SB201: Bill Text

SB201, s. 31 Section 31. 635.02 (3m) of the statutes is amended to read:

SB201,15,18 635.02 (3m) "Health benefit plan" means any hospital or medical policy or certificate, and includes a conversion health insurance policy. "Health benefit plan" does not include accident-only, credit, dental, vision, medicare supplement, medicare replacement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, automobile medical payment insurance, 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.

SB201, s. 32 Section 32. 635.02 (4g) of the statutes is created to read:

SB201,16,3 635.02 (4g) "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, or that sells individual health benefit plans to individuals who are residents of 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), 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).

SB201, s. 33 Section 33. 635.02 (4m) of the statutes is repealed.

SB201, s. 34 Section 34. 635.02 (5) of the statutes is repealed.

SB201, s. 35 Section 35. 635.02 (5m) (d) of the statutes is created to read:

SB201,16,8 635.02 (5m) (d) The health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619.

SB201, s. 36 Section 36. 635.02 (6) of the statutes is repealed.

SB201, s. 37 Section 37. 635.02 (6m) of the statutes is amended to read:

SB201,16,14 635.02 (6m) "Restricted network provision" means a provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on obtaining services or articles from health care providers that have contracted with the small employer insurer to provide health care services or articles to covered individuals.

SB201, s. 38 Section 38. 635.02 (7) (intro.) and (a) of the statutes are consolidated, renumbered 635.02 (7) and amended to read:

SB201,16,23 635.02 (7) "Small employer" means any of the following: (a) 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, and an employer that employs in this state not fewer than 2 nor more than 25 eligible employes. In determining the number of eligible employes, employers that are affiliated, or that are eligible to file a combined tax return for purposes of state taxation, shall be considered one employer.

SB201, s. 39 Section 39. 635.02 (7) (b) of the statutes is repealed.

SB201, s. 40 Section 40. 635.02 (8) of the statutes is repealed.

SB201, s. 41 Section 41. 635.03 of the statutes is created to read:

SB201,17,3 635.03 Duties of the board. In addition to any other duties specifically required under this subchapter, the board shall do all of the following:

SB201,17,4 (1) Perform the duties required under subch. II.

SB201,17,5 (2) Provide data or technical assistance to any purchasing coalition.

SB201,17,7 (3) Develop quality outcomes measures, quality and practice pattern standards and health plan performance criteria.

SB201,17,8 (4) Provide information on technology assessment to any purchasing coalition.

SB201,17,10 (5) Recommend cost containment measures and provide assessments of health care needs to any purchasing coalition.

SB201, s. 42 Section 42. 635.05 of the statutes is repealed and recreated to read:

SB201,17,15 635.05 Community rating. (1) Except as provided in subs. (2) and (4), an insurer shall charge a community rate for coverage under a health benefit plan that is subject to this subchapter and that is issued or renewed on or after the effective date of this subsection .... [revisor inserts date].

SB201,17,18 (2) Subject to rate bands prescribed by the commissioner by rule, the community rate under sub. (1) may be modified by taking into account the following factors:

SB201,17,19 (a) The insured's age.

SB201,17,20 (b) The insured's gender.

SB201,17,22 (c) The insured's geographic area, which may not include less than an entire county.

SB201,17,23 (d) The insured's tobacco use.

SB201,17,25 (e) Whether the insured's coverage is single coverage or a type of family coverage.

SB201,18,3 (3) For each of the following factors, the rate bands prescribed by the commissioner by rule may not restrict the ratio of the highest variance to the lowest variance to a ratio that is less than the ratio shown after each factor:

SB201,18,4 (a) For age, a ratio of 2.5.

SB201,18,5 (b) For gender, a ratio of 1.2.

SB201,18,6 (c) For geographic area, a ratio of 1.2.

SB201,18,9 (4) An insurer may provide a rate discount for healthy lifestyle choices on the part of an insured individual that, given the individual's health condition, tend to reduce the risk of loss.

SB201, s. 43 Section 43. 635.06 of the statutes is created to read:

SB201,18,18 635.06 Transition by rule. Notwithstanding s. 635.05 (1) and (2), the commissioner may promulgate rules that permit an insurer to vary from the community rate required under s. 635.05 (1) and modified under s. 635.05 (2) within restrictions provided in the rules. The restrictions provided in the rules shall be reasonably designed to provide for an orderly transition to the community rates required under s. 635.05 (1) and modified under s. 635.05 (2) for all health benefit plans subject to this subchapter by no later than the first day of the 12th month beginning after the effective date of this section .... [revisor inserts date].

