AB416,6,104
628.34
(3) (a) No insurer may unfairly discriminate among policyholders by
5charging different premiums or by offering different terms of coverage except on the
6basis of classifications related to the nature and the degree of the risk covered or the
7expenses involved, subject to
s. ss. 632.365
and 632.745. Rates are not unfairly
8discriminatory if they are averaged broadly among persons insured under a group,
9blanket or franchise policy, and terms are not unfairly discriminatory merely
10because they are more favorable than in a similar individual policy.
AB416, s. 13
11Section
13. 628.34 (3) (b) of the statutes is amended to read:
AB416,6,1712
628.34
(3) (b) No insurer may refuse to insure or refuse to continue to insure,
13or limit the amount, extent or kind of coverage available to an individual, or charge
14an individual a different rate for the same coverage because of a mental or physical
15disability except when the refusal, limitation or rate differential is based on either
16sound actuarial principles supported by reliable data or actual or reasonably
17anticipated experience
, subject to ss. 632.745, 632.747, 632.749, 635.09 and 635.26.
AB416, s. 14
18Section
14. 632.745 of the statutes is created to read:
AB416,6,21
19632.745 Coverage requirements for group health benefit plans. (1) 20Group health insurance market reform; definitions. In this section and ss. 632.747
21and 632.749:
AB416,7,322
(a) "Eligible employe" means an employe who works on a permanent basis and
23has a normal work week of 30 or more hours. The term includes a sole proprietor,
24a business owner, including the owner of a farm business, a partner of a partnership
25and a member of a limited liability company if the sole proprietor, business owner,
1partner or member is included as an employe under a health benefit plan of an
2employer, but the term does not include an employe who works on a temporary or
3substitute basis.
AB416,7,44
(b) "Employer" means any of the following:
AB416,7,75
1. An individual, firm, corporation, partnership, limited liability company or
6association that is actively engaged in a business enterprise in this state, including
7a farm business.
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2. A municipality, as defined in s. 16.70 (8).
AB416,7,1310
(c) "Group health benefit plan" means a health benefit plan that is issued by
11an insurer to an employer on behalf of a group consisting of eligible employes of the
12employer. The term includes individual health benefit plans covering eligible
13employes when 3 or more are sold to an employer.
AB416,7,2214
(d) "Health benefit plan" means any hospital or medical policy or certificate.
15"Health benefit plan" does not include accident-only, credit accident or health,
16dental, vision, medicare supplement, medicare replacement, long-term care,
17disability income or short-term insurance, coverage issued as a supplement to
18liability insurance, worker's compensation or similar insurance, automobile medical
19payment insurance, individual conversion policies, specified disease policies,
20hospital indemnity policies, as defined in s. 632.895 (1) (c), policies or certificates
21issued under the health insurance risk-sharing plan or an alternative plan under
22subch. II of ch. 619 or other insurance exempted by rule of the commissioner.
AB416,8,423
(e) "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).
AB416,8,65
(f) "Qualifying coverage" means benefits or coverage provided under any of the
6following:
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1. Medicare or medicaid.
AB416,8,108
2. 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 under subch. II of ch. 635.
AB416,8,1311
3. An individual health benefit plan that provides benefits similar to or
12exceeding benefits provided under a basic health benefit plan under subch. II of ch.
13635, if the individual health benefit plan has been in effect for at least one year.
AB416,8,1514
(g) "Self-insured health plan" means a self-insured health plan of the state or
15a county, city, village, town or school district.
AB416,8,21
16(2) Preexisting conditions. A group health benefit plan, or a self-insured
17health plan, may not deny, exclude or limit benefits for a covered individual for losses
18incurred more than 12 months after the effective date of the individual's coverage
19due to a preexisting condition. A group health benefit plan, or a self-insured health
20plan, may not define a preexisting condition more restrictively than any of the
21following:
AB416,8,2522
(a) A condition that would have caused an ordinarily prudent person to seek
23medical advice, diagnosis, care or treatment during the 6 months immediately
24preceding the effective date of coverage and for which the individual did not seek
25coverage.
AB416,9,3
1(b) A condition for which medical advice, diagnosis, care or treatment was
2recommended or received during the 6 months immediately preceding the effective
3date of coverage.
AB416,9,44
(c) A pregnancy existing on the effective date of coverage.
AB416,9,10
5(3) Portability. (a) A group health benefit plan, or a self-insured health plan,
6shall waive any period applicable to a preexisting condition exclusion or limitation
7period with respect to particular services for the period that an individual was
8previously covered by qualifying coverage that provided benefits with respect to such
9services, if the qualifying coverage terminated not more than 60 days before the
10effective date of the new coverage.
