Amendment ASA1-AB416

AB416-ASA1,17,11 (4) Rate service organizations. If an insurer uses rates for health benefit plans that are prepared by a rate service organization designated under s. 625.15, rates filed by the rate service organization on behalf of the insurer shall comply with this section.

AB416-ASA1,17,15 (5) Certification of compliance. An insurer that issues or renews a health benefit plan on or after October 1, 1996, shall file with the commissioner on or before May 1 annually an actuarial opinion by a member of the American Academy of Actuaries certifying all of the following:

AB416-ASA1,17,16 (a) That the insurer is in compliance with the rate provisions of this section.

AB416-ASA1,17,18 (b) That the insurer's rating methods are based on generally accepted and sound actuarial principles, policies and procedures.

AB416-ASA1,17,21 (c) That the opinion is based on the actuary's examination of the insurer's records and a review of the insurer's actuarial assumptions and statistical methods used in setting rates and procedures used in implementing rating plans.

AB416-ASA1,18,2 (6) Commissioner defines community. The commissioner shall by rule define "community" for purposes of the definition of "community rate" under sub. (1) (a). The commissioner may not define "community" as a geographical area that includes less than an entire federal metropolitan statistical area or an entire county, whichever is larger.

AB416-ASA1, s. 25 Section 25. 632.7465 of the statutes is created to read:

AB416-ASA1,18,10 632.7465 Transition by rule. Notwithstanding s. 632.746 (1) and (2), the commissioner may promulgate rules that permit an insurer to vary from the community rate required under s. 632.746 (2) (a) and modified under s. 632.746 (2) (b) within restrictions provided in the rules. The restrictions provided in the rules shall be reasonably designed to provide for an orderly transition to the community rates required under s. 632.746 (2) (a) and modified under s. 632.746 (2) (b) by no later than October 1, 1997.

AB416-ASA1, s. 26 Section 26. 632.747 of the statutes is created to read:

AB416-ASA1,18,17 632.747 Guaranteed issue. (1) Group health benefit plans. (a) Except as provided in sub. (3), an insurer shall provide coverage under a group health benefit plan to an employer, to all of the employer's eligible employes and their dependents, and to any of the employer's other employes for whom the employer desires to provide coverage and their dependents, regardless of health condition or claims experience, if all of the following apply:

AB416-ASA1,18,18 1. The insurer has in force a health benefit plan.

AB416-ASA1,18,20 2. The employer group meets the insurer's minimum participation requirements.

AB416-ASA1,18,22 3. The employer agrees to pay the premium required for coverage under the group health benefit plan.

AB416-ASA1,18,25 4. The employer agrees to comply with all other provisions of the group health benefit plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

AB416-ASA1,19,5 (b) An insurer shall provide coverage under a group health benefit plan to an eligible employe, or to any other employe for whom the employer desires to provide coverage, who becomes eligible for coverage according to the employer's requirements after the commencement of the employer's coverage, and to the eligible or other employe's dependents, regardless of health condition or claims experience.

AB416-ASA1,19,10 (2) Individual health benefit plans. Except as provided in sub. (3) and notwithstanding s. 632.897 (4) (d), an insurer shall provide coverage under an individual health benefit plan to an individual who is a resident and to the individual's dependents, regardless of health condition or claims experience, if all of the following apply:

AB416-ASA1,19,11 (a) The insurer has in force a health benefit plan.

AB416-ASA1,19,13 (b) The individual agrees to pay the premium required for coverage under the individual health benefit plan.

AB416-ASA1,19,16 (c) The individual agrees to comply with all other provisions of the individual health benefit plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

AB416-ASA1,19,21 (3) Exceptions to guaranteed issue. (a) An insurer that is otherwise required to provide coverage under sub. (1) may refuse to issue a group health benefit plan to an employer if all of the individuals in the employer group that are to be covered under the group health benefit plan may be covered under an individual health benefit plan providing single or family coverage.

AB416-ASA1,19,25 (b) An insurer that is otherwise required to provide coverage under sub. (2) may refuse to provide coverage to an individual if the individual was excluded from coverage under an employer's health benefit plan or self-funded health care plan for reasons related to the individual's health condition.

