635.18
635.18
Fair marketing standards. 635.18(1)(1) Every small employer insurer shall actively market 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.
635.18(2)(a)(a) Except as provided in
par. (b), a small employer insurer or an intermediary may not, directly or indirectly, do any of the following:
635.18(2)(a)1.
1. Discourage a small employer from applying, or direct a small employer not to apply, for coverage with the small employer insurer because of the health status, claims experience, industry, occupation or geographic location of the small employer.
635.18(2)(a)2.
2. Encourage or direct a small employer to seek coverage from another insurer because of the health status, claims experience, industry, occupation or geographic location of the small employer.
635.18(2)(b)
(b) Paragraph (a) does not prohibit a small employer insurer or an intermediary from providing a small employer with information about an established geographic service area or a restricted network provision of the small employer insurer.
635.18(3)(a)(a) Except as provided in
par. (b), a small employer 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 intermediary for the sale of a health benefit plan that varies according to the health status, claims experience, industry, occupation or geographic location of the small employer or eligible employes or dependents.
635.18(3)(b)
(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, claims experience, industry, occupation or geographic area of the small employer or eligible employes or dependents.
635.18(3)(c)
(c) A small employer insurer shall provide reasonable compensation to an intermediary, if any, for the sale of a basic health benefit plan.
635.18(4)
(4) A small employer 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, claims experience, occupation or geographic location of the small employers or eligible employes or their dependents placed by the intermediary with the small employer insurer.
635.18(5)
(5) A small employer insurer or an intermediary may not induce or otherwise encourage a small employer to separate or otherwise exclude an employe from health coverage or benefits provided in connection with the employe's employment.
635.18(6)
(6) Denial by a small employer insurer of an application for coverage from a small employer shall be in writing and shall state the reason or reasons for the denial.
635.18(7)
(7) A 3rd-party administrator that enters into a contract, agreement or other arrangement with a small employer insurer to provide administrative, marketing or other services related to the offering of health benefit plans to small employers in this state is subject to this subchapter as if it were a small employer insurer.
635.18(8)
(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 in this state.
635.18 History
History: 1991 a. 250,
315.
SMALL EMPLOYER HEALTH INSURANCE PLAN
635.20
635.20
Definitions. In this subchapter:
635.20(1)
(1) "Basic benefits" means the minimum benefits established by the plan board under
ss. 635.21 and
635.23 (1) (a), and includes all health insurance mandates to the extent determined by the plan board under
s. 635.23 (1) (b).
635.20(2)
(2) "Eligible employer" means an employer that satisfies the requirements of
s. 635.25 (1).
635.20(10)
(10) "Plan" means the health insurance plan for individuals employed by small employers that is created under
s. 635.21 and that consists of a policy under this subchapter containing the basic benefits.
635.20(11)
(11) "Plan board" means the small employer insurance board.
635.20(12)
(12) "Small employer" means any of the following:
635.20(12)(a)
(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 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.
635.20(12)(b)
(b) A village or town that employs not fewer than 2 nor more than 10 eligible employes and that has not provided health insurance coverage to its eligible employes at any time during the past 12 months.
635.20 History
History: 1991 a. 250;
1993 a. 112.
635.21
635.21
Establishment of plan. There is established a plan of health insurance coverage for individuals employed by small employers. The plan board shall formulate, supervise and modify the plan as needed, and shall promulgate rules regarding the establishment and administration of the plan.
635.21 History
History: 1991 a. 250.
635.23
635.23
Duties of plan board. 635.23(1)(a)
(a) By rule determine the basic benefits that small employer insurers may offer to eligible employers for providing coverage to eligible employes and their dependents.
635.23(1)(b)
(b) By rule establish the extent to which the plan shall comply with the health insurance mandates, without elimination of any of those mandates.
635.23(1)(c)
(c) By rule formulate minimum benefit standards for policies providing the basic benefits.
635.23(1)(d)
(d) By rule establish employer eligibility requirements for participation in the plan.
635.23(1)(dm)
(dm) By rule establish deductibles, copayment and maximum payment requirements for policies providing the basic benefits.
635.23(1)(dp)
(dp) By rule determine whether employers participating in the plan may impose a probationary or waiting period on employes who become eligible for coverage after the commencement of the employer's coverage. The plan board may not allow for a probationary or waiting period that exceeds 90 days.
635.23(1)(dr)
(dr) By rule determine enrollment periods, if any, for employer or employe coverage under the plan.
635.23(1)(e)
(e) 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, 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:
635.23(1)(e)1.
1. The number of small employers participating in the plan.
635.23(1)(e)2.
2. The number of employes and dependents participating in the plan.
635.23(1)(e)3.
3. An evaluation of the plan's operation and effectiveness.
635.23(1m)
(1m) The plan board may by rule establish plan features in addition to those specified in
sub. (1).
635.23(1r)
(1r) All aspects of the composition and operation of the plan that are established by the plan board shall be established by rule.
635.23(2)
(2) All rules promulgated by the plan board are subject to approval by the commissioner.
635.23(3)
(3) All final decisions of the plan board under this section concerning the formulation, supervision and modification of the plan shall be adopted by a vote of not less than 8 members of the plan board's current voting membership.
635.23(4)
(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.
635.23(5)
(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.
635.23 History
History: 1991 a. 250.
635.25
635.25
Eligibility for participation in plan. 635.25(1)(a)(a) To be eligible to participate in the plan by purchasing a policy under this subchapter containing the basic benefits, an employer:
635.25(1)(a)2.
2. Must comply with any other eligibility requirements specified by the plan board.
635.25(1)(b)
(b) Except as provided in
ss. 645.43 and
646.35, an 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 to the end of the policy period.
635.25(1m)
(1m) Notwithstanding
sub. (1), an employer is not eligible to participate in the plan if all of the individuals to be covered under the plan may be covered by a single policy providing individual or family coverage.
635.25(2)(a)(a) All eligible employes of an eligible employer that participates in the plan are eligible for coverage under the plan, subject to the policy terms.
635.25(2)(b)
(b) Any dependent of an eligible employe who is covered under the plan is eligible for coverage under the plan, subject to the policy terms.
635.25 History
History: 1991 a. 250.
635.254
635.254
Employer premium contribution. 635.254(1)
(1) An employer that participates in the plan shall pay a premium contribution of not less than 50% of the premium rate on behalf of an eligible employe with individual coverage and not less than 40% of the premium rate on behalf of an eligible employe with family coverage.
635.254(2)
(2) An employer under
sub. (1) shall withhold from the earnings of an employe with coverage under the plan the amount of premium not contributed by the employer under
sub. (1).
635.254(3)
(3) For an eligible employe who obtains coverage under the health insurance risk-sharing plan under
s. 619.12 (2) (e) 2., an employer under
sub. (1) shall pay a premium contribution to the health insurance risk-sharing plan that is equal to the amount that the employer would pay on behalf of the employe for coverage under the plan under this subchapter.
635.254 History
History: 1991 a. 250.
635.26
635.26
Guaranteed issue. 635.26(1)(1) Except as provided in
subs. (2m) to
(4), a small employer insurer shall provide coverage under the plan, regardless of health status or claims experience, to an eligible employer and to all of its eligible employes and their dependents if all of the following apply:
635.26(1)(a)
(a) The employer agrees to pay the premium required for coverage under the plan.
635.26(1)(b)
(b) The employer agrees to comply with all other plan provisions that apply generally to a policyholder or an insured without regard to health status or claims experience.
Effective date note
NOTE: Sub. (1) is shown as affected eff. 5-1-97 by
1995 Wis. Act 289. Prior to 5-1-97 it reads:
Effective date text
(1) (a) Except as provided in subs. (2m) to (4), a small employer insurer shall provide coverage under the plan, regardless of health status or claims experience, to an eligible employer and to all of its eligible employes and their dependents if all of the following apply:
635.26 Note
1. The employer agrees to pay the premium required for coverage under the plan.
635.26 Note
2. The employer agrees to comply with all other plan provisions that apply generally to a policyholder or an insured without regard to health status or claims experience.
635.26 Note
(b) Except as provided in subs. (2m) to (4), a small employer insurer shall provide coverage under the plan, regardless of health status or claims experience, to an eligible employe who becomes eligible for coverage after the commencement of the employer's coverage, and to the eligible employe's dependents, if all of the following apply:
635.26 Note
1. The employe applies for coverage under the plan before the expiration of any applicable enrollment period, if any, required under the plan.
635.26 Note
2. The employer agrees to pay the premium required for coverage of the employe under the plan.
635.26(1m)
(1m) A small employer insurer shall be in compliance with
sub. (1) if it issues a policy that complies with the plan and the minimum benefit standards determined by the plan board under
s. 635.23 (1) (c) but that includes only the basic benefits.
635.26(1s)
(1s) Nothing in
sub. (1) prohibits a small employer insurer that provides coverage under
sub. (1) from imposing preexisting condition provisions, waiting period requirements, or other provisions or requirements related to health status or claims experience, that are permitted or required under the plan.
635.26(2)
(2) A small employer insurer that provides coverage under
sub. (1) may impose payment security provisions reasonably related to the risk covered.
635.26(2m)
(2m) Nothing in
sub. (1) requires a small employer insurer to issue coverage that the small employer insurer is not authorized to issue under its bylaws, charter or certificate of incorporation or authority.
635.26(3)
(3) Subsection (1) does not apply to a small employer insurer if the commissioner determines that any of the following applies:
635.26(3)(a)
(a) It is inequitable to apply
sub. (1) to the small employer insurer due to its disproportionate share of groups with high claims experience.
635.26(3)(b)
(b) It is in the public interest to exempt the small employer insurer from the requirement under
sub. (1) because the small employer insurer is in financially hazardous condition.
