AB416-SSA1,20,2013
619.15
(3) (c) Collect assessments from all insurers to provide for claims paid
14under the plan and for administrative expenses incurred or estimated to be incurred
15during the period for which the assessment is made. The level of payments shall be
16established by the board. Assessment of the insurers shall occur at the end of each
17calendar year or other fiscal year end established by the board. Assessments are due
18and payable within 30 days of receipt by the insurer of the assessment notice. This
19paragraph does not apply after 2 years after the effective date of this paragraph ....
20[revisor inserts date].
AB416-SSA1, s. 52
21Section
52. 619.15 (3) (f) and (g) of the statutes are created to read:
AB416-SSA1,20,2422
619.15
(3) (f) Determine the percentage, but not less than 60%, of the operating
23and administrative costs of the plan at which the commissioner must set premium
24rates under s. 619.14 (5) (a).
AB416-SSA1,21,3
1(g) Establish a threshold amount for the household income, as defined in s.
271.52 (5) and as determined under s. 619.165 (1) (d), of an eligible person for purposes
3of determining premium rates under s. 619.14 (5) (a).
AB416-SSA1, s. 53
4Section
53
. 619.15 (4) (c) of the statutes is repealed and recreated to read:
AB416-SSA1,21,85
619.15
(4) (c) Adjust the surcharge amount under sub. (3) (bm) to ensure
6adequate funding for the payment of claims, the operating and administrative
7expenses of the plan and the administrative expenses retained by health care
8providers. This paragraph does not apply after June 30, 2000.
AB416-SSA1, s. 54
9Section
54
. 619.15 (4) (c) of the statutes, as affected by 1995 Wisconsin Act ....
10(this act), is repealed and recreated to read:
AB416-SSA1,21,1811
619.15
(4) (c) In addition to assessments imposed under sub. (3) (c), levy
12interim assessments to ensure the financial ability of the plan to cover claims
13expense and administrative expenses incurred or estimated to be incurred in the
14operation of the plan prior to the end of the calendar year end or other fiscal year end
15established by the board. Interim assessments shall be due and payable within 30
16days of receipt by an insurer of an interim assessment notice. Interim assessments
17shall be credited against each insurer's annual assessment. This paragraph does not
18apply after 2 years after the effective date of this paragraph .... [revisor inserts date].
AB416-SSA1,21,2421
619.15
(4) (e) By rule provide for a reduction in the assessment under s. 619.13
22against an alternative plan that provides coverage to eligible persons. This
23paragraph does not apply after 2 years after the effective date of this paragraph ....
24[revisor inserts date].
AB416-SSA1,22,4
1619.165
(1) (a) The board shall reduce the premiums established by the
2commissioner under s. 619.11 in conformity with ss. 619.14 (5)
, 619.15 (3) (f) and (g) 3and 619.17
or established by the board under s. 619.145 (1m) (c), for the eligible
4persons and in the manner set forth in pars. (b) to (d).
AB416-SSA1,22,86
619.165
(1) (d) The board shall establish and implement the method for
7determining the household income of an eligible person under par. (b)
and under ss.
8619.14 (5) (a) and 619.15 (3) (g).
AB416-SSA1,22,1310
619.165
(2) The board shall direct the administering carrier to collect, under
11s. 619.16 (3) (b), from the eligible persons under sub. (1) the premiums as reduced
12under sub. (1) rather than the premiums established by the commissioner
or by the
13board.
AB416-SSA1,22,1615
619.17
(1) Subject to
s. ss. 619.14 (5) (a)
and 619.15 (3) (f) and (g), a rating plan
16calculated in accordance with generally accepted actuarial principles.
AB416-SSA1,22,22
18619.175 Waiver or exemption from provisions prohibited. Except as
19provided in s. 619.13 (1) (a), the The commissioner may not waive, or authorize the
20board to waive, any of the requirements of this subchapter or exempt, or authorize
21the board to exempt, an individual or a class of individuals from any of the
22requirements of this subchapter.
AB416-SSA1, s. 62
23Section
62
. 619.175 of the statutes, as affected by 1995 Wisconsin Act .... (this
24act), section 61, is repealed and recreated to read:
AB416-SSA1,23,5
1619.175 Waiver or exemption from provisions prohibited. Except as
2provided in s. 619.13 (1) (a), the commissioner may not waive, or authorize the board
3to waive, any of the requirements of this subchapter or exempt, or authorize the
4board to exempt, an individual or a class of individuals from any of the requirements
5of this subchapter.
AB416-SSA1, s. 63
6Section
63
. 619.175 of the statutes, as affected by 1995 Wisconsin Act .... (this
7act), sections 55 and 56, is repealed and recreated to read:
AB416-SSA1,23,11
8619.175 Waiver or exemption from provisions prohibited. The
9commissioner may not waive, or authorize the board to waive, any of the
10requirements of this subchapter or exempt, or authorize the board to exempt, an
11individual or a class of individuals from any of the requirements of this subchapter.
AB416-SSA1,23,2113
625.12
(2) Classification. Risks Subject to s. 635.09, risks may be classified
14in any reasonable way for the establishment of rates and minimum premiums,
15except that no classifications may be based on race, color, creed or national origin,
16and classifications in automobile insurance may not be based on physical condition
17or developmental disability as defined in s. 51.01 (5). Subject to
s. ss. 632.365
and
18635.09, rates thus produced may be modified for individual risks in accordance with
19rating plans or schedules that establish reasonable standards for measuring
20probable variations in hazards, expenses, or both. Rates may also be modified for
21individual risks under s. 625.13 (2).
AB416-SSA1,24,423
628.34
(3) (a) No insurer may unfairly discriminate among policyholders by
24charging different premiums or by offering different terms of coverage except on the
25basis of classifications related to the nature and the degree of the risk covered or the
1expenses involved, subject to
s. ss. 632.365
, 635.03, 635.09 and 635.16. Rates are not
2unfairly discriminatory if they are averaged broadly among persons insured under
3a group, blanket or franchise policy, and terms are not unfairly discriminatory
4merely because they are more favorable than in a similar individual policy.
AB416-SSA1,24,116
628.34
(3) (b) No insurer may refuse to insure or refuse to continue to insure,
7or limit the amount, extent or kind of coverage available to an individual, or charge
8an individual a different rate for the same coverage because of a mental or physical
9disability except when the refusal, limitation or rate differential is based on either
10sound actuarial principles supported by reliable data or actual or reasonably
11anticipated experience
, subject to ss. 635.03 to 635.09, 635.16 and 635.17.
AB416-SSA1,24,14
13632.727 Electronic claims capability. (1) Definition. In this section,
14"health care provider" has the meaning given in s. 146.81 (1) (a) to (m) and (p).
AB416-SSA1,24,16
15(2) Insurers. Beginning on January 1, 1997, every insurer that offers disability
16insurance must have and use the capability to accept all claims electronically.
AB416-SSA1,24,19
17(3) Health care providers. (a) Beginning on January 1, 1997, every health
18care provider that has annual gross revenues of more than $1,000,000 must have and
19use the capability to electronically transmit disability insurance claims information.
AB416-SSA1,24,2220
(b) Beginning on January 1, 1998, every health care provider not specified in
21par. (a) must have and use the capability to electronically transmit disability
22insurance claims information.
AB416-SSA1,25,424
632.76
(2) (a) No claim for loss incurred or disability commencing after 2 years
25from the date of issue of the policy may be reduced or denied on the ground that a
1disease or physical condition existed prior to the effective date of coverage, unless the
2condition was excluded from coverage by name or specific description by a provision
3effective on the date of loss.
This paragraph does not apply to a health benefit plan,
4as defined in s. 635.02 (3), which is subject to s. 635.03 (2) or 635.16 (2).
AB416-SSA1,25,116
632.896
(4) Preexisting conditions. Notwithstanding
s. ss. 632.76 (2) (a)
,
7635.03 (2) and 635.16 (2), a disability insurance policy that is subject to sub. (2) and
8that is in effect when a court makes a final order granting adoption or when the child
9is placed for adoption may not exclude or limit coverage of a disease or physical
10condition of the child on the ground that the disease or physical condition existed
11before coverage is required to begin under sub. (3).
AB416-SSA1, s. 70
12Section
70. Chapter 635 (title) of the statutes is amended to read:
AB416-SSA1,25,15
14SMALL EMPLOYER regulation
15of HEALTH INSURANCE
AB416-SSA1, s. 72
17Section
72. 635.02 of the statutes is repealed and recreated to read:
AB416-SSA1,25,18
18635.02 Definitions. In this subchapter:
AB416-SSA1,25,20
19(1) "Basic health benefit plan" means a small employer health insurance plan
20under subch. II.
AB416-SSA1,25,24
21(2) "Dependent" means a spouse, an unmarried child under the age of 19 years,
22an unmarried child who is a full-time student under the age of 21 years and who is
23financially dependent upon the parent, or an unmarried child of any age who is
24medically certified as disabled and who is dependent upon the parent.
AB416-SSA1,26,10
1(3) "Health benefit plan" means any hospital or medical policy or certificate.
2"Health benefit plan" does not include accident-only, credit accident or health,
3dental, vision, medicare supplement, medicare replacement, long-term care,
4disability income or short-term insurance, coverage issued as a supplement to
5liability insurance, worker's compensation or similar insurance, automobile medical
6payment insurance, student-only medical plans, policies issued to medicaid
7recipients, individual conversion policies, specified disease policies, hospital
8indemnity policies, as defined in s. 632.895 (1) (c), policies or certificates issued under
9the health insurance risk-sharing plan or an alternative plan under subch. II of ch.
10619 or other insurance exempted by rule of the commissioner.
AB416-SSA1,26,14
11(4) "Short-term insurance" means a temporary individual major medical or
12accident insurance policy issued for a term of 6 months or less, except that such a
13policy may be renewed one time at the expiration of the initial term for a term of 6
14months or less.
AB416-SSA1,26,19
15(5) "Student-only medical plan" means a limited nonmedically underwritten
16individual or group health benefit plan that is guaranteed renewable while the
17covered person is enrolled as a regular, full-time undergraduate or graduate student
18at an accredited technical or trade school, college or university and to which any of
19the following applied at issuance:
AB416-SSA1,26,2020
(a) The student was not insured under a health benefit plan.
AB416-SSA1,26,2321
(b) The student was eligible for coverage under a health benefit plan of his or
22her parent, stepparent or guardian but was unable to access the full health benefits
23of the plan due to limitations in the plan's geographic service area.
AB416-SSA1,27,2
1635.03 Coverage requirements for all group health benefit plans. (1) 2Definitions. In this section and s. 635.04:
AB416-SSA1,27,93
(a) 1. Except as provided in subd. 2., "eligible employe" means an employe who
4works on a permanent basis and has a normal workweek of 30 or more hours. The
5term includes a sole proprietor, a business owner, including the owner of a farm
6business, a partner of a partnership and a member of a limited liability company if
7the sole proprietor, business owner, partner or member is included as an employe
8under a health benefit plan of an employer, but the term does not include an employe
9who works on a temporary or substitute basis.
AB416-SSA1,27,1210
2. For purposes of a group health benefit plan, or a self-insured health plan,
11that is offered by the state under s. 40.51 (6) or by the group insurance board under
12s. 40.51 (7), "eligible employe" has the meaning given in s. 40.02 (25).
AB416-SSA1,27,1313
(b) "Employer" means any of the following:
AB416-SSA1,27,1614
1. An individual, firm, corporation, partnership, limited liability company or
15association that is actively engaged in a business enterprise in this state, including
16a farm business.
AB416-SSA1,27,1717
2. A municipality, as defined in s. 16.70 (8).
AB416-SSA1,27,1818
3. The state.
AB416-SSA1,27,2219
(c) "Group health benefit plan" means a health benefit plan that is issued by
20an insurer to an employer on behalf of a group consisting of eligible employes of the
21employer. The term includes individual health benefit plans covering eligible
22employes when 3 or more are sold to an employer.
AB416-SSA1,28,423
(d) "Insurer" means an insurer that is authorized to do business in this state,
24in one or more lines of insurance that includes health insurance, and that offers
25group health benefit plans covering eligible employes of one or more employers in
1this state. The term includes a health maintenance organization, as defined in s.
2609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), an insurer operating
3as a cooperative association organized under ss. 185.981 to 185.985 and a limited
4service health organization, as defined in s. 609.01 (3).
AB416-SSA1,28,65
(e) 1. "Qualifying coverage" means benefits or coverage provided under any of
6the following:
AB416-SSA1,28,77
a. Medicare or medicaid.
AB416-SSA1,28,108
b. A group health benefit plan or an employer-based health benefit
9arrangement that provides benefits similar to or exceeding benefits provided under
10a basic health benefit plan.
AB416-SSA1,28,1311
c. An individual health benefit plan that provides benefits similar to or
12exceeding benefits provided under a basic health benefit plan, if the individual
13health benefit plan has been in effect for at least one year.
AB416-SSA1,28,1614
2. Notwithstanding subd. 1. b. and c., "qualifying coverage" does not include
15catastrophic coverage that is linked to a tax-preferred savings plan for payment of
16medical expenses.
AB416-SSA1,28,1817
(f) "Self-insured health plan" means a self-insured health plan of the state or
18a county, city, village, town or school district.
AB416-SSA1,28,22
19(2) Preexisting conditions. (a) A group health benefit plan, or a self-insured
20health plan, may not deny, exclude or limit benefits for a covered individual for losses
21incurred more than 12 months after the effective date of the individual's coverage
22due to a preexisting condition.
AB416-SSA1,28,2523
(b) Except as provided in par. (c), a group health benefit plan, or a self-insured
24health plan, may not define a preexisting condition more restrictively than any of the
25following:
AB416-SSA1,29,4
11. A condition that would have caused an ordinarily prudent person to seek
2medical advice, diagnosis, care or treatment during the 6 months immediately
3preceding the effective date of coverage and for which the individual did not seek
4medical advice, diagnosis, care or treatment.
AB416-SSA1,29,75
2. A condition for which medical advice, diagnosis, care or treatment was
6recommended or received during the 6 months immediately preceding the effective
7date of coverage.
AB416-SSA1,29,118
(c) Notwithstanding par. (b) 1. and 2., a group health benefit plan, or a
9self-insured health plan, shall exclude pregnancy from the definition of a preexisting
10condition for the purpose of coverage of expenses related to prenatal and postnatal
11care, delivery and any complications of pregnancy.
AB416-SSA1,29,18
12(3) Portability. (a) A group health benefit plan, or a self-insured health plan,
13shall waive any period applicable to a preexisting condition exclusion or limitation
14period with respect to particular services for the period that an individual was
15previously covered by qualifying coverage that was not sponsored by the employer
16sponsoring the group health benefit plan or the self-insured health plan and that
17provided benefits with respect to such services, if the qualifying coverage terminated
18not more than 60 days before the effective date of the new coverage.
AB416-SSA1,29,2319
(b) Paragraph (a) does not prohibit the application of a waiting period to all new
20enrollees under a group health benefit plan or a self-insured health plan; however,
21a waiting period may not be applied when determining whether the qualifying
22coverage terminated not more than 60 days before the effective date of the new
23coverage.
AB416-SSA1,30,4
24(4) Minimum participation of employes. (a) Except as provided in par. (d),
25requirements used by an insurer in determining whether to provide coverage under
1a group health benefit plan to an employer, including requirements for minimum
2participation of eligible employes and minimum employer contributions, shall be
3applied uniformly among all employers that apply for or receive coverage from the
4insurer.
AB416-SSA1,30,75
(b) An insurer may vary its minimum participation requirements and
6minimum employer contribution requirements only by the size of the employer group
7based on the number of eligible employes.
AB416-SSA1,30,138
(c) In applying minimum participation requirements with respect to an
9employer, an insurer may not count eligible employes who have other coverage that
10is qualifying coverage in determining whether the applicable percentage of
11participation is met, except that an insurer may count eligible employes who have
12coverage under another health benefit plan that is sponsored by that employer and
13that is qualifying coverage.
AB416-SSA1,30,1614
(d) An insurer may not increase a requirement for minimum employe
15participation or a requirement for minimum employer contribution that applies to
16an employer after the employer has been accepted for coverage.
AB416-SSA1,30,1817
(e) This subsection does not apply to a group health benefit plan offered by the
18state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).
AB416-SSA1,30,25
19(5) Prohibited coverage practices. (a) 1. Except as provided in rules
20promulgated under subd. 3., if an insurer offers a group health benefit plan to an
21employer, the insurer shall offer coverage to all of the eligible employes of the
22employer and their dependents. Except as provided in rules promulgated under
23subd. 3., an insurer may not offer coverage to only certain individuals in an employer
24group or to only part of the group, except for an eligible employe who has not yet
25satisfied an applicable waiting period, if any.
AB416-SSA1,31,7
12. Except as provided in rules promulgated under subd. 3., if the state or a
2county, city, village, town or school district offers coverage under a self-insured
3health plan, it shall offer coverage to all of its eligible employes and their dependents.
4Except as provided in rules promulgated under subd. 3., the state or a county, city,
5village, town or school district may not offer coverage to only certain individuals in
6the employer group or to only part of the group, except for an eligible employe who
7has not yet satisfied an applicable waiting period, if any.
AB416-SSA1,31,148
3. The secretary of employe trust funds, with the approval of the group
9insurance board, shall promulgate rules related to offering coverage to eligible
10employes under a group health benefit plan, or a self-insured health plan, offered
11by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7). The
12rules shall conform to the intent of subds. 1. and 2. and may not allow the state or
13the group insurance board to refuse to offer coverage to an eligible employe or
14dependent for reasons related to health condition.
AB416-SSA1,31,1815
(b) 1. An insurer may not modify a group health benefit plan with respect to
16an employer or an eligible employe or dependent, through riders, endorsements or
17otherwise, to restrict or exclude coverage for certain diseases or medical conditions
18otherwise covered by the group health benefit plan.
AB416-SSA1,31,2219
2. The state or a county, city, village, town or school district may not modify a
20self-insured health plan with respect to an eligible employe or dependent, through
21riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases
22or medical conditions otherwise covered by the self-insured health plan.
AB416-SSA1,32,223
3. Nothing in this paragraph limits the authority of the group insurance board
24to fulfill its obligations as trustee under s. 40.03 (6) (d) or to design or modify
1procedures or provisions pertaining to enrollment, premium transmitted or coverage
2of eligible employes for health care benefits under s. 40.51 (1).
AB416-SSA1,32,9
4635.04 Guaranteed acceptance. (1) Employe becomes eligible after
5commencement of coverage. If an insurer provides coverage under a group health
6benefit plan, the insurer shall provide coverage under the group health benefit plan
7to an eligible employe who becomes eligible for coverage after the commencement of
8the employer's coverage, and to the eligible employe's dependents, regardless of
9health condition or claims experience, if all of the following apply: