Amendment SSA1-AB416

AB416-SSA1,48,20 4. 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-SSA1,48,23 (b) Notwithstanding sub. (1m), an insurer that issues individual health benefit plans may elect not to renew an individual health benefit plan if the insurer complies with all of the following:

AB416-SSA1,48,25 1. The insurer ceases to renew all other individual health benefit plans issued by the insurer.

AB416-SSA1,49,3 2. 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.

AB416-SSA1,49,5 3. The insurer does not issue an individual health benefit plan before 5 years after the nonrenewal of the individual health benefit plans.

AB416-SSA1,49,9 4. 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-SSA1,49,11 (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-SSA1,49,14 (4) Applicability to certain government plans. This section does not apply to a 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, s. 85 Section 85. 635.18 (title) of the statutes is amended to read:

AB416-SSA1,49,17 635.18 (title) Fair marketing standards for all group and individual health benefit plans.

AB416-SSA1, s. 86 Section 86. 635.18 (1) of the statutes is renumbered 635.18 (1) (intro.) and amended to read:

AB416-SSA1,50,4 635.18 (1) (intro.) Every small employer insurer that provides coverage under a health benefit plan shall actively market such health benefit plan coverage, including basic health benefit plans, to small employers in the state. If a small employer insurer denies coverage to a small employer under a health benefit plan that is not a basic health benefit plan on the basis of the health status or claims experience of the small employer or its eligible employes or their dependents, the small employer insurer shall offer the small employer the opportunity to purchase a basic health benefit plan. In addition to other marketing limitations that the commissioner may authorize by rule, an insurer may limit its marketing under this subsection to any of the following:

AB416-SSA1, s. 87 Section 87. 635.18 (1) (a) and (b) of the statutes are created to read:

AB416-SSA1,50,6 635.18 (1) (a) Health benefit plans for employer groups of all sizes.

AB416-SSA1,50,7 (b) Health benefit plans for individuals.

AB416-SSA1, s. 88 Section 88. 635.18 (2) of the statutes is amended to read:

AB416-SSA1,50,10 635.18 (2) (a) Except as provided in par. (b), a small employer an insurer or an intermediary may not, directly or indirectly, do any of the following:

AB416-SSA1,50,14 1. Discourage a small an employer or an individual from applying, or direct a small an employer or an individual not to apply, for coverage with the small employer insurer because of the health status condition, claims experience, industry, occupation or geographic location area of the small employer or individual.

AB416-SSA1,50,17 2. Encourage or direct a small an employer or an individual to seek coverage from another insurer because of the health status condition, claims experience, industry, occupation or geographic location area of the small employer or individual.

AB416-SSA1,50,21 (b) Paragraph (a) does not prohibit a small employer an insurer or an intermediary from providing a small an employer or an individual with information about an established geographic service area or a restricted network provision of the small employer insurer.

AB416-SSA1, s. 89 Section 89. 635.18 (3) of the statutes is amended to read:

AB416-SSA1,51,3 635.18 (3) (a) Except as provided in par. (b), a small employer 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 an the intermediary for the sale of a health benefit plan that varies according to the health status condition, claims experience, industry, occupation or geographic location area of the small employer or, eligible employes, insured individual or dependents.

AB416-SSA1,51,7 (b) Payment of compensation on the basis of percentage of premium is not a violation of par. (a) if the percentage does not vary based on the health status condition, claims experience, industry, occupation or geographic area of the small employer or, eligible employes, insured individual or dependents.

AB416-SSA1,51,9 (c) A small employer An insurer shall provide reasonable compensation to an intermediary, if any, for the sale of a basic health benefit plan.

AB416-SSA1, s. 90 Section 90. 635.18 (4) of the statutes is amended to read:

AB416-SSA1,51,15 635.18 (4) A small employer 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 status condition, claims experience, occupation or geographic location area of the small employers or, eligible employes , insured individuals or their dependents placed by the intermediary with the small employer insurer.

AB416-SSA1, s. 91 Section 91. 635.18 (5) of the statutes is amended to read:

AB416-SSA1,51,20 635.18 (5) A small employer An insurer or an intermediary may not induce or otherwise encourage a small an employer to separate or otherwise exclude an employe from health coverage or benefits provided in connection with the employe's employment.

AB416-SSA1, s. 92 Section 92. 635.18 (6) of the statutes is amended to read:

AB416-SSA1,51,24 635.18 (6) Denial by a small employer an insurer of an application for coverage from a small employer under a health benefit plan shall be in writing and shall state the reason or reasons for the denial.

AB416-SSA1, s. 93 Section 93. 635.18 (7) of the statutes is amended to read:

AB416-SSA1,52,5 635.18 (7) A 3rd-party administrator that enters into a contract, agreement or other arrangement with a small employer an insurer to provide administrative, marketing or other services related to the offering of health benefit plans to small employers or individuals in this state is subject to this subchapter as if it were a small employer an insurer.

AB416-SSA1, s. 94 Section 94. 635.18 (8) of the statutes is amended to read:

AB416-SSA1,52,10 635.18 (8) The commissioner may by rule establish additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers and individuals in this state, including requirements designed to prevent evasion of the purposes of this chapter.

AB416-SSA1, s. 95 Section 95. 635.20 (1c) of the statutes is amended to read:

AB416-SSA1,52,12 635.20 (1c) "Dependent" has the meaning given in s. 635.02 (3c) (2).

AB416-SSA1, s. 96 Section 96. 635.20 (1m) of the statutes is repealed and recreated to read:

AB416-SSA1,52,20 635.20 (1m) "Eligible employe" means an employe of a small employer 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 a small employer, but the term does not include an employe who works on a temporary or substitute basis.

AB416-SSA1, s. 97 Section 97. 635.20 (2) of the statutes is amended to read:

AB416-SSA1,52,23 635.20 (2) "Eligible small employer" means an employer that satisfies the requirements of s. 635.25 (1).

AB416-SSA1, s. 98 Section 98. 635.20 (13) of the statutes is repealed and recreated to read:

AB416-SSA1,53,9 635.20 (13) "Small employer 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 small employers in this state, or that sells 3 or more individual health benefit plans to a small employer, covering eligible employes of the small employer. 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), and an insurer operating as a cooperative association organized under ss. 185.981 to 185.985, but does not include a limited service health organization, as defined in s. 609.01 (3).

AB416-SSA1, s. 99 Section 99. 635.23 (1) (a), (d), (dp), (dr) and (e) (intro.), 1., 2. and 3. of the statutes are amended to read:

AB416-SSA1,53,14 635.23 (1) (a) By rule determine the basic benefits that small employer insurers may offer to eligible small employers for providing coverage to eligible employes and their dependents.

AB416-SSA1,53,16 (d) By rule establish small employer eligibility requirements for participation in the plan the purchase of a policy providing the basic benefits.

AB416-SSA1,53,21 (dp) By rule determine whether small employers participating in the plan that purchase a policy providing the basic benefits may impose a probationary or waiting period on employes who become eligible for coverage after the commencement of the small employer's coverage. The plan board may not allow for a probationary or waiting period that exceeds 90 days.

AB416-SSA1,53,23 (dr) By rule determine enrollment periods, if any, for small employer or employe coverage under the plan.

AB416-SSA1,54,3 (e) (intro.) Annually submit a report to the chief clerk of each house of the legislature, for distribution under s. 13.172 (3) to the appropriate standing committees, under s. 13.172 (3) summarizing the activities of the plan board and the operation of the plan in the preceding year, and including but not limited to all of the following:

AB416-SSA1,54,5 1. The number of small employers participating in the plan purchasing a policy providing the basic benefits.

AB416-SSA1,54,7 2. The number of employes and dependents participating in the plan covered under a policy providing the basic benefits.

AB416-SSA1,54,8 3. An evaluation of the plan's operation and, effectiveness and availability.

AB416-SSA1, s. 100 Section 100. 635.23 (4) and (5) of the statutes are amended to read:

AB416-SSA1,54,16 635.23 (4) In the formulation of the plan, for the purpose of cost containment the plan board shall encourage the use, to the extent possible, of the services of health care providers other than physicians. The plan board shall report any recommendations on ways to encourage the use of the services of health care providers other than physicians to the chief clerk of each house of the legislature for distribution under s. 13.172 (3) to the standing committees with jurisdiction over health insurance under s. 13.172 (3).

AB416-SSA1,54,20 (5) The plan board may submit any recommendations for legislation to improve the plan to the chief clerk of each house of the legislature for distribution under s. 13.172 (3) to the standing committees with jurisdiction over health insurance under s. 13.172 (3).

AB416-SSA1, s. 101 Section 101. 635.25 (title) of the statutes is amended to read:

AB416-SSA1,54,22 635.25 (title) Eligibility for participation in plan.

AB416-SSA1, s. 102 Section 102. 635.25 (1) (a) (intro.) of the statutes is amended to read:

AB416-SSA1,54,25 635.25 (1) (a) (intro.) To be eligible to participate in the plan by purchasing purchase a policy under this subchapter containing the basic benefits, an employer:

AB416-SSA1, s. 103 Section 103. 635.25 (1) (b) of the statutes is amended to read:

AB416-SSA1,55,5 635.25 (1) (b) Except as provided in ss. 645.43 and 646.35, an a small employer that purchases a policy under this subchapter containing the basic benefits and that ceases to be eligible to participate in the plan during a policy period shall retain coverage under the plan policy to the end of the policy period.

AB416-SSA1, s. 104 Section 104. 635.25 (1m) of the statutes is amended to read:

AB416-SSA1,55,10 635.25 (1m) Notwithstanding sub. (1), an a small employer is not eligible to participate in the plan purchase a policy under this subchapter containing the basic benefits if all of the individuals to be covered under the plan policy may be covered by a single under an individual policy providing individual single or family coverage.

AB416-SSA1, s. 105 Section 105. 635.25 (2) of the statutes is amended to read:

AB416-SSA1,55,14 635.25 (2) Employes and dependents. (a) All eligible employes of an eligible small employer that participates in the plan purchases a policy under this subchapter are eligible for coverage under the plan policy, subject to the policy terms.

AB416-SSA1,55,16 (b) Any dependent of an eligible employe who is covered under the plan policy is also eligible for coverage under the plan policy, subject to the policy terms.

AB416-SSA1, s. 106 Section 106. 635.254 of the statutes is amended to read:

AB416-SSA1,55,22 635.254 Employer premium contribution. (1) An A small employer that participates in the plan purchases a policy under this subchapter shall pay a premium contribution of not less than 50% of the premium rate on behalf of an eligible employe with individual single coverage and not less than 40% of the premium rate on behalf of an eligible employe with family coverage.

AB416-SSA1,55,25 (2) An A small employer under sub. (1) shall withhold from the earnings of an employe with coverage under the plan policy under this subchapter the amount of premium not contributed by the small employer under sub. (1).

AB416-SSA1,56,5 (3) For an eligible employe who obtains coverage under the health insurance risk-sharing plan under s. 619.12 (2) (e) 2., an a small employer under sub. (1) shall pay a premium contribution to the health insurance risk-sharing plan that is equal to the amount that the small employer would pay on behalf of the employe for coverage under the plan policy under this subchapter.

AB416-SSA1, s. 107 Section 107. 635.26 of the statutes is repealed.

AB416-SSA1, s. 108 Section 108. 635.272 (1) of the statutes is amended to read:

AB416-SSA1,56,12 635.272 (1) Contracting health care providers. A health care provider that contracts with a small employer insurer to provide services to individuals with coverage under the plan a policy under this subchapter shall accept amounts payable under the contract for the basic benefits under the policy as payment in full for those services. This subsection does not affect liability for deductibles or copayments.

AB416-SSA1, s. 109 Section 109. 635.28 of the statutes is amended to read:

AB416-SSA1,56,17 635.28 Liability of state and plan board. Neither the state nor the plan board is liable for any obligation arising under the plan. Plan board members are immune from civil liability for acts or omissions while performing in the performance of their duties under this subchapter.

AB416-SSA1, s. 110 Section 110. 635.29 (title) of the statutes is repealed and recreated to read:

AB416-SSA1,56,19 635.29 (title) Applicability of health insurance mandates.

AB416-SSA1, s. 111 Section 111. Nonstatutory provisions.

AB416-SSA1,57,2 (1)  Risk adjustment committee. The commissioner of insurance shall appoint a committee on risk adjustment under section 15.04 (1) (c) of the statutes, consisting of 5 to 8 members, to advise the commissioner on, and to assist the commissioner in developing rules for, the group risk adjustment mechanism under section 635.07 (4) of the statutes, as affected by this act. The commissioner shall appoint at least 5 representatives of insurers to be members of the committee.

AB416-SSA1,57,10 (2)  Risk adjustment mechanism emergency rule-making authority. Using the procedure under section 227.24 of the statutes, the commissioner of insurance may promulgate rules under section 635.07 (4) (e) of the statutes, as affected by this act, for the period before the effective date of the permanent rules promulgated under section 635.07 (4) (e) of the statutes, as affected by this act, but not to exceed the period authorized under section 227.24 (1) (c) and (2) of the statutes. Notwithstanding section 227.24 (1) and (3) of the statutes, the commissioner is not required to make a finding of emergency.

AB416-SSA1,57,11 (3)  Health insurance risk-sharing plan board member terms.

AB416-SSA1,57,15 (a)  Notwithstanding section 15.07 (1) (c) of the statutes and section 619.15 (1) of the statutes, as affected by this act, the terms of the 7 appointed members currently serving on the board of governors of the health insurance risk-sharing plan shall expire on July 1, 1996.

AB416-SSA1,57,18 (b)  Notwithstanding section 619.15 (1) of the statutes, as affected by this act, the new members of the board of governors of the health insurance risk-sharing plan shall be appointed for the following terms:

AB416-SSA1,57,21 1. One representative of an insurer, one representative of a health care provider and one public member, to be determined by the commissioner, for terms expiring on May 1, 1997.

AB416-SSA1,57,24 2. One representative of an insurer, one representative of a health care provider and one public member, to be determined by the commissioner, for terms expiring on May 1, 1998.

AB416-SSA1,58,3 3. One representative of an insurer, one representative of a health care provider and one public member, to be determined by the commissioner, for terms expiring on May 1, 1999.

AB416-SSA1,58,4 (4)  Study by health insurance risk-sharing plan board.

AB416-SSA1,58,7 (a)  The board of governors of the health insurance risk-sharing plan shall study alternatives for reducing costs under the plan through the use of managed care plans. The board shall study at least all of the following:

AB416-SSA1,58,10 1.  The feasibility of including plan enrollees in the program administered by the department of health and social services that provides health care services to medical assistance recipients through managed care providers.

AB416-SSA1,58,13 2.  The development of a competitive bid process for the provision of covered services to plan enrollees. As part of this requirement, the board shall consider all of the following competitive bidding and pricing alternatives: