1995 Wisconsin Act 289

1. An individual, firm, corporation, partnership, limited liability company or association that is actively engaged in a business enterprise in this state, including a farm business.

2. A municipality, as defined in s. 16.70 (8).

3. The state.

(c) “Group health benefit plan" means a health benefit plan that is issued by an insurer to an employer on behalf of a group consisting of eligible employes of the employer. The term includes individual health benefit plans covering eligible employes when 3 or more are sold to an employer.

(d) “Health benefit plan" means any hospital or medical policy or certificate. “Health benefit plan" does not include accident-only, credit accident or health, dental, vision, medicare supplement, medicare replacement, long-term care, disability income or short-term insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, automobile medical payment insurance, individual conversion policies, specified disease policies, hospital indemnity policies, as defined in s. 632.895 (1) (c), policies or certificates issued under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619 or other insurance exempted by rule of the commissioner.

(e) “Insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers group health benefit plans covering eligible employes of one or more employers in this state. The term includes a health maintenance organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), an insurer operating as a cooperative association organized under ss. 185.981 to 185.985 and a limited service health organization, as defined in s. 609.01 (3).

(f) 1. “Qualifying coverage" means benefits or coverage provided under any of the following:

a. Medicare, medicaid or the Wisconsin works healthplan.

b. A group health benefit plan or an employer-based health benefit arrangement that provides benefits similar to or exceeding benefits provided under a basic health benefit plan under subch. II of ch. 635.

c. An individual health benefit plan that provides benefits similar to or exceeding benefits provided under a basic health benefit plan under subch. II of ch. 635, if the individual health benefit plan has been in effect for at least one year.

2. Notwithstanding subd. 1. b. and c., “qualifying coverage" does not include a high cost-share health benefit plan that is linked to a tax-preferred savings plan for payment of medical expenses if the employer that provides the individual's new coverage offers its eligible employes a choice of health benefit plan options that includes a high cost-share health benefit plan that may be linked to a tax-preferred savings plan for payment of medical expenses and the individual's new coverage is not such a high cost-share health benefit plan.

(g) “Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.

(2) Preexisting conditions. (a) A group health benefit plan, or a self-insured health plan, may not deny, exclude or limit benefits for a covered individual for losses incurred more than 12 months after the effective date of the individual's coverage due to a preexisting condition.

(b) Except as provided in par. (c), a group health benefit plan, or a self-insured health plan, may not define a preexisting condition more restrictively than any of the following:

1. A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 6 months immediately preceding the effective date of coverage and for which the individual did not seek medical advice, diagnosis, care or treatment.

2. A condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of coverage.

(c) Notwithstanding par. (b) 1. and 2., a group health benefit plan, or a self-insured health plan, shall exclude pregnancy from the definition of a preexisting condition for the purpose of coverage of expenses related to prenatal and postnatal care, delivery and any complications of pregnancy.

(3) Portability. (a) A group health benefit plan, or a self-insured health plan, shall waive any period applicable to a preexisting condition exclusion or limitation period with respect to particular services for the period that an individual was previously covered by qualifying coverage that was not sponsored by the employer sponsoring the group health benefit plan or the self-insured health plan and that provided benefits with respect to such services, if the qualifying coverage terminated not more than 60 days before the effective date of the new coverage.

(b) Paragraph (a) does not prohibit the application of a waiting period to all new enrollees under a group health benefit plan or a self-insured health plan; however, a waiting period may not be applied when determining whether the qualifying coverage terminated not more than 60 days before the effective date of the new coverage.

(c) If the federal government enacts legislation providing for a federal income tax exemption for amounts deposited in a savings plan for payment of medical expenses that is linked to a high cost-share health benefit plan, and for any interest, dividends or other gain that accrues in the savings plan if redeposited in the savings plan, 6 years after the enactment of the federal legislation the commissioner shall conduct a study of individuals and groups that had coverage under a high cost-share health benefit plan linked to a tax-preferred savings plan for payment of medical expenses and that terminated that coverage in order to enroll in a health benefit plan that was not such a high cost-share health plan. If as a result of the study the commissioner determines that s. 632.745 (1) (f) 2. is not necessary for the purpose for which it was intended, the commissioner shall certify that determination to the revisor of statutes. Upon the certification, the revisor of statutes shall publish notice in the Wisconsin administrative register of the determination, the date of the certification and that after 30 days after the date of the certification s. 632.745 (1) (f) 2. is not effective.

(4) Minimum participation of employes. (a) Except as provided in par. (d), requirements used by an insurer in determining whether to provide coverage under a group health benefit plan to an employer, including requirements for minimum participation of eligible employes and minimum employer contributions, shall be applied uniformly among all employers that apply for or receive coverage from the insurer.

(b) An insurer may vary its minimum participation requirements and minimum employer contribution requirements only by the size of the employer group based on the number of eligible employes.

(c) In applying minimum participation requirements with respect to an employer, an insurer may not count eligible employes who have other coverage that is qualifying coverage in determining whether the applicable percentage of participation is met, except that an insurer may count eligible employes who have coverage under another health benefit plan that is sponsored by that employer and that is qualifying coverage.

(d) An insurer may not increase a requirement for minimum employe participation or a requirement for minimum employer contribution that applies to an employer after the employer has been accepted for coverage.

(e) This subsection does not apply to a group health benefit plan offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).

(5) Prohibited coverage practices. (a) 1. Except as provided in rules promulgated under subd. 3., if an insurer offers a group health benefit plan to an employer, the insurer shall offer coverage to all of the eligible employes of the employer and their dependents. Except as provided in rules promulgated under subd. 3., an insurer may not offer coverage to only certain individuals in an employer group or to only part of the group, except for an eligible employe who has not yet satisfied an applicable waiting period, if any.

2. Except as provided in rules promulgated under subd. 3., if the state or a county, city, village, town or school district offers coverage under a self-insured health plan, it shall offer coverage to all of its eligible employes and their dependents. Except as provided in rules promulgated under subd. 3., the state or a county, city, village, town or school district may not offer coverage to only certain individuals in the employer group or to only part of the group, except for an eligible employe who has not yet satisfied an applicable waiting period, if any.

3. The secretary of employe trust funds, with the approval of the group insurance board, shall promulgate rules related to offering coverage to eligible employes under a group health benefit plan, or a self-insured health plan, offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7). The rules shall conform to the intent of subds. 1. and 2. and may not allow the state or the group insurance board to refuse to offer coverage to an eligible employe or dependent for reasons related to health condition.

(b) 1. An insurer may not modify a group health benefit plan with respect to an employer or an eligible employe or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the group health benefit plan.

2. The state or a county, city, village, town or school district may not modify a self-insured health plan with respect to an eligible employe or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the self-insured health plan.

3. Nothing in this paragraph limits the authority of the group insurance board to fulfill its obligations as trustee under s. 40.03 (6) (d) or to design or modify procedures or provisions pertaining to enrollment, premium transmitted or coverage of eligible employes for health care benefits under s. 40.51 (1).

289,250m Section 250m. 632.745 (1) (f) 2. of the statutes, as created by 1995 Wisconsin Act .... (this act), is repealed.

289,251 Section 251 . 632.747 of the statutes is created to read:

632.747 Guaranteed acceptance. (1) Employe becomes eligible after commencement of coverage. If an insurer provides coverage under a group health benefit plan, the insurer shall provide coverage under the group health benefit plan to an eligible employe who becomes eligible for coverage after the commencement of the employer's coverage, and to the eligible employe's dependents, regardless of health condition or claims experience, if all of the following apply:

(a) The employe has satisfied any applicable waiting period.

(b) The employer agrees to pay the premium required for coverage of the employe under the group health benefit plan.

(2) Employe waived coverage previously. If an insurer provides coverage under a group health benefit plan, the insurer shall provide coverage under the group health benefit plan to an eligible employe who waived coverage during an enrollment period during which the employe was entitled to enroll in the group health benefit plan, regardless of health condition or claims experience, if all of the following apply:

(a) The eligible employe was covered as a dependent under qualifying coverage when he or she waived coverage under the group health benefit plan.

(b) The eligible employe's coverage under the qualifying coverage has terminated or will terminate due to a divorce from the insured under the qualifying coverage, the death of the insured under the qualifying coverage, loss of employment by the insured under the qualifying coverage or involuntary loss of coverage under the qualifying coverage by the insured under the qualifying coverage.

(c) The eligible employe applies for coverage under the group health benefit plan not more than 30 days after termination of his or her coverage under the qualifying coverage.

(d) The employer agrees to pay the premium required for coverage of the employe under the group health benefit plan.

(3) State or municipal self-insured plans. If the state or a county, city, village, town or school district provides coverage under a self-insured health plan, it shall provide coverage under the self-insured health plan to an eligible employe who waived coverage during an enrollment period during which the employe was entitled to enroll in the self-insured health plan, regardless of health condition or claims experience, if all of the following apply:

(a) The eligible employe was covered as a dependent under qualifying coverage when he or she waived coverage under the self-insured health plan.

(b) The eligible employe's coverage under the qualifying coverage has terminated or will terminate due to a divorce from the insured under the qualifying coverage, the death of the insured under the qualifying coverage, loss of employment by the insured under the qualifying coverage or involuntary loss of coverage under the qualifying coverage by the insured under the qualifying coverage.

(c) The eligible employe applies for coverage under the self-insured health plan not more than 30 days after termination of his or her coverage under the qualifying coverage.

289,252 Section 252 . 632.749 of the statutes is created to read:

632.749 Contract termination and renewability. (1) Midterm cancellation. Notwithstanding s. 631.36 (2) to (4m), a group health benefit plan may not be canceled by an insurer before the expiration of the agreed term, and shall be renewable to the policyholder and all insureds and dependents eligible under the terms of the group health benefit plan at the expiration of the agreed term at the option of the policyholder, except for any of the following reasons:

(a) Failure to pay a premium when due.

(b) Fraud or misrepresentation by the policyholder, or, with respect to coverage for an insured individual, fraud or misrepresentation by that insured individual.

(c) Substantial breaches of contractual duties, conditions or warranties.

(d) The number of individuals covered under the group health benefit plan is less than the number required by the group health benefit plan.

(e) The employer to which the group health benefit plan is issued is no longer actively engaged in a business enterprise.

(2) Nonrenewal. Notwithstanding sub. (1), an insurer may elect not to renew a group health benefit plan if the insurer complies with all of the following:

(a) The insurer ceases to renew all other group health benefit plans issued by the insurer.

(b) The insurer provides notice to all affected policyholders and to the commissioner in each state in which an affected insured individual resides at least one year before termination of coverage.

(c) The insurer does not issue a group health benefit plan before 5 years after the nonrenewal of the group health benefit plans.

(d) The insurer does not transfer or otherwise provide coverage to a policyholder from the nonrenewed business unless the insurer offers to transfer or provide coverage to all affected policyholders from the nonrenewed business without regard to claims experience, health condition or duration of coverage.

(3) Insurer in liquidation. This section does not apply to a group health benefit plan if the insurer that issued the group health benefit plan is in liquidation.

(4) Applicability to certain government plans. This section does not apply to a group health benefit plan offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).

289,253 Section 253 . 632.76 (2) (a) of the statutes is 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 (1) (c), which is subject to s. 632.745 (2).

289,254 Section 254 . 632.896 (4) of the statutes is amended to read:

632.896 (4) Preexisting conditions. Notwithstanding s. ss. 632.745 (2) and 632.76 (2) (a), a disability insurance policy that is subject to sub. (2) and that is in effect when a court makes a final order granting adoption or when the child is placed for adoption may not exclude or limit coverage of a disease or physical condition of the child on the ground that the disease or physical condition existed before coverage is required to begin under sub. (3).

289,255 Section 255 . 635.02 (5m) of the statutes is repealed.

289,256 Section 256 . 635.07 of the statutes is repealed.

289,257 Section 257 . 635.17 of the statutes is repealed.

289,258 Section 258 . 635.26 (1) (a) of the statutes is renumbered 635.26 (1).

289,259 Section 259 . 635.26 (1) (b) of the statutes is repealed.

289,260 Section 260 . 767.045 (1) (c) 1. of the statutes is amended to read:

767.045 (1) (c) 1. Aid is provided under s. 46.261, 48.57 (3m), 49.19 or 49.45 on behalf of the child, or benefits are provided to the child's custodial parent under ss. 49.141 to 49.161, but the state and its delegate under s. 46.25 (7) are barred by a statute of limitations from commencing an action under s. 767.45 on behalf of the child.

289,261 Section 261 . 767.075 (1) (c) of the statutes is amended to read:

767.075 (1) (c) Whenever aid under s. 46.261, 48.57 (3m), 49.19 or 49.45 is provided to on behalf of a dependent child or benefits are provided to the child's custodial parent under ss. 49.141 to 49.161.

289,262m Section 262m. 767.075 (1) (cm) of the statutes is created to read:

767.075 (1) (cm) Whenever aid under s. 46.261, 48.57 (3m), 49.19 or 49.45 has, in the past, been provided on behalf of a dependent child, or benefits have, in the past, been provided to the child's custodial parent under ss. 49.141 to 49.161, and the child's family is eligible for continuing child support services under 45 CFR 302.33.

289,263 Section 263 . 767.077 (intro.) of the statutes is amended to read:

767.077 Support for dependent child. (intro.) The state or its delegate under s. 46.25 (7) shall bring an action for support of a minor child under s. 767.02 (1) (f) or, if appropriate, for paternity determination and child support under s. 767.45 whenever the child's right to support is assigned to the state under s. 46.261, 48.57 (3m) (b) 2. or 49.19 (4) (h) 1. b. if all of the following apply:

289,264 Section 264 . 767.078 (1) (a) 2. of the statutes is amended to read:

767.078 (1) (a) 2. The child's right to support is assigned to the state under s. 48.57 (3m) (b) 2. or 49.19 (4) (h) 1. b.

289,265 Section 265 . 767.15 (1) of the statutes is amended to read:

767.15 (1) In any action affecting the family in which either party is a recipient of benefits under ss. 49.141 to 49.161 or aid under s. 46.261, 49.19 or 49.45, each party shall, either within 20 days after making service on the opposite party of any motion or pleading requesting the court or family court commissioner to order, or to modify a previous order, relating to child support, maintenance or family support, or before filing the motion or pleading in court, serve a copy of the motion or pleading upon the child support program designee under s. 59.07 (97) of the county in which the action is begun.

289,266 Section 266 . 767.24 (6) (c) of the statutes is amended to read:

767.24 (6) (c) In making an order of joint legal custody and periods of physical placement, the court may specify one parent as the primary caretaker of the child and one home as the primary home of the child, for the purpose of determining eligibility for aid under s. 49.19 or benefits under ss. 49.141 to 49.161 or for any other purpose the court considers appropriate.

289,267 Section 267 . 767.29 (1m) (c) of the statutes is amended to read:

767.29 (1m) (c) The party entitled to the support or maintenance money has applied for or is receiving aid to families with dependent children and there is an assignment to the state under s. 48.57 (3m) (b) 2. or 49.19 (4) (h) 1. b. of the party's right to the support or maintenance money.

289,268 Section 268 . 767.29 (2) of the statutes, as affected by 1995 Wisconsin Act 27, is amended to read:

767.29 (2) If any party entitled to maintenance payments or support money, or both, is receiving public assistance under ch. 49, the party may assign the party's right thereto to the county department under s. 46.215, 46.22 or 46.23 granting such assistance. Such assignment shall be approved by order of the court granting the maintenance payments or support money, and may be terminated in like manner; except that it shall not be terminated in cases where there is any delinquency in the amount of maintenance payments and support money previously ordered or adjudged to be paid to the assignee without the written consent of the assignee or upon notice to the assignee and hearing. When an assignment of maintenance payments or support money, or both, has been approved by the order, the assignee shall be deemed a real party in interest within s. 803.01 but solely for the purpose of securing payment of unpaid maintenance payments or support money adjudged or ordered to be paid, by participating in proceedings to secure the payment thereof. Notwithstanding assignment under this subsection, and without further order of the court, the clerk of court, upon receiving notice that a party or a minor child of the parties is receiving aid under s. 49.19, shall forward all support assigned under s. 48.57 (3m) (b) 2., 49.19 (4) (h) 1. or 49.45 (19) to the department of industry, labor and human relations.

289,269 Section 269 . 767.29 (4) of the statutes is amended to read:

767.29 (4) If an order or judgment providing for the support of one or more children not receiving aid under s. 48.57 (3m) or 49.19 includes support for a minor who is the beneficiary of aid under s. 48.57 (3m) or 49.19, any support payment made under the order or judgment is assigned to the state under s. 48.57 (3m) (b) 2. or 49.19 (4) (h) 1. b. in the amount that is the proportionate share of the minor receiving aid under s. 48.57 (3m) or 49.19, except as otherwise ordered by the court on the motion of a party.

289,270 Section 270 . 767.32 (1) (a) of the statutes, as affected by 1995 Wisconsin Act 77, is amended to read: