Amendment SSA1-AB416

AB416-SSA1,21,8 619.15 (4) (c) Adjust the surcharge amount under sub. (3) (bm) to ensure adequate funding for the payment of claims, the operating and administrative expenses of the plan and the administrative expenses retained by health care providers. This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 54 Section 54 . 619.15 (4) (c) of the statutes, as affected by 1995 Wisconsin Act .... (this act), is repealed and recreated to read:

AB416-SSA1,21,18 619.15 (4) (c) In addition to assessments imposed under sub. (3) (c), levy interim assessments to ensure the financial ability of the plan to cover claims expense and administrative expenses incurred or estimated to be incurred in the operation of the plan prior to the end of the calendar year end or other fiscal year end established by the board. Interim assessments shall be due and payable within 30 days of receipt by an insurer of an interim assessment notice. Interim assessments shall be credited against each insurer's annual assessment. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 55 Section 55. 619.15 (4) (e) of the statutes is repealed.

AB416-SSA1, s. 56 Section 56. 619.15 (4) (e) of the statutes is created to read:

AB416-SSA1,21,24 619.15 (4) (e) By rule provide for a reduction in the assessment under s. 619.13 against an alternative plan that provides coverage to eligible persons. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 57 Section 57. 619.165 (1) (a) of the statutes is amended to read:

AB416-SSA1,22,4 619.165 (1) (a) The board shall reduce the premiums established by the commissioner under s. 619.11 in conformity with ss. 619.14 (5), 619.15 (3) (f) and (g) and 619.17 or established by the board under s. 619.145 (1m) (c), for the eligible persons and in the manner set forth in pars. (b) to (d).

AB416-SSA1, s. 58 Section 58. 619.165 (1) (d) of the statutes is amended to read:

AB416-SSA1,22,8 619.165 (1) (d) The board shall establish and implement the method for determining the household income of an eligible person under par. (b) and under ss. 619.14 (5) (a) and 619.15 (3) (g).

AB416-SSA1, s. 59 Section 59. 619.165 (2) of the statutes is amended to read:

AB416-SSA1,22,13 619.165 (2) The board shall direct the administering carrier to collect, under s. 619.16 (3) (b), from the eligible persons under sub. (1) the premiums as reduced under sub. (1) rather than the premiums established by the commissioner or by the board.

AB416-SSA1, s. 60 Section 60. 619.17 (1) of the statutes is amended to read:

AB416-SSA1,22,16 619.17 (1) Subject to s. ss. 619.14 (5) (a) and 619.15 (3) (f) and (g), a rating plan calculated in accordance with generally accepted actuarial principles.

AB416-SSA1, s. 61 Section 61 . 619.175 of the statutes is amended to read:

AB416-SSA1,22,22 619.175 Waiver or exemption from provisions prohibited. Except as provided in s. 619.13 (1) (a), the The commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.

AB416-SSA1, s. 62 Section 62 . 619.175 of the statutes, as affected by 1995 Wisconsin Act .... (this act), section 61, is repealed and recreated to read:

AB416-SSA1,23,5 619.175 Waiver or exemption from provisions prohibited. Except as provided in s. 619.13 (1) (a), the commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.

AB416-SSA1, s. 63 Section 63 . 619.175 of the statutes, as affected by 1995 Wisconsin Act .... (this act), sections 55 and 56, is repealed and recreated to read:

AB416-SSA1,23,11 619.175 Waiver or exemption from provisions prohibited. The commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.

AB416-SSA1, s. 64 Section 64. 625.12 (2) of the statutes is amended to read:

AB416-SSA1,23,21 625.12 (2) Classification. Risks Subject to s. 635.09, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to s. ss. 632.365 and 635.09, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB416-SSA1, s. 65 Section 65. 628.34 (3) (a) of the statutes is amended to read:

AB416-SSA1,24,4 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to s. ss. 632.365, 635.03, 635.09 and 635.16. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB416-SSA1, s. 66 Section 66. 628.34 (3) (b) of the statutes is amended to read:

AB416-SSA1,24,11 628.34 (3) (b) No insurer may refuse to insure or refuse to continue to insure, or limit the amount, extent or kind of coverage available to an individual, or charge an individual a different rate for the same coverage because of a mental or physical disability except when the refusal, limitation or rate differential is based on either sound actuarial principles supported by reliable data or actual or reasonably anticipated experience, subject to ss. 635.03 to 635.09, 635.16 and 635.17.

AB416-SSA1, s. 67 Section 67. 632.727 of the statutes is created to read:

AB416-SSA1,24,14 632.727 Electronic claims capability. (1) Definition. In this section, "health care provider" has the meaning given in s. 146.81 (1) (a) to (m) and (p).

AB416-SSA1,24,16 (2) Insurers. Beginning on January 1, 1997, every insurer that offers disability insurance must have and use the capability to accept all claims electronically.

AB416-SSA1,24,19 (3) Health care providers. (a) Beginning on January 1, 1997, every health care provider that has annual gross revenues of more than $1,000,000 must have and use the capability to electronically transmit disability insurance claims information.

AB416-SSA1,24,22 (b) Beginning on January 1, 1998, every health care provider not specified in par. (a) must have and use the capability to electronically transmit disability insurance claims information.

AB416-SSA1, s. 68 Section 68. 632.76 (2) (a) of the statutes is amended to read:

AB416-SSA1,25,4 632.76 (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. 635.02 (3), which is subject to s. 635.03 (2) or 635.16 (2).

AB416-SSA1, s. 69 Section 69. 632.896 (4) of the statutes is amended to read:

AB416-SSA1,25,11 632.896 (4) Preexisting conditions. Notwithstanding s. ss. 632.76 (2) (a), 635.03 (2) and 635.16 (2), 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-SSA1, s. 70 Section 70. Chapter 635 (title) of the statutes is amended to read:

AB416-SSA1,25,13 CHAPTER 635

AB416-SSA1,25,15 SMALL EMPLOYER regulation of HEALTH INSURANCE

AB416-SSA1, s. 71 Section 71. 635.01 of the statutes is repealed.

AB416-SSA1, s. 72 Section 72. 635.02 of the statutes is repealed and recreated to read:

AB416-SSA1,25,18 635.02 Definitions. In this subchapter:

AB416-SSA1,25,20 (1) "Basic health benefit plan" means a small employer health insurance plan under subch. II.

AB416-SSA1,25,24 (2) "Dependent" means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.

AB416-SSA1,26,10 (3) "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, student-only medical plans, policies issued to medicaid recipients, 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.

AB416-SSA1,26,14 (4) "Short-term insurance" means a temporary individual major medical or accident insurance policy issued for a term of 6 months or less, except that such a policy may be renewed one time at the expiration of the initial term for a term of 6 months or less.

AB416-SSA1,26,19 (5) "Student-only medical plan" means a limited nonmedically underwritten individual or group health benefit plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate or graduate student at an accredited technical or trade school, college or university and to which any of the following applied at issuance:

AB416-SSA1,26,20 (a) The student was not insured under a health benefit plan.

AB416-SSA1,26,23 (b) The student was eligible for coverage under a health benefit plan of his or her parent, stepparent or guardian but was unable to access the full health benefits of the plan due to limitations in the plan's geographic service area.

AB416-SSA1, s. 73 Section 73. 635.03 of the statutes is created to read:

AB416-SSA1,27,2 635.03 Coverage requirements for all group health benefit plans. (1) Definitions. In this section and s. 635.04:

AB416-SSA1,27,9 (a) 1. Except as provided in subd. 2., "eligible employe" means an employe who works on a permanent basis and has a normal workweek of 30 or more hours. The term includes a sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership and a member of a limited liability company if the sole proprietor, business owner, partner or member is included as an employe under a health benefit plan of an employer, but the term does not include an employe who works on a temporary or substitute basis.

AB416-SSA1,27,12 2. For purposes of a group health benefit plan, or a self-insured health plan, that is offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7), "eligible employe" has the meaning given in s. 40.02 (25).

AB416-SSA1,27,13 (b) "Employer" means any of the following:

AB416-SSA1,27,16 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.

AB416-SSA1,27,17 2. A municipality, as defined in s. 16.70 (8).

AB416-SSA1,27,18 3. The state.

AB416-SSA1,27,22 (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.

AB416-SSA1,28,4 (d) "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).

AB416-SSA1,28,6 (e) 1. "Qualifying coverage" means benefits or coverage provided under any of the following:

AB416-SSA1,28,7 a. Medicare or medicaid.

AB416-SSA1,28,10 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.

AB416-SSA1,28,13 c. An individual health benefit plan that provides benefits similar to or exceeding benefits provided under a basic health benefit plan, if the individual health benefit plan has been in effect for at least one year.

AB416-SSA1,28,16 2. Notwithstanding subd. 1. b. and c., "qualifying coverage" does not include catastrophic coverage that is linked to a tax-preferred savings plan for payment of medical expenses.

AB416-SSA1,28,18 (f) "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.

AB416-SSA1,28,22 (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.

AB416-SSA1,28,25 (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:

AB416-SSA1,29,4 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.

AB416-SSA1,29,7 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.

AB416-SSA1,29,11 (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.

AB416-SSA1,29,18 (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.

AB416-SSA1,29,23 (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.

AB416-SSA1,30,4 (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.

AB416-SSA1,30,7 (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.

AB416-SSA1,30,13 (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.

AB416-SSA1,30,16 (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.

AB416-SSA1,30,18 (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).

AB416-SSA1,30,25 (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.

AB416-SSA1,31,7 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.

AB416-SSA1,31,14 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.

AB416-SSA1,31,18 (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.

AB416-SSA1,31,22 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.

AB416-SSA1,32,2 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).

AB416-SSA1, s. 74 Section 74. 635.04 of the statutes is created to read:

AB416-SSA1,32,9 635.04 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:

AB416-SSA1,32,10 (a) The employe has satisfied any applicable waiting period.

AB416-SSA1,32,12 (b) The employer agrees to pay the premium required for coverage of the employe under the group health benefit plan.

AB416-SSA1,32,18 (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:

AB416-SSA1,32,20 (a) The eligible employe was covered as a dependent under qualifying coverage when he or she waived coverage under the group health benefit plan.

AB416-SSA1,32,25 (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.