AB416,9,1511
(b) Paragraph (a) does not prohibit the application of a waiting period to all new
12enrollees under a group health benefit plan or a self-insured health plan; however,
13a waiting period may not be applied when determining whether the qualifying
14coverage terminated not more than 60 days before the effective date of the new
15coverage.
AB416,9,21
16(4) Minimum participation of employes. (a) Except as provided in par. (d),
17requirements used by an insurer in determining whether to provide coverage under
18a group health benefit plan to an employer, including requirements for minimum
19participation of eligible employes and minimum employer contributions, shall be
20applied uniformly among all employers that apply for or receive coverage from the
21insurer.
AB416,9,2422
(b) An insurer may vary its minimum participation requirements and
23minimum employer contribution requirements only by the size of the employer group
24based on the number of eligible employes.
AB416,10,6
1(c) In applying minimum participation requirements with respect to an
2employer, an insurer may not count eligible employes who have other coverage that
3is qualifying coverage in determining whether the applicable percentage of
4participation is met, except that an insurer may count eligible employes who have
5coverage under another health benefit plan that is sponsored by that employer and
6that is qualifying coverage.
AB416,10,97
(d) An insurer may not increase a requirement for minimum employe
8participation or a requirement for minimum employer contribution that applies to
9an employer after the employer has been accepted for coverage.
AB416,10,14
10(5) Prohibited coverage practices. (a) 1. If an insurer offers a group health
11benefit plan to an employer, the insurer shall offer coverage to all of the eligible
12employes of the employer and their dependents. An insurer may not offer coverage
13to only certain individuals in an employer group or to only part of the group, except
14for an eligible employe who has not yet satisfied an applicable waiting period, if any.
AB416,10,2015
2. If the state or a county, city, village, town or school district offers coverage
16under a self-insured health plan, it shall offer coverage to all of its eligible employes
17and their dependents. The state or a county, city, village, town or school district may
18not offer coverage to only certain individuals in the employer group or to only part
19of the group, except for an eligible employe who has not yet satisfied an applicable
20waiting period, if any.
AB416,10,2421
(b) 1. An insurer may not modify a group health benefit plan with respect to
22an employer or an eligible employe or dependent, through riders, endorsements or
23otherwise, to restrict or exclude coverage for certain diseases or medical conditions
24otherwise covered by the group health benefit plan.
AB416,11,4
12. The state or a county, city, village, town or school district may not modify a
2self-insured health plan with respect to an eligible employe or dependent, through
3riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases
4or medical conditions otherwise covered by the self-insured health plan.
AB416, s. 15
5Section
15. 632.747 of the statutes is created to read:
AB416,11,11
6632.747 Guaranteed acceptance. (1) Employe becomes eligible after
7commencement of coverage. If an insurer provides coverage under a group health
8benefit plan, the insurer shall provide coverage under the group health benefit plan
9to an eligible employe who becomes eligible for coverage after the commencement of
10the employer's coverage, and to the eligible employe's dependents, regardless of
11health condition or claims experience, if all of the following apply:
AB416,11,1212
(a) The employe has satisfied any applicable waiting period.
AB416,11,1413
(b) The employer agrees to pay the premium required for coverage of the
14employe under the group health benefit plan.
AB416,11,20
15(2) Employe waived coverage previously. If an insurer provides coverage
16under a group health benefit plan, the insurer shall provide coverage under the
17group health benefit plan to an eligible employe who waived coverage during an
18enrollment period during which the employe was entitled to enroll in the group
19health benefit plan, regardless of health condition or claims experience, if all of the
20following apply:
AB416,11,2221
(a) The eligible employe was covered as a dependent under qualifying coverage
22when he or she waived coverage under the group health benefit plan.
AB416,12,223
(b) The eligible employe's coverage under the qualifying coverage has
24terminated or will terminate due to a divorce from the insured under the qualifying
1coverage, the death of the insured under the qualifying coverage or loss of coverage
2under the qualifying coverage by the insured under the qualifying coverage.
AB416,12,53
(c) The eligible employe applies for coverage under the group health benefit
4plan not more than 30 days after termination of his or her coverage under the
5qualifying coverage.
AB416,12,76
(d) The employer agrees to pay the premium required for coverage of the
7employe under the group health benefit plan.
AB416,12,13
8(3) State or municipal self-insured plans. If the state or a county, city, village,
9town or school district provides coverage under a self-insured health plan, it shall
10provide coverage under the self-insured health plan to an eligible employe who
11waived coverage during an enrollment period during which the employe was entitled
12to enroll in the self-insured health plan, regardless of health condition or claims
13experience, if all of the following apply:
AB416,12,1514
(a) The eligible employe was covered as a dependent under qualifying coverage
15when he or she waived coverage under the self-insured health plan.
AB416,12,1916
(b) The eligible employe's coverage under the qualifying coverage has
17terminated or will terminate due to a divorce from the insured under the qualifying
18coverage, the death of the insured under the qualifying coverage or loss of coverage
19under the qualifying coverage by the insured under the qualifying coverage.
AB416,12,2220
(c) The eligible employe applies for coverage under the self-insured health plan
21not more than 30 days after termination of his or her coverage under the qualifying
22coverage.
AB416, s. 16
23Section
16. 632.749 of the statutes is created to read:
AB416,13,4
24632.749 Contract termination and renewability. (1) Midterm
25cancellation. Notwithstanding s. 631.36 (2) to (4m), a group health benefit plan
1may not be canceled by an insurer before the expiration of the agreed term, and shall
2be renewable to the policyholder and all insureds and dependents eligible under the
3terms of the group health benefit plan at the expiration of the agreed term at the
4option of the policyholder, except for any of the following reasons:
AB416,13,55
(a) Failure to pay a premium when due.
AB416,13,76
(b) Fraud or misrepresentation by the policyholder, or, with respect to coverage
7for an insured individual, fraud or misrepresentation by that insured individual.
AB416,13,88
(c) Substantial breaches of contractual duties, conditions or warranties.
AB416,13,109
(d) The number of individuals covered under the group health benefit plan is
10less than the number required by the group health benefit plan.
AB416,13,1211
(e) The employer to which the group health benefit plan is issued is no longer
12actively engaged in a business enterprise.
AB416,13,14
13(2) Nonrenewal. Notwithstanding sub. (1), an insurer may elect not to renew
14a group health benefit plan if the insurer complies with all of the following:
AB416,13,1615
(a) The insurer ceases to renew all other group health benefit plans issued by
16the insurer.
AB416,13,1917
(b) The insurer provides notice to all affected policyholders and to the
18commissioner in each state in which an affected insured individual resides at least
19one year before termination of coverage.
AB416,13,2120
(c) The insurer does not issue a group health benefit plan before 5 years after
21the nonrenewal of the group health benefit plans.
AB416,13,2522
(d) The insurer does not transfer or otherwise provide coverage to a
23policyholder from the nonrenewed business unless the insurer offers to transfer or
24provide coverage to all affected policyholders from the nonrenewed business without
25regard to claims experience, health condition or duration of coverage.
AB416,14,2
1(3) Insurer in liquidation. This section does not apply to a group health benefit
2plan if the insurer that issued the group health benefit plan is in liquidation.
AB416, s. 17
3Section
17. 632.76 (2) (a) of the statutes is amended to read:
AB416,14,94
632.76
(2) (a) No claim for loss incurred or disability commencing after 2 years
5from the date of issue of the policy may be reduced or denied on the ground that a
6disease or physical condition existed prior to the effective date of coverage, unless the
7condition was excluded from coverage by name or specific description by a provision
8effective on the date of loss.
This paragraph does not apply to a group health benefit
9plan, as defined in s. 632.745 (1) (c), which is subject to s. 632.745 (2).
AB416, s. 18
10Section
18. 632.896 (4) of the statutes is amended to read:
AB416,14,1611
632.896
(4) Preexisting conditions. Notwithstanding
s. ss. 632.745 (2) and 12632.76 (2) (a), a disability insurance policy that is subject to sub. (2) and that is in
13effect when a court makes a final order granting adoption or when the child is placed
14for adoption may not exclude or limit coverage of a disease or physical condition of
15the child on the ground that the disease or physical condition existed before coverage
16is required to begin under sub. (3).
AB416, s. 19
17Section
19. 635.02 (5m) of the statutes is repealed.
AB416, s. 20
18Section
20. 635.07 of the statutes is repealed.
AB416, s. 21
19Section
21. 635.17 of the statutes is repealed.
AB416, s. 22
20Section
22. 635.26 (1) (a) of the statutes is renumbered 635.26 (1).
AB416, s. 23
21Section
23. 635.26 (1) (b) of the statutes is repealed.
AB416,15,2
23(1) This act first applies to group health benefit plans that are issued or
24renewed, and to self-insured health plans that are extended, modified or renewed
1under collective bargaining agreements, on the first day of the 12th month beginning
2after publication.
AB416,15,5
4(1)
This act takes effect on the first day of the 12th month beginning after
5publication.