plan and for the purpose of setting any deductibles, copayments, or coinsurance under a group or individual disability insurance policy or a self-insured health plan, the policy or plan may not consider whether an individual, including a dependent, who would be covered under the plan has a preexisting condition.

AB64-ASA1-AA8,2219j Section 2219j. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB64-ASA1-AA8,22,3 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant's or beneficiary's enrollment date under the plan on a participant or beneficiary under the plan.

AB64-ASA1-AA8,2219n Section 2219n. 632.746 (1) (b) of the statutes is repealed.

AB64-ASA1-AA8,2219p Section 2219p. 632.746 (2) (a) of the statutes is amended to read:

AB64-ASA1-AA8,22,8 632.746 (2) (a) An insurer offering a group health benefit plan may not treat genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

AB64-ASA1-AA8,2219r Section 2219r. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB64-ASA1-AA8,2219t Section 2219t. 632.746 (3) (a) of the statutes is repealed.

AB64-ASA1-AA8,2219v Section 2219v. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB64-ASA1-AA8,2219x Section 2219x. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB64-ASA1-AA8,2219z Section 2219z. 632.746 (5) of the statutes is repealed.

AB64-ASA1-AA8,2220b Section 2220b. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB64-ASA1-AA8,22,18 632.746 (8) (a) (intro.) A health maintenance organization that offers a group health benefit plan and that does not impose any preexisting condition exclusion under sub. (1) with respect to a particular coverage option may impose an affiliation period for that coverage option, but only if all of the following apply:

AB64-ASA1-AA8,2220d Section 2220d. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB64-ASA1-AA8,23,3 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746, a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c).

AB64-ASA1-AA8,23,9 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB64-ASA1-AA8,23,15 2. Except as provided in subd. 3., an An individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB64-ASA1-AA8,2220f Section 2220f. 632.76 (2) (ac) 3. of the statutes is repealed.

AB64-ASA1-AA8,1 Section 1. 632.795 (4) (a) of the statutes is amended to read:

AB64-ASA1-AA8,24,4 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods , or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.

AB64-ASA1-AA8,2220h Section 2220h. 632.897 (11) (a) of the statutes is amended to read:

AB64-ASA1-AA8,24,14 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may promulgate rules establishing standards requiring insurers to provide continuation of coverage for any individual covered at any time under a group policy who is a terminated insured or an eligible individual under any federal program that provides for a federal premium subsidy for individuals covered under continuation of coverage under a group policy, including rules governing election or extension of election periods, notice, rates, premiums, premium payment, application of preexisting condition exclusions, election of alternative coverage, and status as an eligible individual, as defined in s. 149.10 (2t), 2011 stats.”.

AB64-ASA1-AA8,24,15 26. Page 925, line 14: after that line insert:

AB64-ASA1-AA8,24,16 “ Section 2218t. 609.896 of the statutes is created to read:

AB64-ASA1-AA8,24,18 609.896 Preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m).