AB416-SSA1,51,1511
635.18
(4) A small employer An insurer may not terminate, fail to renew or
12limit its contract or agreement of representation with an intermediary for any reason
13related to the health
status condition, claims experience, occupation or geographic
14location area of the
small employers
or, eligible employes
, insured individuals or
15their dependents placed by the intermediary with the
small employer insurer.
AB416-SSA1,51,2017
635.18
(5) A small employer An insurer or an intermediary may not induce or
18otherwise encourage
a small an employer to separate or otherwise exclude an
19employe from health coverage or benefits provided in connection with the employe's
20employment.
AB416-SSA1,51,2422
635.18
(6) Denial by
a small employer
an insurer of an application for coverage
23from a small employer under a health benefit plan shall be in writing and shall state
24the reason or reasons for the denial.
AB416-SSA1,52,5
1635.18
(7) A 3rd-party administrator that enters into a contract, agreement
2or other arrangement with
a small employer an insurer to provide administrative,
3marketing or other services related to the offering of health benefit plans to
small 4employers
or individuals in this state is subject to this subchapter as if it were
a small
5employer an insurer.
AB416-SSA1,52,107
635.18
(8) The commissioner may by rule establish additional standards to
8provide for the fair marketing and broad availability of health benefit plans to
small 9employers
and individuals in this state
, including requirements designed to prevent
10evasion of the purposes of this chapter.
AB416-SSA1,52,1212
635.20
(1c) "Dependent" has the meaning given in s. 635.02
(3c) (2).
AB416-SSA1, s. 96
13Section
96. 635.20 (1m) of the statutes is repealed and recreated to read:
AB416-SSA1,52,2014
635.20
(1m) "Eligible employe" means an employe of a small employer who
15works on a permanent basis and has a normal workweek of 30 or more hours. The
16term includes a sole proprietor, a business owner, including the owner of a farm
17business, a partner of a partnership and a member of a limited liability company if
18the sole proprietor, business owner, partner or member is included as an employe
19under a health benefit plan of a small employer, but the term does not include an
20employe who works on a temporary or substitute basis.
AB416-SSA1,52,2322
635.20
(2) "Eligible
small employer" means an employer that satisfies the
23requirements of s. 635.25 (1).
AB416-SSA1, s. 98
24Section
98. 635.20 (13) of the statutes is repealed and recreated to read:
AB416-SSA1,53,9
1635.20
(13) "Small employer insurer" means an insurer that is authorized to
2do business in this state, in one or more lines of insurance that includes health
3insurance, and that offers group health benefit plans covering eligible employes of
4one or more small employers in this state, or that sells 3 or more individual health
5benefit plans to a small employer, covering eligible employes of the small employer.
6The term includes a health maintenance organization, as defined in s. 609.01 (2), a
7preferred provider plan, as defined in s. 609.01 (4), and an insurer operating as a
8cooperative association organized under ss. 185.981 to 185.985, but does not include
9a limited service health organization, as defined in s. 609.01 (3).
AB416-SSA1, s. 99
10Section
99. 635.23 (1) (a), (d), (dp), (dr) and (e) (intro.), 1., 2. and 3. of the
11statutes are amended to read:
AB416-SSA1,53,1412
635.23
(1) (a) By rule determine the basic benefits that small employer insurers
13may offer to eligible
small employers for providing coverage to eligible employes and
14their dependents.
AB416-SSA1,53,1615
(d) By rule establish
small employer eligibility requirements for
participation
16in the plan the purchase of a policy providing the basic benefits.
AB416-SSA1,53,2117
(dp) By rule determine whether
small employers
participating in the plan that
18purchase a policy providing the basic benefits may impose a probationary or waiting
19period on employes who become eligible for coverage after the commencement of the
20small employer's coverage. The plan board may not allow for a probationary or
21waiting period that exceeds 90 days.
AB416-SSA1,53,2322
(dr) By rule determine enrollment periods, if any, for
small employer or
23employe coverage under the plan.
AB416-SSA1,54,324
(e) (intro.) Annually submit a report
to the chief clerk of each house of the
25legislature, for distribution under s. 13.172 (3) to the appropriate standing
1committees
, under s. 13.172 (3) summarizing the activities of the plan board and the
2operation of the plan in the preceding year, and including but not limited to all of the
3following:
AB416-SSA1,54,54
1. The number of small employers
participating in the plan purchasing a policy
5providing the basic benefits.
AB416-SSA1,54,76
2. The number of employes and dependents
participating in the plan covered
7under a policy providing the basic benefits.
AB416-SSA1,54,88
3. An evaluation of the plan's operation
and, effectiveness
and availability.
AB416-SSA1,54,1610
635.23
(4) In the formulation of the plan, for the purpose of cost containment
11the plan board shall encourage the use, to the extent possible, of the services of health
12care providers other than physicians. The plan board shall report any
13recommendations on ways to encourage the use of the services of health care
14providers other than physicians
to the chief clerk of each house of the legislature for
15distribution under s. 13.172 (3) to the standing committees with jurisdiction over
16health insurance
under s. 13.172 (3).
AB416-SSA1,54,20
17(5) The plan board may submit any recommendations for legislation to improve
18the plan
to the chief clerk of each house of the legislature for distribution under s.
1913.172 (3) to the standing committees with jurisdiction over health insurance
under
20s. 13.172 (3).
AB416-SSA1,54,22
22635.25 (title)
Eligibility for participation in plan.
AB416-SSA1, s. 102
23Section
102. 635.25 (1) (a) (intro.) of the statutes is amended to read:
AB416-SSA1,54,2524
635.25
(1) (a) (intro.) To be eligible to
participate in the plan by purchasing 25purchase a policy under this subchapter containing the basic benefits, an employer:
AB416-SSA1,55,52
635.25
(1) (b) Except as provided in ss. 645.43 and 646.35,
an a small employer
3that purchases a policy under this subchapter containing the basic benefits and that
4ceases to be eligible
to participate in the plan during a policy period shall retain
5coverage under the
plan policy to the end of the policy period.
AB416-SSA1,55,107
635.25
(1m) Notwithstanding sub. (1),
an a small employer is not eligible to
8participate in the plan purchase a policy under this subchapter containing the basic
9benefits if all of the individuals to be covered under the
plan policy may be covered
10by a single under an individual policy providing
individual single or family coverage.
AB416-SSA1,55,1412
635.25
(2) Employes and dependents. (a) All eligible employes of an eligible
13small employer that
participates in the plan purchases a policy under this
14subchapter are eligible for coverage under the
plan policy, subject to the policy terms.
AB416-SSA1,55,1615
(b) Any dependent of an eligible employe who is covered under the
plan policy 16is
also eligible for coverage under the
plan policy, subject to the policy terms.
AB416-SSA1,55,22
18635.254 Employer premium contribution. (1) An A small employer that
19participates in the plan purchases a policy under this subchapter shall pay a
20premium contribution of not less than 50% of the premium rate on behalf of an
21eligible employe with
individual single coverage and not less than 40% of the
22premium rate on behalf of an eligible employe with family coverage.
AB416-SSA1,55,25
23(2) An A small employer under sub. (1) shall withhold from the earnings of an
24employe with coverage under the
plan policy under this subchapter the amount of
25premium not contributed by the
small employer under sub. (1).
AB416-SSA1,56,5
1(3) For an eligible employe who obtains coverage under the health insurance
2risk-sharing plan under s. 619.12 (2) (e) 2.,
an
a small employer under sub. (1) shall
3pay a premium contribution to the health insurance risk-sharing plan that is equal
4to the amount that the
small employer would pay on behalf of the employe for
5coverage under the
plan policy under this subchapter.
AB416-SSA1,56,128
635.272
(1) Contracting health care providers. A health care provider that
9contracts with a small employer insurer to provide services to individuals with
10coverage under
the plan a policy under this subchapter shall accept amounts payable
11under the contract for
the basic benefits
under the policy as payment in full for those
12services.
This subsection does not affect liability for deductibles or copayments.
AB416-SSA1,56,17
14635.28 Liability of state and plan board. Neither the state nor the plan
15board is liable for any obligation arising under the plan. Plan board members are
16immune from civil liability for acts or omissions
while performing in the performance
17of their duties under this subchapter.
AB416-SSA1, s. 110
18Section
110. 635.29 (title) of the statutes is repealed and recreated to read:
AB416-SSA1,56,19
19635.29 (title)
Applicability of health insurance mandates.
AB416-SSA1,57,2
21(1) R
isk adjustment committee. The commissioner of insurance shall appoint
22a committee on risk adjustment under section 15.04 (1) (c) of the statutes, consisting
23of 5 to 8 members, to advise the commissioner on, and to assist the commissioner in
24developing rules for, the group risk adjustment mechanism under section 635.07 (4)
1of the statutes, as affected by this act. The commissioner shall appoint at least 5
2representatives of insurers to be members of the committee.
AB416-SSA1,57,10
3(2)
Risk adjustment mechanism emergency rule-making authority. Using the
4procedure under section 227.24 of the statutes, the commissioner of insurance may
5promulgate rules under section 635.07 (4) (e) of the statutes, as affected by this act,
6for the period before the effective date of the permanent rules promulgated under
7section 635.07 (4) (e) of the statutes, as affected by this act, but not to exceed the
8period authorized under section 227.24 (1) (c) and (2) of the statutes.
9Notwithstanding section 227.24 (1) and (3) of the statutes, the commissioner is not
10required to make a finding of emergency.
AB416-SSA1,57,11
11(3)
Health insurance risk-sharing plan board member terms.
AB416-SSA1,57,15
12(a) Notwithstanding section 15.07 (1) (c) of the statutes and section 619.15 (1)
13of the statutes, as affected by this act, the terms of the 7 appointed members
14currently serving on the board of governors of the health insurance risk-sharing
15plan shall expire on July 1, 1996.
AB416-SSA1,57,18
16(b) Notwithstanding section 619.15 (1) of the statutes, as affected by this act,
17the new members of the board of governors of the health insurance risk-sharing plan
18shall be appointed for the following terms:
AB416-SSA1,57,21
191. One representative of an insurer, one representative of a health care provider
20and one public member, to be determined by the commissioner, for terms expiring on
21May 1, 1997.
AB416-SSA1,57,24
222. One representative of an insurer, one representative of a health care provider
23and one public member, to be determined by the commissioner, for terms expiring on
24May 1, 1998.
AB416-SSA1,58,3
13. One representative of an insurer, one representative of a health care provider
2and one public member, to be determined by the commissioner, for terms expiring on
3May 1, 1999.
AB416-SSA1,58,4
4(4)
Study by health insurance risk-sharing plan board.
AB416-SSA1,58,7
5(a) The board of governors of the health insurance risk-sharing plan shall
6study alternatives for reducing costs under the plan through the use of managed care
7plans. The board shall study at least all of the following:
AB416-SSA1,58,10
81. The feasibility of including plan enrollees in the program administered by
9the department of health and social services that provides health care services to
10medical assistance recipients through managed care providers.
AB416-SSA1,58,13
112. The development of a competitive bid process for the provision of covered
12services to plan enrollees. As part of this requirement, the board shall consider all
13of the following competitive bidding and pricing alternatives:
AB416-SSA1,58,14
14a. Fully capitated bids.
AB416-SSA1,58,18
15b. Bids under which the health insurance risk-sharing plan and the health
16care plan providing the covered services share the risk that costs will exceed a
17predetermined amount and the savings when costs are below a predetermined
18amount.
AB416-SSA1,58,19
19c. Bids under which only specified services are provided on a capitated basis.
AB416-SSA1,58,21
20d. Bids under which only identified groups of plan enrollees are covered on a
21capitated basis.
AB416-SSA1,58,24
22(b) The board shall submit a report of the results of the study and its
23recommendations to the legislature under section 13.172 (2) of the statutes no later
24than July 1, 1996.
AB416-SSA1,59,5
1(5)
Rules on health insurance risk-sharing plan managed care initiative.
2The board of governors of the health insurance risk-sharing plan shall submit in
3proposed form the rules required under section 619.145 (1m) of the statutes, as
4created by this act, to the legislative council staff under section 227.15 (1) of the
5statutes no later than January 1, 1997.
AB416-SSA1,59,6
6(6)
Study on establishing a basic health insurance plan.
AB416-SSA1,59,9
7(a) The department of health and social services and the office of the
8commissioner of insurance shall jointly study the establishment of a basic health
9insurance plan. The study shall include consideration of all of the following:
AB416-SSA1,59,13
101. The feasibility of including coverage under the basic health insurance plan
11for different groups of people, including low-income persons, persons with coverage
12under the health insurance risk-sharing plan and recipients of medical assistance
13or health care benefits under another public assistance program.
AB416-SSA1,59,14
142. The benefits to be provided under the basic health insurance plan.
AB416-SSA1,59,18
153. A plan and a timetable for phasing out the imposition of surcharges under
16section 619.13 of the statutes, as affected by this act, for the health insurance
17risk-sharing plan and for replacing the lost revenues with other funds, including
18premiums collected for the basic health insurance plan or state or federal funds.
AB416-SSA1,59,22
19(b) The department of health and social services and the office of the
20commissioner of insurance shall submit a report of the study with their
21recommendations, addressing each of the items under paragraph (a), to the
22legislature under section 13.172 (2) of the statutes no later than January 1, 1997.
AB416-SSA1,59,23
23(7)
Evaluation of market reforms.
AB416-SSA1,60,3
1(a) The commissioner of insurance shall evaluate the effectiveness of the health
2insurance market reforms under chapter 635 of the statutes, as affected by this act,
3including the effectiveness of the reforms with respect to all of the following:
AB416-SSA1,60,5
41. Accessibility of health insurance coverage, including such accessibility for
5persons who reside in rural areas of the state.
AB416-SSA1,60,6
62. Availability of health insurance coverage for uninsured persons.
AB416-SSA1,60,7
73. Affordability of health insurance coverage.
AB416-SSA1,60,10
8(b) The commissioner shall submit a report of the results of the evaluation and
9any recommendations to the legislature under section 13.172 (2) of the statutes no
10later than the first day of the 24th month beginning after publication.
AB416-SSA1,60,22
12(1)
Health insurance market reform. The treatment of sections 40.51 (8) and
13(8m), 111.70 (4) (o), 111.91 (2) (L), 120.13 (2) (g), 185.983 (1g), 625.12 (2), 628.34 (3)
14(a) and (b), 632.76 (2) (a), 632.896 (4), 635.01, 635.02, 635.03, 635.04, 635.05, 635.07,
15635.09, 635.11 (intro.), (1) and (4), 635.13, 635.15, 635.16, 635.17, 635.18 (title), (1)
16(a) and (b), (2), (3), (4), (5), (6), (7) and (8), 635.20 (1c), (1m), (2) and (13), 635.23 (1)
17(a), (d), (dp), (dr) and (e) (intro.), 1., 2. and 3., (4) and (5), 635.25 (1) (a) (intro.) and
18(b), (1m) and (2), 635.254, 635.26, 635.272 (1) and 635.28 of the statutes, the
19renumbering of section 635.18 (1) of the statutes, the amendment of section 66.184
20(1) of the statutes, the repeal and recreation of section 111.70 (1) (a) (by
Section 14
21of the statutes and the creation of section 60.23 (25) (h) and (i) of the statutes first
22apply to all of the following:
AB416-SSA1,60,25
23(a) Except as provided in paragraphs (b) and (c), health benefit plans that are
24issued or renewed, and self-insured health plans that are established, extended,
25modified or renewed, on the effective date of this paragraph.
AB416-SSA1,61,3
1(b) Health benefit plans covering employes who are affected by a collective
2bargaining agreement containing provisions inconsistent with this act that are
3issued or renewed on the earlier of the following:
AB416-SSA1,61,4
41. The day on which the collective bargaining agreement expires.
AB416-SSA1,61,6
52. The day on which the collective bargaining agreement is extended, modified
6or renewed.