Skip navigation Wisconsin State Legislature
LRB-2091/P1
TJD:cjs&wlj
2019 - 2020 LEGISLATURE
DOA:......Ames, BB0405 - Preexisting conditions coverage
For 2019-2021 Budget -- Not Ready For Introduction
An Act relating to: the budget.
Analysis by the Legislative Reference Bureau
insurance
1. Coverage of individuals with preexisting conditions, essential health benefits, and preventive services
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.
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 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.
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:
Section 1. 40.51 (8) of the statutes is amended to read:
40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.728, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.
Section 2. 40.51 (8m) of the statutes is amended to read:
40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.728, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.867, 632.885, 632.89, and 632.895 (11) (8) and (10) to (17).
Section 3. 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 a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.728, 632.746 (1) and (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) (8) to (17), 632.896, and 767.513 (4).
Section 4. 120.13 (2) (g) of the statutes is amended to read:
120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.728, 632.746 (1) and (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) (8) to (17), 632.896, and 767.513 (4).
Section 5. 185.983 (1) (intro.) of the statutes is amended to read:
185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.728, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.867, 632.87 (2) to (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association shall:
Section 6. 609.713 of the statutes is created to read:
609.713 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).
Section 7. 609.847 of the statutes is created to read:
609.847 Preexisting condition discrimination and certain benefit limits prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.
Section 8. 625.12 (1) (a) of the statutes is amended to read:
625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.
Section 9. 625.12 (1) (e) of the statutes is amended to read:
625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.
Section 10. 625.12 (2) of the statutes is amended to read:
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).
Section 11. 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 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.
Section 12. 628.34 (3) (a) of the statutes is amended to read:
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.
Section 13. 632.728 of the statutes is created to read:
632.728 Coverage of persons with preexisting conditions; guaranteed issue; 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).
(2) Guaranteed issue. (a) Every individual health benefit plan shall accept every individual in this state who, and every group health benefit plan shall accept every employer in this state that, applies for coverage, regardless of sexual orientation, gender identity, or whether or not any employee or individual has a preexisting condition. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.
(b) The commissioner shall establish a statewide open enrollment period of no shorter than 30 days for every individual health benefit plan to allow individuals, including individuals who do not have coverage, to enroll in coverage.
(3) Prohibiting discrimination based on health status. (a) An individual health benefit plan or a self-insured health plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
1. Health status.
2. Medical condition, including both physical and mental illnesses.
3. Claims experience.
4. Receipt of health care.
5. Medical history.
6. Genetic information.
7. Evidence of insurability, including conditions arising out of acts of domestic violence.
8. Disability.
(b) An insurer offering an individual health benefit plan or a self-insured health plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor under par. (a) with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.
(c) Nothing in this subsection prevents an insurer offering an individual health benefit plan or a self-insured health plan from establishing premium discounts or rebates or modifying otherwise applicable cost sharing in return for adherence to programs of health promotion and disease prevention.
(4) Premium rate variation. A health benefit plan offered on the individual or small employer market or a self-insured health plan may vary premium rates for a specific plan based only on the following considerations:
(a) Whether the policy or plan covers an individual or a family.
(b) Rating area in the state, as established by the commissioner.
(c) Age, except that the rate may not vary by more than 3 to 1 for adults over the age groups and the age bands shall be consistent with recommendations of the National Association of Insurance Commissioners.
(d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
(5) Annual and lifetime limits. An individual or group health benefit plan or a self-insured health plan may not establish any of the following:
(a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.
(b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.
(6) Short-term plans. This section and s. 632.76 apply to every short-term, limited-duration health insurance policy. In this subsection, “short-term, limited-duration health insurance policy” means health coverage that is provided under a contract with an insurer, has an expiration date specified in the contract that is less than 12 months after the original effective date of the contract, and, taking into account renewals or extensions, has a duration of no longer than 36 months in total. “Short-term, limited-duration health insurance policy” includes any short-term policy subject to s. 632.7495 (4).
Section 14. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:
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.
Section 15. 632.746 (1) (b) of the statutes is repealed.
Section 16. 632.746 (2) (a) of the statutes is amended to read:
632.746 (2) (a) An insurer offering a group health benefit plan may not treat impose a preexisting condition exclusion based on genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.
Section 17. 632.746 (2) (c), (d) and (e) of the statutes are repealed.
Section 18. 632.746 (3) (a) of the statutes is repealed.
Section 19 . 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).
Section 20 . 632.746 (3) (d) 2. and 3. of the statutes are repealed.
Section 21 . 632.746 (5) of the statutes is repealed.
Section 22. 632.746 (8) (a) (intro.) of the statutes is amended to read:
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:
Section 23 . 632.748 (2) of the statutes is amended to read:
632.748 (2) An insurer offering a group health benefit plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.
Section 24. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:
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).
(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.
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 that was present before the date of enrollment for the coverage, whether physical or mental, regardless of the cause of the condition, for which and regardless of whether medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.
Section 25. 632.76 (2) (ac) 3. of the statutes is repealed.
Section 26. 632.795 (4) (a) of the statutes is amended to read:
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.
Section 27. 632.895 (8) (d) of the statutes is amended to read:
632.895 (8) (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c), and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy. Coverage under this subsection may not be subject to any deductibles, copayments, or coinsurance.
Section 28. 632.895 (13m) of the statutes is created to read:
632.895 (13m) Preventive services. (a) In this section, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).
(b) Every disability insurance policy, except any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12., and every self-insured health plan shall provide coverage for all of the following preventive services:
1. Mammography in accordance with sub. (8).
2. Genetic breast cancer screening and counseling and preventive medication for adult women at high risk for breast cancer.
3. Papanicolaou test for cancer screening for women 21 years of age or older with an intact cervix.
4. Human papillomavirus testing for women who have attained the age of 30 years but have not attained the age of 66 years.
5. Colorectal cancer screening in accordance with sub. (16m).
6. Annual tomography for lung cancer screening for adults who have attained the age of 55 years but have not attained the age of 80 years and who have health histories demonstrating a risk for lung cancer.
7. Skin cancer screening for individuals who have attained the age of 10 years but have not attained the age of 22 years.
8. Counseling for skin cancer prevention for adults who have attained the age of 18 years but have not attained the age of 25 years.
9. Abdominal aortic aneurysm screening for men who have attained the age of 65 years but have not attained the age of 75 years and who have ever smoked.
10. Hypertension screening for adults and blood pressure testing for adults, for children under the age of 3 years who are at high risk for hypertension, and for children 3 years of age or older.
11. Lipid disorder screening for minors 2 years of age or older, adults 20 years of age or older at high risk for lipid disorders, and all men 35 years of age or older.
12. Aspirin therapy for cardiovascular health for adults who have attained the age of 55 years but have not attained the age of 80 years and for men who have attained the age of 45 years but have not attained the age of 55 years.
13. Behavioral counseling for cardiovascular health for adults who are overweight or obese and who have risk factors for cardiovascular disease.
14. Type II diabetes screening for adults with elevated blood pressure.
15. Depression screening for minors 11 years of age or older and for adults when follow-up supports are available.
16. Hepatitis B screening for minors at high risk for infection and adults at high risk for infection.
17. Hepatitis C screening for adults at high risk for infection and one-time hepatitis C screening for adults born in any year from 1945 to 1965.
18. Obesity screening and management for all minors and adults with a body mass index indicating obesity, counseling and behavioral interventions for obese minors who are 6 years of age or older, and referral for intervention for obesity for adults with a body mass index of 30 kilograms per square meter or higher.
19. Osteoporosis screening for all women 65 years of age or older and for women at high risk for osteoporosis under the age of 65 years.
20. Immunizations in accordance with sub. (14).
21. Anemia screening for individuals 6 months of age or older and iron supplements for individuals at high risk for anemia and who have attained the age of 6 months but have not attained the age of 12 months.
22. Fluoride varnish for prevention of tooth decay for minors at the age of eruption of their primary teeth.
23. Fluoride supplements for prevention of tooth decay for minors 6 months of age or older who do not have fluoride in their water source.
24. Gonorrhea prophylaxis treatment for newborns.
25. Health history and physical exams for prenatal visits and for minors.
26. Length and weight measurements for newborns and height and weight measurements for minors.
27. Head circumference and weight-for-length measurements for newborns and minors who have not attained the age of 3 years.
28. Body mass index for minors 2 years of age or older.
29. Blood pressure measurements for minors 3 years of age or older and a blood pressure risk assessment at birth.
30. Risk assessment and referral for oral health issues for minors who have attained the age of 6 months but have not attained the age of 7 years.
31. Blood screening for newborns and minors who have not attained the age of 2 months.
32. Screening for critical congenital health defects for newborns.
33. Lead screenings in accordance with sub. (10).
34. Metabolic and hemoglobin screening and screening for phenylketonuria, sickle cell anemia, and congenital hypothyroidism for minors including newborns.
35. Tuberculin skin test based on risk assessment for minors one month of age or older.
36. Tobacco counseling and cessation interventions for individuals who are 5 years of age or older.
37. Vision and hearing screening and assessment for minors including newborns.
38. Sexually transmitted infection and human immunodeficiency virus counseling for sexually active minors.
39. Risk assessment for sexually transmitted infection for minors who are 10 years of age or older and screening for sexually transmitted infection for minors who are 16 years of age or older.
40. Alcohol misuse screening and counseling for minors 11 years of age or older.
41. Autism screening for minors who have attained the age of 18 months but have not attained the age of 25 months.
42. Developmental screening and surveillance for minors including newborns.
43. Psychosocial and behavioral assessment for minors including newborns.
44. Alcohol misuse screening and counseling for pregnant adults and a risk assessment for all adults.
45. Fall prevention and counseling and preventive medication for fall prevention for community-dwelling adults 65 years of age or older.
46. Screening and counseling for intimate partner violence for adult women.
47. Well-woman visits for women who have attained the age of 18 years but have not attained the age of 65 years and well-woman visits for recommended preventive services, preconception care, and prenatal care.
48. Counseling on, consultations with a trained provider on, and equipment rental for breastfeeding for pregnant and lactating women.
49. Folic acid supplement for adult women with reproductive capacity.
50. Iron deficiency anemia screening for pregnant and lactating women.
51. Preeclampsia preventive medicine for pregnant adult women at high risk for preeclampsia.
52. Low-dose aspirin after 12 weeks of gestation for pregnant women at high risk for miscarriage, preeclampsia, or clotting disorders.
53. Screenings for hepatitis B and bacteriuria for pregnant women.
54. Screening for gonorrhea for pregnant and sexually active females 24 years of age or younger and females older than 24 years of age who are at risk for infection.
55. Screening for chlamydia for pregnant and sexually active females 24 years of age and younger and females older than 24 years of age who are at risk for infection.
56. Screening for syphilis for pregnant women and adults who are at high risk for infection.
57. Human immunodeficiency virus screening for adults who have attained the age of 15 years but have not attained the age of 66 years and individuals at high risk of infection who are younger than 15 years of age or older than 65 years of age.
58. All contraceptives and services in accordance with sub. (17).
59. Any services not already specified under this paragraph having an A or B rating in current recommendations from the U.S. preventive services task force.
60. Any preventive services not already specified under this paragraph that are recommended by the federal health resources and services administration's Bright Futures project.
61. Any immunizations, not already specified under sub. (14), that are recommended and determined to be for routine use by the federal advisory committee on immunization practices.
(c) Subject to par. (d), no disability insurance policy and no self-insured health plan may subject the coverage of any of the preventive services under par. (b) to any deductibles, copayments, or coinsurance under the policy or plan.
(d) 1. If an office visit and a preventive service specified under par. (b) are billed separately by the health care provider, the disability insurance policy or self-insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit but not on the preventive service.
2. If the primary reason for an office visit is not to obtain a preventive service, the disability insurance policy or self-insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit.
3. Except as otherwise provided in this subdivision, if a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy's or self-insured health plan's network of providers, the policy or plan may apply deductibles to and impose copayments or coinsurance on the office visit and the preventive service. If a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy's or self-insured health plan's network of providers because there is no available health care provider in the policy's or plan's network of providers that provides the preventive service, the policy or plan may not apply deductibles to or impose copayments or coinsurance on the preventive service.
4. If multiple well-woman visits described under par. (b) 47. are required to fulfill all necessary preventive services and are in accordance with clinical recommendations, the disability insurance policy or self-insured health plan may not apply a deductible to or impose a copayment or coinsurance on any of those well-woman visits.
Section 29. 632.895 (14) (a) 1. i. and j. of the statutes are amended to read:
632.895 (14) (a) 1. i. Hepatitis A and B.
j. Varicella and herpes zoster.
Section 30. 632.895 (14) (a) 1. k. to o. of the statutes are created to read:
632.895 (14) (a) 1. k. Human papillomavirus.
L. Meningococcal meningitis.
m. Pneumococcal pneumonia.
n. Influenza.
o. Rotavirus.
Section 31. 632.895 (14) (b) of the statutes is amended to read:
632.895 (14) (b) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for an insured or plan participant, including a dependent who is a child of the insured or plan participant.
Section 32. 632.895 (14) (c) of the statutes is amended to read:
632.895 (14) (c) The coverage required under par. (b) may not be subject to any deductibles, copayments, or coinsurance under the policy or plan. This paragraph applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in s. 609.01 (3m), in the plan.
Section 33. 632.895 (14) (d) 3. of the statutes is amended to read:
632.895 (14) (d) 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).
Section 34. 632.895 (14m) of the statutes is created to read:
632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).
(b) On a date specified by the commissioner, by rule, every disability insurance policy, except as provided in par. (g), and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).
(c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:
1. Include benefits, items, and services in, at least, all of the following categories:
a. Ambulatory patient services.
b. Emergency services.
c. Hospitalization.
d. Maternity and newborn care.
e. Mental health and substance use disorder services, including behavioral health treatment.
f. Prescription drugs.
g. Rehabilitative and habilitative services and devices.
h. Laboratory services.
i. Preventive and wellness services and chronic disease management.
j. Pediatric services, including oral and vision care.
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.
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.
4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.
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.
6. Establish essential health benefits in a way that takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.
7. Ensure that essential health benefits established under this subsection are not 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.
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.
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.
(d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.
(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.
(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.
(g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.
Section 35. 632.895 (16m) (b) of the statutes is amended to read:
632.895 (16m) (b) The coverage required under this subsection may be subject to any limitations, or exclusions, or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan. The coverage required under this subsection may not be subject to any deductibles, copayments, or coinsurance.
Section 36. 632.895 (17) (b) 2. of the statutes is amended to read:
632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan sterilization procedures, and patient education and counseling for all females with reproductive capacity.
Section 37. 632.895 (17) (c) of the statutes is amended to read:
632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions, and limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan. A disability insurance policy or self-insured health plan may not apply a deductible or impose a copayment or coinsurance to at least one of each type of contraceptive method approved by the federal food and drug administration for which coverage is required under this subsection. The disability insurance policy or self-insured health plan may apply reasonable medical management to a method of contraception to limit coverage under this subsection that is provided without being subject to a deductible, copayment, or coinsurance to prescription drugs without a brand name. The disability insurance policy or self-insured health plan may apply a deductible or impose a copayment or coinsurance for coverage of a contraceptive that is prescribed for a medical need if the services for the medical need would otherwise be subject to a deductible, copayment, or coinsurance.
Section 38. 632.897 (11) (a) of the statutes is amended to read:
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.
Section 9323. Initial applicability; Insurance.
(1) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services.
(a) For policies and plans containing provisions inconsistent with these sections, the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.713, 609.847, 625.12 (1) (a) and (e) and (2), 625.15 (1), 628.34 (3) (a), 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1., 2., and 3., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c) and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b ).
(b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with these sections, the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.713, 609.847, 625.12 (1) (a) and (e) and (2), 625.15 (1), 628.34 (3) (a), 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1., 2., and 3., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c) and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is entered into, extended, modified, or renewed, whichever is later.
Section 9423. Effective dates; Insurance.
(1) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services. The treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.713, 609.847, 625.12 (1) (a) and (e) and (2), 625.15 (1), 628.34 (3) (a), 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1., 2., and 3., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c) and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) and Section 9323 (1) of this act take effect on the first day of the 4th month beginning after publication.
(End)