SB201, s. 44 Section 44. 635.07 (1) (intro.), (b), (d) and (e) of the statutes are amended to read:

SB201,19,2 635.07 (1) (intro.) Notwithstanding s. 631.36 (2) to (4m), a health benefit plan or policy subject to this subchapter may not be canceled by an insurer before the expiration of the agreed term, and shall be renewable to the employer and all employes policyholder and all insureds and dependents eligible under the terms of the health benefit plan or policy at the expiration of the agreed term at the option of the small employer policyholder, except for any of the following reasons:

SB201,19,5 (b) Fraud or misrepresentation by the small employer policyholder, or, with respect to coverage for an insured individual, fraud or misrepresentation by the that insured individual.

SB201,19,7 (d) The number of individuals covered under the health benefit plan or policy is less than the number required by the health benefit plan or policy.

SB201,19,8 (e) The small employer is no longer actively engaged in a business enterprise.

SB201, s. 45 Section 45. 635.07 (1) (f) of the statutes is created to read:

SB201,19,11 635.07 (1) (f) The health benefit plan is an individual policy and the commissioner permits cancellation or nonrenewal of such a policy by rule.

SB201, s. 46 Section 46. 635.07 (2) of the statutes is amended to read:

SB201,19,15 635.07 (2) Notwithstanding sub. (1), a small employer an insurer may elect not to renew a health insurance benefit plan or policy subject to this subchapter if the small employer insurer complies with all of the following:

SB201,19,18 (a) The small employer insurer ceases to renew all other health benefit plans or policies subject to this subchapter that are issued to all other small employers in the same class of business.

SB201,19,21 (b) The small employer insurer provides notice to all affected small employers policyholders and to the commissioner in each state in which an affected insured individual resides not later than one year before termination of coverage.

SB201,19,24 (c) The small employer insurer does not establish a new class of business issue a health benefit plan subject to this subchapter earlier than 5 years after the nonrenewal of the health benefit plans or policies.

SB201,20,6 (d) The small employer insurer does not transfer or otherwise provide coverage to a small employer policyholder from the nonrenewed class of business unless the small employer insurer offers to transfer or provide coverage to all affected small employers policyholders from the nonrenewed class of business without regard to case characteristics, claim claims experience, health status condition or duration of coverage.

SB201, s. 47 Section 47. 635.07 (3) of the statutes is amended to read:

SB201,20,10 635.07 (3) This section does not apply to a health benefit plan or policy subject to this subchapter if the small employer insurer that issued the policy health benefit plan is in liquidation.

SB201, s. 48 Section 48. 635.09 of the statutes is repealed.

SB201, s. 49 Section 49. 635.11 (intro.), (1) and (4) of the statutes are amended to read:

SB201,20,16 635.11 Disclosure of rating factors and renewability provisions. (intro.) Before the sale of a health benefit plan or policy subject to this subchapter, a small employer an insurer shall disclose to a small employer an applicant all of the following:

SB201,20,18 (1) The small employer insurer's right to increase premium rates and the factors limiting the amount of increase.

SB201,20,19 (4) The small employer's A policyholder's renewability rights.

SB201, s. 50 Section 50. 635.13 (1) of the statutes is amended to read:

SB201,20,25 635.13 (1) Records. A small employer insurer shall maintain at its principal place of business complete and detailed records relating to its rating methods and practices and its renewal underwriting methods and practices, and shall make the records available to the commissioner and the small employer insurance or the board upon request.

SB201, s. 51 Section 51. 635.13 (1) of the statutes, as affected by 1995 Wisconsin Act .... (this act), is repealed and recreated to read:

SB201,21,6 635.13 (1) Records. An insurer shall maintain at its principal place of business complete and detailed records relating to its rating methods and practices and its renewal underwriting methods and practices, and shall make the records available to the commissioner or the board upon request.

SB201, s. 52 Section 52. 635.13 (2) of the statutes is amended to read:

SB201,21,10 635.13 (2) Certification. A small employer An insurer shall file with the commissioner on or before May 1 annually an actuarial opinion by a member of the American academy of actuaries certifying all of the following:

SB201,21,12 (a) That the small employer insurer is in compliance with the rate provisions of s. 635.05 and any rules promulgated under s. 635.06.

SB201,21,14 (b) That the small employer insurer's rating methods are based on generally accepted and sound actuarial principles, policies and procedures.

SB201,21,18 (c) That the opinion is based on the actuary's examination of the small employer insurer's records and a review of the small employer insurer's actuarial assumptions and statistical methods used in setting rates and procedures used in implementing rating plans.

SB201, s. 53 Section 53. 635.15 of the statutes is repealed and recreated to read:

SB201,21,24 635.15 Guaranteed issue. (1) Group health benefit plans. (a) Except as provided in sub. (3), an insurer shall provide coverage under a group health benefit plan that is subject to this subchapter to an employer and to all of the employer's eligible employes and their dependents, regardless of health condition or claims experience, if all of the following apply:

SB201,22,2 1. The insurer has in force a health benefit plan that is subject to this subchapter.

SB201,22,4 2. The employer agrees to pay the premium required for coverage under the group health benefit plan.

SB201,22,7 3. The employer agrees to comply with all other provisions of the group health benefit plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

SB201,22,10 (b) An insurer shall provide coverage under a group health benefit plan that is subject to this subchapter to all of the following, regardless of health condition or claims experience:

SB201,22,12 1. An eligible employe who becomes eligible for coverage after the commencement of the employer's coverage, and the eligible employe's dependents.

SB201,22,16 2. An eligible employe who was excluded from coverage, including an eligible employe with coverage under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619 on or before the effective date of this subdivision .... [revisor inserts date], and the eligible employe's dependents.

SB201,22,20 3. An eligible employe's dependent who was excluded from coverage, including an eligible employe's dependent with coverage under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619 on or before the effective date of this subdivision .... [revisor inserts date].

SB201,22,25 (2) Individual health benefit plans. Except as provided in sub. (3) and notwithstanding s. 632.897 (4) (d), an insurer shall provide coverage under an individual health benefit plan subject to this subchapter to an individual who is a resident of this state, and to the individual's dependents, regardless of health condition or claims experience, if all of the following apply:

SB201,23,2 (a) The insurer has in force a health benefit plan that is subject to this subchapter.

SB201,23,4 (b) The individual agrees to pay the premium required for coverage under the individual health benefit plan.

SB201,23,7 (c) The individual agrees to comply with all other provisions of the individual health benefit plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

SB201,23,12 (3) Exceptions to guaranteed issue. (a) An insurer that is otherwise required to provide coverage under sub. (1) may refuse to issue a group health benefit plan to an employer if all of the individuals in the employer group that are to be covered under the group health benefit plan may be covered under an individual health benefit plan providing single or family coverage.

SB201,23,16 (b) An insurer that is otherwise required to provide coverage under sub. (2) may refuse to provide coverage to an individual if the individual was excluded from coverage under an employer's health benefit plan or self-funded health care plan for reasons related to the individual's health condition.

SB201,23,20 (c) An insurer that is otherwise required to provide coverage under sub. (2) may refuse to provide coverage to an individual if the individual waived coverage under an employer's health benefit plan or self-funded health care plan for reasons related to the individual's health condition.

SB201,23,22 (d) 1. In this paragraph, "municipal" means county, city, village, town or school district.

SB201,24,2 2. Subsections (1) and (2) do not require an insurer to issue coverage that the insurer is not authorized to issue under its bylaws, charter or certificate of incorporation or authority if the insurer is authorized under its bylaws, charter or certificate of incorporation or authority to issue coverage only to state or municipal employes and former employes and their dependents.

SB201,24,6 (e) An insurer that offers health care coverage exclusively to a single category or limited categories of employers may, with prior approval of the commissioner, limit its compliance with subs. (1) and (2) to that single category or those limited categories of employers.

SB201,24,8 (f) The commissioner may exempt an insurer from the requirements of sub. (1) or (2) if the commissioner determines that any of the following applies:

SB201,24,10 1. It is inequitable to apply sub. (1) or (2) to the insurer due to its disproportionate share of groups or individuals with high claims experience.

SB201,24,12 2. It is in the public interest to exempt the insurer from the requirements under sub. (1) or (2) because the insurer is in financially hazardous condition.

SB201,24,14 (g) An insurer may limit its issuance of health benefit plans under subs. (1) and (2) to any of the following: