Under current law, a city, village, town, county, or school district may offer a
self-insured health plan (self-insured governmental health plan) to its employees.
The Office of the Commissioner of Insurance (OCI) may enforce laws that specify
some of the coverage a self-insured governmental health plan must offer. Current
law requires that a self-insured governmental health plan must offer coverage to all
eligible employees and their dependents and dictates other requirements for plan
participation. Current law also mandates coverage that a self-insured
governmental health plan must offer, such as drugs for treatment of human
immunodeficiency virus (HIV), lead poisoning screening, treatment for the
correction of temporomandibular disorders, anesthetic and surgery center charges
in conjunction with dental care, breast reconstruction if the plan also covers
mastectomy, certain immunizations, and health care for students on medical leave.
Current law requires that if a self-insured governmental health plan covers
dependent children, the plan must also cover adopted children. Among other
requirements, self-insured governmental health plans must develop procedures for
physicians to request an exception for a plan participant for drugs or devices that are
routinely not covered under the plan, must specify any limits on coverage of
experimental treatment, may not require preauthorization for emergency services
if the plan covers emergency services, and may not exclude coverage for treatment
of a condition by a dentist if the treatment is covered when performed by another
health care provider.
This bill expands the authority of OCI to regulate a self-insured health plan of
a city, village, town, county, or school district (governmental body), similar to the way
OCI currently regulates insurers offering a health insurance policy or group health
benefit plan. The bill allows OCI to require a governmental body that provides a
self-insured health plan to provide reports pertaining to the self-insured health
plan and to reply to requests for information made to a person with authority over
the self-insured health plan. OCI may examine the affairs of the governmental body

as they relate to the self-insured health plan. The bill allows OCI to seek an
injunction or temporary restraining order for a violation of the statutes pertaining
to a self-insured governmental health plan and allows forfeitures and criminal
penalties to be imposed for those violations. OCI must promulgate rules regarding
the level of reserves and surpluses that the governmental body must maintain with
respect to its self-insured health plan. The governmental body may reinsure the
self-insured health plan under this bill but must report the name of the reinsurer
to OCI. The bill applies laws pertaining to rehabilitation and liquidation of insurers
and the insurance security fund to governmental bodies, with respect to a
self-insured health plan.
The bill imposes coverage requirements on self-insured governmental health
plans similar to requirements imposed on health insurance policies and group health
benefit plans. Self-insured governmental health plans, under the bill, may not limit
coverage of HIV treatment if limits are not imposed on other illnesses or medical
conditions, may not refuse to provide or renew coverage based on the health plan
participant being a victim of domestic violence, must establish an internal grievance
procedure and an independent review plan for the review of adverse and
experimental treatment determinations, may not exclude coverage of treatment by
a licensed chiropractor, must provide an explanation for a restriction or termination
of coverage, must cover home care in certain circumstances, must cover skilled
nursing care meeting certain requirements, must cover maternity and newborn
children, must cover diabetes treatment and diabetic supplies, may not deny
coverage based on possible coverage under a liability policy, and must cover
mammograms, among other requirements.
Because this bill creates a new crime or revises a penalty for an existing crime,
the Joint Review Committee on Criminal Penalties may be requested to prepare a
report concerning the proposed penalty and the costs or savings that are likely to
result if the bill is enacted.
For further information see the state and local fiscal estimate, which will be
printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB466, s. 1 1Section 1. 66.0137 (4) of the statutes, as affected by 2009 Wisconsin Act 28,
2is amended to read:
SB466,4,33 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
4a village provides health care benefits under its home rule power, or if a town
5provides health care benefits, to its officers and employees on a self-insured basis,
6the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),

1631.95, 632.726, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.748, 632.83, 632.835,
2632.85, 632.853, 632.855, 632.857, 632.86, 632.87 (4), (5), and (6), 632.875, 632.88,
3632.885, 632.89, 632.895 (9) to (17), 632.896, 632.897, and 767.513 (4).
SB466, s. 2 4Section 2. 120.13 (2) (g) of the statutes, as affected by 2009 Wisconsin Act 28,
5is amended to read:
SB466,4,106 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
749.493 (3) (d), 631.89, 631.90, 631.93 (2), 631.95, 632.726, 632.746 (10) (a) 2. and (b)
82.
, 632.747 (3), 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.857, 632.86,
9632.87 (4), (5), and (6), 632.875, 632.88, 632.885, 632.89, 632.895 (9) to (17), 632.896,
10632.897, and 767.513 (4).
SB466, s. 3 11Section 3. 153.01 (5m) of the statutes is amended to read:
SB466,4,1412 153.01 (5m) "Insurer" has the meaning given under s. 632.745 (15) but does
13not include a city, town, village, county, or school district that provides a self-insured
14health plan, with respect to the self-insured health plan
.
SB466, s. 4 15Section 4. 601.41 (8) (a) 1. of the statutes is amended to read:
SB466,4,1716 601.41 (8) (a) 1. "Group health benefit plan" has the meaning given in s.
17632.745 (9) (a) and (b).
SB466, s. 5 18Section 5. 601.42 (1g) (intro.) of the statutes is amended to read:
SB466,4,2219 601.42 (1g) Reports. (intro.) The commissioner may require any of the
20following from any person subject to regulation under chs. 600 to 655 and from any
21city, village, town, county, or school district that provides a self-insured health plan,
22with respect to the self-insured health plan
:
SB466, s. 6 23Section 6. 601.42 (4) of the statutes is amended to read:
SB466,5,1124 601.42 (4) Replies. Any officer, manager or general agent of any insurer
25authorized to do or doing an insurance business in this state, any person controlling

1or having a contract under which the person has a right to control such an insurer,
2whether exclusively or otherwise, any person with executive authority over or in
3charge of any segment of such an insurer's affairs, any person with authority over
4or in charge of a self-insured health plan of a city, town, village, county or school
5district,
any individual practice association or officer, director or manager of an
6individual practice association, any insurance agent or other person licensed under
7chs. 600 to 646, any provider of services under a continuing care contract, as defined
8in s. 647.01 (2), any independent review organization certified or recertified under
9s. 632.835 (4) or any health care provider, as defined in s. 655.001 (8), shall reply
10promptly in writing or in other designated form, to any written inquiry from the
11commissioner requesting a reply.
SB466, s. 7 12Section 7. 601.43 (1) (a) of the statutes is amended to read:
SB466,5,2113 601.43 (1) (a) Insurers, other licensees and other persons subject to regulation.
14Whenever the commissioner deems it necessary in order to inform himself or herself
15about any matter related to the enforcement of chs. 600 to 647, the commissioner may
16examine the affairs and condition of any licensee or permittee under chs. 600 to 647
17or applicant for a license or permit, of any person or organization of persons doing
18or in process of organizing to do an insurance business in this state, of any city,
19village, town, county, or school district that provides a self-insured health plan, with
20respect to the self-insured health plan,
and of any advisory organization serving any
21of the foregoing in this state.
SB466, s. 8 22Section 8. 601.43 (1) (d) of the statutes is amended to read:
SB466,6,223 601.43 (1) (d) Delivery of records to the office. On order of the commissioner any
24licensee or permittee under chs. 600 to 647, or a city, town, village, county, or school
25district that provides a self-insured health plan, with respect to the self-insured

1health plan,
shall bring to the office for examination such records as the order
2reasonably requires.
SB466, s. 9 3Section 9. 601.64 (1) of the statutes is amended to read:
SB466,6,104 601.64 (1) Injunctions and restraining orders. The commissioner may
5commence an action in circuit court in the name of the state to restrain by temporary
6or permanent injunction or by temporary restraining order any violation of chs. 600
7to 655 or s. 59.52 (11) (c), 66.0137 (4) or (4m), 120.13 (2) (b) to (g), or 149.13, any rule
8promulgated under chs. 600 to 655, or any order issued under s. 601.41 (4). The
9commissioner need not show irreparable harm or lack of an adequate remedy at law
10in an action commenced under this subsection.
SB466, s. 10 11Section 10. 601.64 (3) (a) of the statutes is amended to read:
SB466,6,1612 601.64 (3) (a) Restitutionary forfeiture. Whoever violates an effective order
13issued under s. 601.41 (4), any insurance statute or rule, or s. 59.52 (11) (c), 66.0137
14(4) or (4m), 120.13 (2) (b) to (g), or
149.13 shall forfeit to the state twice the amount
15of any profit gained from the violation, in addition to any other forfeiture or penalty
16imposed.
SB466, s. 11 17Section 11. 601.64 (3) (c) of the statutes is amended to read:
SB466,6,2418 601.64 (3) (c) Forfeiture for violation of statute or rule. Whoever violates an
19insurance statute or rule or s. 149.13, intentionally aids a person in violating an
20insurance statute or rule or s. 59.52 (11) (c), 66.0137 (4) or (4m), 120.13 (2) (b) to (g),
21or
149.13, or knowingly permits a person over whom he or she has authority to violate
22an insurance statute or rule or s. 149.13 shall forfeit to the state not more than $1,000
23for each violation. If the statute or rule imposes a duty to make a report to the
24commissioner, each week of delay in complying with the duty is a new violation.
SB466, s. 12 25Section 12. 601.64 (4) of the statutes is amended to read:
SB466,7,6
1601.64 (4) Criminal penalty. Whoever intentionally violates or intentionally
2permits any person over whom he or she has authority to violate or intentionally aids
3any person in violating any insurance statute or rule of this state, s. 59.52 (11) (c),
466.0137 (4) or (4m), 120.13 (2) (b) to (g), or
149.13, or any effective order issued under
5s. 601.41 (4) is guilty of a Class I felony, unless a specific penalty is provided
6elsewhere in the statutes. Intent has the meaning expressed under s. 939.23.
SB466, s. 13 7Section 13. 623.17 of the statutes is created to read:
SB466,7,12 8623.17 Self-insured governmental health plans. (1) The commissioner
9shall promulgate rules regarding the level of reserves, compulsory surplus, and
10security surplus that must be maintained by a city, village, town, county, or school
11district that provides a self-insured health plan, with respect to the self-insured
12health plan.
SB466,7,15 13(2) The commissioner may order a city, village, town, county, or school district
14to adjust its reserves or surpluses if they do not bear an appropriate relation to its
15obligations with regard to a self-insured health plan.
SB466,7,17 16(3) A city, village, town, county, or school district that provides a self-insured
17health plan shall do all of the following:
SB466,7,1818 (a) Comply with rules promulgated and orders issued under this section.
SB466,7,2019 (b) Report to the commissioner annually the levels of reserves and surpluses
20maintained with respect to a self-insured health plan.
SB466, s. 14 21Section 14. 627.23 (2) of the statutes is amended to read:
SB466,8,522 627.23 (2) Power to cede reinsurance. Subject to s. 611.78, any authorized
23insurer or a city, town, village, county, or school district that provides a self-insured
24health plan, with respect to the self-insured health plan,
may cede to any insurer
25authorized to assume it under chs. 611 to 618 and sub. (1) any liability it has

1undertaken on risks lawfully written under its certificate of authority. It may also
2cede reinsurance to any authorized agency of the federal government or of this state.
3Subject to rules promulgated by the commissioner for calculation of its reserves and
4its surplus, and subject to sub. (3), an authorized insurer may also cede reinsurance
5to an unauthorized insurer.
SB466, s. 15 6Section 15. 627.23 (6) of the statutes is created to read:
SB466,8,107 627.23 (6) Reinsurance of self-insured health plans. A city, town, village,
8county, or school district that provides a self-insured health plan, with respect to the
9self-insured health plan, shall report annually to the commissioner the name of any
10reinsurer.
SB466, s. 16 11Section 16. 631.90 (2) (intro.) of the statutes is amended to read:
SB466,8,1412 631.90 (2) (intro.) With regard to policies or plans issued or renewed on and
13after July 20, 1985, an insurer or self-insured health plan, as defined in s. 632.85 (1)
14(c) 2. and 3.,
may not do any of the following:
SB466, s. 17 15Section 17. 631.90 (2) (b) of the statutes is amended to read:
SB466,8,1916 631.90 (2) (b) Condition the provision of insurance or plan coverage on whether
17an individual has obtained a test for the presence of HIV, antigen or nonantigenic
18products of HIV or an antibody to HIV or what the results of this test, if obtained by
19the individual, were.
SB466, s. 18 20Section 18. 631.90 (2) (c) of the statutes is amended to read:
SB466,8,2421 631.90 (2) (c) Consider in the determination of rates or any other aspect of
22insurance or plan coverage provided to an individual whether an individual has
23obtained a test for the presence of HIV, antigen or nonantigenic products of HIV or
24an antibody to HIV or what the results of this test, if obtained by the individual, were.
SB466, s. 19 25Section 19. 631.93 (2) of the statutes is amended to read:
SB466,9,6
1631.93 (2) Accident and health insurance. An accident or health insurance
2policy or self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., may not
3contain exclusions or limitations, including deductibles or copayments, for coverage
4of the treatment of HIV infection or any illness or medical condition arising from or
5related to HIV infection, unless the exclusions or limitations apply generally to other
6illnesses or medical conditions covered by the policy or plan.
SB466, s. 20 7Section 20. 631.95 (2m) of the statutes is created to read:
SB466,9,118 631.95 (2m) Prohibitions and exceptions for self-insured health plans. (a)
9In this subsection, "self-insured governmental body" means a city, town, village,
10county, or school district that provides a self-insured health plan, with respect to the
11health plan.
SB466,9,1312 (b) Except as provided in par. (c), a self-insured governmental body may not
13do any of the following:
SB466,9,2014 1. Refuse to provide or renew coverage to a health plan participant under the
15self-insured health plan on the basis that the health plan participant has been, or
16the self-insured governmental body has reason to believe that the health plan
17participant is, a victim of abuse or domestic abuse or that a member of the health plan
18participant's family has been, or the self-insured governmental body has reason to
19believe that a member of the health plan participant's family is, a victim of abuse or
20domestic abuse.
SB466,9,2521 2. Use as a factor in the determination of employee contributions or any other
22aspect of coverage under the self-insured health plan, the knowledge or suspicion
23that a health plan participant has been or is a victim of abuse or domestic abuse or
24that a member of the health plan participant's family has been or is a victim of abuse
25or domestic abuse.
SB466,10,7
13. Exclude or limit coverage of, or deny a claim for, health care services or items
2related to the treatment of injury or disease resulting from abuse or domestic abuse
3on the basis that a health plan participant has been, or the self-insured
4governmental body has reason to believe that a health plan participant is, a victim
5of abuse or domestic abuse or that a member of the health plan participant's family
6has been, or the self-insured governmental body has reason to believe that a member
7of the health plan participant's family is, a victim of abuse or domestic abuse.
SB466,10,138 (c) In establishing any employee contribution amounts for a self-insured
9health plan, a self-insured governmental body may inquire about a person's existing
10medical condition and, based on the opinion of a qualified actuary, as defined in s.
11623.06 (1c), use information related to a person's existing medical condition,
12regardless of whether that condition is or may have been caused by abuse or domestic
13abuse.
SB466, s. 21 14Section 21. 631.95 (4) of the statutes is amended to read:
SB466,10,1915 631.95 (4) Immunity for insurers. An insurer or a city, town, village, county,
16or school district that provides a self-insured health plan, with respect to the
17self-insured health plan,
is immune from any civil or criminal liability for any action
18taken under sub. (2m) (c) or (3) or for the death of, or injury to, an insured or health
19plan participant
that results from abuse or domestic abuse.
SB466, s. 22 20Section 22. 631.95 (5) (a) of the statutes is renumbered 631.95 (5) (ar).
SB466, s. 23 21Section 23. 631.95 (5) (ag) of the statutes is created to read:
SB466,10,2222 631.95 (5) (ag) In this subsection, unless the context requires otherwise:
SB466,10,2423 1. "Insurance" includes a self-insured health plan of a city, town, village,
24county, or school district.
SB466,11,2
12. "Insured" includes a person who participates in a self-insured health plan
2provided by a city, town, village, county, or school district.
SB466,11,43 3. "Insurer" includes a city, town, village, county, or school district that provides
4a self-insured health plan, with respect to the self-insured health plan.
SB466, s. 24 5Section 24. 631.95 (5) (c) (intro.) of the statutes is amended to read:
SB466,11,96 631.95 (5) (c) (intro.) Paragraphs (a) (ar) and (b) do not apply if the use,
7disclosure or transfer of the information is made with the consent of the individual
8to whom the information relates or if the use, disclosure or transfer satisfies any of
9the following:
SB466, s. 25 10Section 25. 632.726 (2) of the statutes is amended to read:
SB466,11,1711 632.726 (2) If an insurer or a city, town, village, county, or school district that
12provides a self-insured health plan, with respect to the self-insured health plan,

13changes a current procedural terminology code that was submitted by a health care
14provider on a health insurance claim form, the insurer or city, town, village, county,
15or school district
shall include on the explanation of benefits form the reason for the
16change to the current procedural terminology code and shall cite on the explanation
17of benefits form the source for the change.
SB466, s. 26 18Section 26. 632.745 (intro.) of the statutes is amended to read:
SB466,11,21 19632.745 Coverage requirements for group and individual health
20benefit plans; definitions.
(intro.) In this section and ss. 632.746 to 632.7495,
21unless the context requires otherwise
:
SB466, s. 27 22Section 27. 632.745 (9) of the statutes is renumbered 632.745 (9) (intro.) and
23amended to read:
SB466,11,2424 632.745 (9) (intro.) "Group health benefit plan" means a any of the following:
SB466,12,3
1(a) A health benefit plan that is issued by an insurer to or through an employer
2on behalf of a group consisting of at least 2 employees or a group including at least
32 eligible employees. The term includes individual
SB466,12,5 4(b) Individual health benefit plans covering eligible employees when 3 or more
5are sold to or through an employer.
SB466, s. 28 6Section 28. 632.745 (9) (c) of the statutes is created to read:
SB466,12,77 632.745 (9) (c) A self-insured health plan under sub. (24) (b) and (c).
SB466, s. 29 8Section 29. 632.745 (15) of the statutes is amended to read:
SB466,12,179 632.745 (15) "Insurer" means an insurer that is authorized to do business in
10this state, in one or more lines of insurance that includes health insurance, and that
11offers health benefit plans covering individuals in this state or eligible employees of
12one or more employers in this state. The term includes a health maintenance
13organization, a preferred provider plan, as defined in s. 609.01 (4), an insurer
14operating as a cooperative association organized under ss. 185.981 to 185.985, a city,
15town, village, county, or school district that provides a self-insured health plan, with
16respect to the self-insured health plan,
and a limited service health organization, as
17defined in s. 609.01 (3).
SB466, s. 30 18Section 30. 632.745 (24) of the statutes is renumbered 632.745 (24) (intro.) and
19amended to read:
SB466,12,2120 632.745 (24) "Self-insured health plan" means a self-insured health plan of
21the any of the following:
SB466,12,22 22(a) The state or a .
SB466,12,23 23(b) A county, city, village, or town or.
SB466,12,24 24(c) A school district.
SB466, s. 31
1Section 31. 632.83 (1) of the statutes is renumbered 632.83 (1) (intro.) and
2amended to read:
SB466,13,33 632.83 (1) In this section, "health :
SB466,13,8 4(a) "Health benefit plan" has the meaning given in s. 632.745 (11), except that
5"health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10. and
6includes a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., and a
7policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only
8limited-scope dental or vision benefits.
SB466, s. 32 9Section 32. 632.83 (1) (b) of the statutes is created to read:
SB466,13,1110 632.83 (1) (b) "Insured" includes a person who participates in a self-insured
11health plan, as defined in s. 632.85 (1) (c) 2. and 3.
SB466, s. 33 12Section 33. 632.83 (1) (c) of the statutes is created to read:
Loading...
Loading...