AB416: Bill Text

AB416,8,6 (f) "Qualifying coverage" means benefits or coverage provided under any of the following:

AB416,8,7 1. Medicare or medicaid.

AB416,8,10 2. 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 under subch. II of ch. 635.

AB416,8,13 3. An individual health benefit plan that provides benefits similar to or exceeding benefits provided under a basic health benefit plan under subch. II of ch. 635, if the individual health benefit plan has been in effect for at least one year.

AB416,8,15 (g) "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.

AB416,8,21 (2) Preexisting conditions. 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. A group health benefit plan, or a self-insured health plan, may not define a preexisting condition more restrictively than any of the following:

AB416,8,25 (a) 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 coverage.

AB416,9,3 (b) 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.

AB416,9,4 (c) A pregnancy existing on the effective date of coverage.

AB416,9,10 (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 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.

AB416,9,15 (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.

AB416,9,21 (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.

AB416,9,24 (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.

AB416,10,6 (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.

AB416,10,9 (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.

AB416,10,14 (5) Prohibited coverage practices. (a) 1. 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. 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.

AB416,10,20 2. 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. 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.

AB416,10,24 (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.

AB416,11,4 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, s. 15 Section 15. 632.747 of the statutes is created to read:

AB416,11,11 632.747 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:

AB416,11,12 (a) The employe has satisfied any applicable waiting period.

AB416,11,14 (b) The employer agrees to pay the premium required for coverage of the employe under the group health benefit plan.

AB416,11,20 (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:

AB416,11,22 (a) The eligible employe was covered as a dependent under qualifying coverage when he or she waived coverage under the group health benefit plan.

AB416,12,2 (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 or loss of coverage under the qualifying coverage by the insured under the qualifying coverage.

AB416,12,5 (c) The eligible employe applies for coverage under the group health benefit plan not more than 30 days after termination of his or her coverage under the qualifying coverage.

AB416,12,7 (d) The employer agrees to pay the premium required for coverage of the employe under the group health benefit plan.

AB416,12,13 (3) State or municipal self-insured plans. If the state or a county, city, village, town or school district provides coverage under a self-insured health plan, it shall provide coverage under the self-insured health plan to an eligible employe who waived coverage during an enrollment period during which the employe was entitled to enroll in the self-insured health plan, regardless of health condition or claims experience, if all of the following apply:

AB416,12,15 (a) The eligible employe was covered as a dependent under qualifying coverage when he or she waived coverage under the self-insured health plan.

AB416,12,19 (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 or loss of coverage under the qualifying coverage by the insured under the qualifying coverage.

AB416,12,22 (c) The eligible employe applies for coverage under the self-insured health plan not more than 30 days after termination of his or her coverage under the qualifying coverage.

AB416, s. 16 Section 16. 632.749 of the statutes is created to read:

AB416,13,4 632.749 Contract termination and renewability. (1) Midterm cancellation. Notwithstanding s. 631.36 (2) to (4m), a group health benefit plan may not be canceled by an insurer before the expiration of the agreed term, and shall be renewable to the policyholder and all insureds and dependents eligible under the terms of the group health benefit plan at the expiration of the agreed term at the option of the policyholder, except for any of the following reasons:

AB416,13,5 (a) Failure to pay a premium when due.

AB416,13,7 (b) Fraud or misrepresentation by the policyholder, or, with respect to coverage for an insured individual, fraud or misrepresentation by that insured individual.

AB416,13,8 (c) Substantial breaches of contractual duties, conditions or warranties.

AB416,13,10 (d) The number of individuals covered under the group health benefit plan is less than the number required by the group health benefit plan.

AB416,13,12 (e) The employer to which the group health benefit plan is issued is no longer actively engaged in a business enterprise.

AB416,13,14 (2) Nonrenewal. Notwithstanding sub. (1), an insurer may elect not to renew a group health benefit plan if the insurer complies with all of the following:

AB416,13,16 (a) The insurer ceases to renew all other group health benefit plans issued by the insurer.

AB416,13,19 (b) 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.

AB416,13,21 (c) The insurer does not issue a group health benefit plan before 5 years after the nonrenewal of the group health benefit plans.

AB416,13,25 (d) 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.

AB416,14,2 (3) Insurer in liquidation. This section does not apply to a group health benefit plan if the insurer that issued the group health benefit plan is in liquidation.

AB416, s. 17 Section 17. 632.76 (2) (a) of the statutes is amended to read:

AB416,14,9 632.76 (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 group health benefit plan, as defined in s. 632.745 (1) (c), which is subject to s. 632.745 (2).

AB416, s. 18 Section 18. 632.896 (4) of the statutes is amended to read:

AB416,14,16 632.896 (4) Preexisting conditions. Notwithstanding s. ss. 632.745 (2) and 632.76 (2) (a), 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, s. 19 Section 19. 635.02 (5m) of the statutes is repealed.

AB416, s. 20 Section 20. 635.07 of the statutes is repealed.

AB416, s. 21 Section 21. 635.17 of the statutes is repealed.

AB416, s. 22 Section 22. 635.26 (1) (a) of the statutes is renumbered 635.26 (1).

AB416, s. 23 Section 23. 635.26 (1) (b) of the statutes is repealed.

AB416, s. 24 Section 24. Initial applicability.

AB416,15,2 (1)  This act first applies to group health benefit plans that are issued or renewed, and to self-insured health plans that are extended, modified or renewed under collective bargaining agreements, on the first day of the 12th month beginning after publication.

AB416, s. 25 Section 25. Effective date.

AB416,15,5 (1)  This act takes effect on the first day of the 12th month beginning after publication.

AB416,15,6 (End)