AB416-ASA1,20,4 (c) An insurer that is otherwise required to provide coverage under sub. (2) may refuse to provide coverage to an individual if the individual waived coverage under an employer's health benefit plan or self-funded health care plan for reasons related to the individual's health condition.

AB416-ASA1,20,6 (d) 1. In this paragraph, "municipal" means county, city, village, town or school district.

AB416-ASA1,20,11 2. Subsections (1) and (2) do not require an insurer to issue coverage that the insurer is not authorized to issue under its bylaws, charter or certificate of incorporation or authority if the insurer is authorized under its bylaws, charter or certificate of incorporation or authority to issue coverage only to state or municipal employes and former employes and their dependents.

AB416-ASA1,20,15 (e) An insurer that offers health care coverage exclusively to a single category or limited categories of employers may, with prior approval of the commissioner, limit its compliance with subs. (1) and (2) to that single category or those limited categories of employers.

AB416-ASA1,20,17 (f) The commissioner may exempt an insurer from the requirements of sub. (1) or (2) if the commissioner determines that any of the following applies:

AB416-ASA1,20,19 1. It is inequitable to apply sub. (1) or (2) to the insurer due to its disproportionate share of groups or individuals with high claims experience.

AB416-ASA1,20,21 2. It is in the public interest to exempt the insurer from the requirements under sub. (1) or (2) because the insurer is in financially hazardous condition.

AB416-ASA1,20,23 (g) An insurer may limit its issuance of health benefit plans under subs. (1) and (2) to any of the following:

AB416-ASA1,20,25 1. Group health benefit plans, and related individual conversion policies, to small employer groups.

AB416-ASA1,21,2 2. Group health benefit plans, and related individual conversion policies, to employer groups that are not small employer groups.

AB416-ASA1,21,3 3. Individual health benefit plans.

AB416-ASA1,21,6 (4) Risk adjustment; rules. (a) The commissioner shall promulgate rules establishing a risk adjustment mechanism for insurers issuing health benefit plans under this section.

AB416-ASA1,21,7 (b) The rules promulgated under par. (a) shall do all of the following:

AB416-ASA1,21,9 1. Define "high-risk medical conditions", using diagnostic criteria and other criteria.

AB416-ASA1,21,11 2. Place a dollar value on each high-risk medical condition based on the severity of the condition.

AB416-ASA1,21,13 3. Determine the percentage of individuals with high-risk medical conditions covered by health benefit plans.

AB416-ASA1,21,18 4. Provide for an annual assessment against each insurer insuring a lower percentage of individuals with high-risk medical conditions than the percentage established under subd. 3. Any moneys received from assessments imposed under the rules promulgated under this subdivision shall be credited to the appropriation under s. 20.145 (1) (h).

AB416-ASA1,21,21 5. Provide for an annual reimbursement for each insurer insuring a higher percentage of individuals with high-risk medical conditions than the percentage established under subd. 3.

AB416-ASA1,22,2 (5) Advisory committee. (a) The commissioner shall establish and appoint the members of an advisory committee to advise the commissioner on the contents of the rules to be promulgated under sub. (4) including definitions, assessments and reimbursements. The committee shall also review the rules developed under sub. (4) and submitted to the legislature under s. 227.19 (2) and make recommendations to the legislature on the rules.

AB416-ASA1,22,4 (b) The advisory committee established by the commissioner under par. (a) shall consist of the commissioner or his or her designee and all of the following:

AB416-ASA1,22,5 1. A representative of an insurer that issues individual health benefit plans.

AB416-ASA1,22,6 2. A representative of an insurer that issues group health benefit plans.

AB416-ASA1,22,7 3. A representative of a health maintenance organization.

AB416-ASA1,22,8 4. Two actuaries who are fellows of the American Academy of Actuaries.

AB416-ASA1,22,10 5. An underwriter employed by an insurer that issues individual health benefit plans.

AB416-ASA1,22,12 6. An underwriter employed by an insurer that issues group health benefit plans.

AB416-ASA1,22,13 7. A medical director.

AB416-ASA1, s. 27 Section 27. 632.748 of the statutes is created to read:

AB416-ASA1,22,20 632.748 Contract termination and renewability. (1) Midterm cancellation. Notwithstanding s. 631.36 (2) to (4m), a 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 health benefit plan at the expiration of the agreed term at the option of the policyholder, except for any of the following reasons:

AB416-ASA1,22,21 (a) Failure to pay a premium when due.

AB416-ASA1,22,23 (b) Fraud or misrepresentation by the policyholder or, with respect to coverage for an insured individual, fraud or misrepresentation by that insured individual.

AB416-ASA1,22,24 (c) Substantial breaches of contractual duties, conditions or warranties.

AB416-ASA1,23,2 (d) The number of individuals covered under the health benefit plan is less than the number required by the health benefit plan.

AB416-ASA1,23,4 (e) If the health benefit plan covers an employer group, the employer is no longer actively engaged in a business enterprise.

AB416-ASA1,23,6 (2) Nonrenewal. Notwithstanding sub. (1), an insurer may elect not to renew a health benefit plan if the insurer complies with all of the following:

AB416-ASA1,23,8 (a) The insurer ceases to renew all other health benefit plans issued by the insurer.

AB416-ASA1,23,11 (b) The insurer provides notice to all affected policyholders and to the commissioner in each state in which an affected insured individual resides not later than one year before termination of coverage.

AB416-ASA1,23,13 (c) The insurer does not issue a health benefit plan earlier than 5 years after the nonrenewal of the health benefit plans.

AB416-ASA1,23,17 (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.

AB416-ASA1,23,19 (3) Insurer in liquidation. This section does not apply to a health benefit plan if the insurer that issued the health benefit plan is in liquidation.

AB416-ASA1, s. 28 Section 28. 632.749 of the statutes is created to read:

AB416-ASA1,23,23 632.749 Fair marketing standards. (1) Active marketing. Every insurer shall actively market health benefit plan coverage to employers and individuals in this state.

AB416-ASA1,24,3 (2) Prohibitions related to case characteristics. (a) 1. Except as provided in subd. 2., an insurer or an intermediary may not directly or indirectly do any of the following:

AB416-ASA1,24,7 a. Discourage an employer or an individual from applying, or direct an employer or an individual not to apply, for coverage with the insurer because of the health condition, claims experience, industry, occupation or geographic area of the employer or individual.

AB416-ASA1,24,10 b. Encourage or direct an employer or an individual to seek coverage from another insurer because of the health condition, claims experience, industry, occupation or geographic area of the employer or individual.

AB416-ASA1,24,13 2. Subdivision 1. does not prohibit an insurer or an intermediary from providing an employer or an individual with information about an established geographic service area or a restricted network provision of the insurer.

AB416-ASA1,24,19 (b) 1. Except as provided in subd. 2., an insurer may not directly or indirectly enter into any contract, agreement or arrangement with an intermediary that provides for or results in compensation to the intermediary for the sale of a health benefit plan that varies according to the health condition, claims experience, industry, occupation or geographic area of an employer, any of the employer's covered employes, an insured individual or any dependents.

AB416-ASA1,24,23 2. Payment of compensation on the basis of percentage of premium is not a violation of subd. 1. if the percentage does not vary based on the health condition, claims experience, industry, occupation or geographic area of an employer, any of the employer's covered employes, an insured individual or any dependents.

AB416-ASA1,25,3 (c) An insurer may not terminate, fail to renew or limit its contract or agreement of representation with an intermediary for any reason related to the health condition, claims experience, industry, occupation or geographic area of the employers, covered employes, insured individuals or dependents placed by the intermediary with the insurer.

AB416-ASA1,25,7 (3) Prohibition related to excluding employe. An insurer or an intermediary may not induce or otherwise encourage an employer to separate or otherwise exclude an employe from health coverage or benefits provided in connection with the employe's employment.

AB416-ASA1,25,10 (4) Written denial required. Denial by an insurer of an application for coverage from an employer shall be in writing and shall state the reason or reasons for the denial.

AB416-ASA1,25,15 (5) Third-party administrators. A 3rd-party administrator that enters into a contract, agreement or other arrangement with an insurer to provide administrative, marketing or other services related to the offering of health benefit plans to employers or individuals in this state is subject to this section as if it were an insurer.

AB416-ASA1,25,19 (6) Insurer ceasing to issue. (a) An insurer that has in force one or more health benefit plans that are included in a category under s. 632.747 (3) (g) 1. to 3. shall actively market and issue health benefit plans in that category, as provided in s. 632.747, unless the insurer complies with all of the following:

AB416-ASA1,25,21 1. Files notice with the commissioner that the insurer is ceasing to issue health benefit plans in that category.

AB416-ASA1,25,22 2. Ceases to issue health benefit plans in that category for not less than 5 years.

AB416-ASA1,25,25 3. Does not commence marketing or issuing health benefit plans in that category until the insurer files notice with the commissioner that the insurer intends to market and issue such health benefit plans.

AB416-ASA1,26,3 (b) An insurer may not cease to actively market or issue health benefit plans in all categories under s. 632.747 (3) (g) 1. to 3. unless the insurer complies with s. 632.748 (2).

AB416-ASA1,26,6 (7) Additional standards by rule. The commissioner may by rule establish additional standards to provide for the fair marketing and broad availability of health benefit plans to employers and individuals in this state.

AB416-ASA1, s. 29 Section 29. 632.76 (2) (a) of the statutes is amended to read:

AB416-ASA1,26,13 632.76 (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 health benefit plan, as defined in s. 632.745 (1) (d), which is subject to s. 632.745.

AB416-ASA1, s. 30 Section 30. 632.83 of the statutes is created to read:

AB416-ASA1,26,19 632.83 Regulation of certain related policies. The commissioner may by rule prescribe standards for specified disease policies, hospital indemnity policies, as defined in s. 632.895 (1) (c), or limited benefit health policies, including prohibiting certain specified types of products, prescribing minimum coverage and establishing marketing or suitability standards.

AB416-ASA1, s. 31 Section 31. 632.896 (4) of the statutes is amended to read:

AB416-ASA1,27,2 632.896 (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).

AB416-ASA1, s. 32 Section 32. 632.897 (2) (d) of the statutes is amended to read:

AB416-ASA1,27,20 632.897 (2) (d) If the employer is notified to terminate the coverage for any of the reasons provided under par. (b), the employer shall provide the terminated insured written notification of the right to continue group coverage or convert to individual coverage and the payment amounts required for either continued or converted coverage including the manner, place and time in which the payments shall be made. This notice shall be given not more than 5 days after the employer receives notice to terminate coverage. The payment amount for continued group coverage may not exceed the group rate in effect for a group member, including an employer's contribution, if any, for a group policy as defined in sub. (1) (c) 1. or 1m. or the equivalent value of the monthly contribution of a group member to a group policy as defined in sub. (1) (c) 2. or the equivalent value of the monthly premium for franchise insurance as defined in sub. (1) (c) 3. The premium for converted coverage shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risks of each person to be covered under that policy and to the type and amount of coverage provided, subject to s. 632.746 and any rules promulgated under s. 632.7465. The notice may be sent to the terminated insured's home address as shown on the records of the employer.

AB416-ASA1, s. 33 Section 33. 632.897 (9) (c) of the statutes is amended to read:

AB416-ASA1,28,9 632.897 (9) (c) When the insurer is notified that the coverage of a spouse may be terminated because of a divorce or annulment, the insurer shall provide the former spouse written notification of the right to obtain individual coverage under sub. (4), the premium amounts required and the manner, place and time in which premiums may be paid. This notice shall be given not less than 30 days before the former spouse's coverage would otherwise terminate. The premium shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of every person to be covered and to the type and amount of coverage provided, subject to s. 632.746 and any rules promulgated under s. 632.7465. If the former spouse tenders the first monthly premium to the insurer within 30 days after the notice provided by this paragraph, sub. (4) shall apply and the former spouse shall receive individual coverage commencing immediately upon termination of his or her coverage under the insured's policy.