Amendment SSA1-SB218

SB218-SSA1,3,24 185.981 (4t) A sickness care plan operated by a cooperative association is subject to ss. 252.14, 631.89, 632.72 (2), 632.745 to 632.749 632.7492, 632.7497 to 632.7499, 632.87 (2m), (3), (4) and (5), 632.895 (10) to (13) and 632.897 (10) and chs. 149 and 155.

SB218-SSA1, s. 8 Section 8. 185.983 (1) (intro.) of the statutes, as affected by 1997 Wisconsin Act 27, section 3134m, is amended to read:

SB218-SSA1,4,8 185.983 (1) (intro.)  Every such voluntary nonprofit sickness care plan shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.89, 631.93, 632.72 (2), 632.745 to 632.749 632.7492, 632.7497 to 632.7499, 632.775, 632.79, 632.795, 632.87 (2m), (3), (4) and (5), 632.895 (5) and (9) to (13), 632.896 and 632.897 (10) and chs. 609, 630, 635, 645 and 646, but the sponsoring association shall:

SB218-SSA1, s. 9 Section 9. 185.983 (1g) of the statutes is repealed.

SB218-SSA1, s. 10 Section 10. 600.01 (2) (b) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,4,14 600.01 (2) (b) Group or blanket insurance described in sub. (1) (b) 3. and 4. is not exempt from ss. 632.745 to 632.749 632.7492 or 632.7497 to 632.7499 or ch. 633 or 635.

SB218-SSA1, s. 11 Section 11. 613.03 (3) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,4,20 613.03 (3) Applicability of insurance laws. Except as otherwise specifically provided, service insurance corporations organized or operating under this chapter are subject to ss. 610.01, 610.11, 610.21, 610.23 and 610.24 and chs. 600, 601, 609, 617, 620, 623, 625, 627, 628, 631, 632, 635 and 645 and to no other insurance laws.

SB218-SSA1, s. 12 Section 12. 625.12 (2) of the statutes is amended to read:

SB218-SSA1,5,5 625.12 (2) Classification. Risks Subject to s. 632.7497, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to s. ss. 632.365 and 632.7497, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

SB218-SSA1, s. 13 Section 13. 628.34 (3) (a) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,5,15 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.745 and 632.746, 632.748, 632.7494 and 632.7497. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

SB218-SSA1, s. 14 Section 14. 628.34 (3) (b) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,5,24 628.34 (3) (b) No insurer may refuse to insure or refuse to continue to insure, or limit the amount, extent or kind of coverage available to an individual, or charge an individual a different rate for the same coverage because of a mental or physical disability except when the refusal, limitation or rate differential is based on either sound actuarial principles supported by reliable data or actual or reasonably anticipated experience, subject to ss. 632.746 to 632.749, 632.7494, 632.7495 and 632.7497.

SB218-SSA1, s. 15 Section 15. 632.745 (intro.) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,6,5 632.745 Coverage requirements for group and individual health benefit plans; definitions. (intro.) In this section and ss. 632.746 to 632.7495 632.7499:

SB218-SSA1, s. 16 Section 16. 632.745 (1m) of the statutes is created to read:

SB218-SSA1,6,9 632.745 (1m) "Base premium rate" means the lowest premium rate chargeable under a rating system to employers or individuals with similar case characteristics and the same or similar benefit design characteristics.

SB218-SSA1, s. 17 Section 17. 632.745 (2m) of the statutes is created to read:

SB218-SSA1,6,13 632.745 (2m) "Benefit design characteristics" means covered services, cost sharing, utilization management, managed care networks and other features that differentiate plan or coverage designs.

SB218-SSA1, s. 18 Section 18. 632.745 (3m) of the statutes is created to read:

SB218-SSA1,6,16 632.745 (3m) "Case characteristics" means the age, gender, geographic location and tobacco use of the individuals covered under a health benefit plan.

SB218-SSA1, s. 19 Section 19. 632.745 (7) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,6,22 632.745 (7) "Enrollment date" means, with respect to an individual covered under a self-insured health plan, group health plan or health insurance, the date of enrollment of the individual under the plan or insurance or, if earlier, the first day of the waiting period for such enrollment.

SB218-SSA1, s. 20 Section 20. 632.745 (7m) of the statutes is created to read:

SB218-SSA1,7,3 632.745 (7m) "Established geographic service area" means a geographic area within which an insurer provides coverage and that has been approved by the commissioner.

SB218-SSA1, s. 21 Section 21. 632.745 (18) (intro.) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,7,9 632.745 (18) (intro.) "Late enrollee" means, with respect to coverage under a self-insured health plan, a group health plan or health insurance coverage, a participant, beneficiary or individual who enrolls under the plan or coverage at any time other than during any of the following:

SB218-SSA1, s. 22 Section 22. 632.745 (18m) of the statutes is created to read:

SB218-SSA1,7,12 632.745 (18m) "Midpoint rate" means the arithmetic average of the base premium rate and the corresponding highest premium rate.

SB218-SSA1, s. 23 Section 23. 632.745 (19m) of the statutes is created to read:

SB218-SSA1,7,16 632.745 (19m) "New business premium rate" means the premium rate charged or offered to employers or individuals with similar case characteristics for newly issued health insurance with the same or similar benefit design characteristics.

SB218-SSA1, s. 24 Section 24. 632.745 (23m) of the statutes is created to read:

SB218-SSA1,7,19 632.745 (23m) "Rating period" means the period, determined by an insurer, during which a premium rate established by the insurer remains in effect.

SB218-SSA1, s. 25 Section 25. 632.745 (23p) of the statutes is created to read:

SB218-SSA1,7,24 632.745 (23p) "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 insurer to provide health care services or articles to covered individuals.

SB218-SSA1, s. 26 Section 26. 632.745 (25) of the statutes, as affected by 1997 Wisconsin Act 27, is repealed and recreated to read:

SB218-SSA1,8,9 632.745 (25) "Small employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 2 but not more than 50 employes on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 2 but not more than 50 employes on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 employes on the first day of the plan year.

SB218-SSA1, s. 27 Section 27. 632.745 (26m) of the statutes is created to read:

SB218-SSA1,8,15 632.745 (26m) "Student-only medical plan" means a limited nonmedically underwritten individual or group health benefit plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate or graduate student at an accredited technical or trade school, college or university and to which any of the following applied at issuance:

SB218-SSA1,8,16 (a) The student was not insured under a health benefit plan.

SB218-SSA1,8,19 (b) The student was eligible for coverage under a health benefit plan of his or her parent, stepparent or guardian but was unable to access the full health benefits of the plan due to limitations in the plan's geographic service area.

SB218-SSA1, s. 28 Section 28. 632.745 (27) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,9,2 632.745 (27) "Waiting period" means, with respect to a self-insured health plan, a group health plan or health insurance coverage and an individual who is a potential participant or beneficiary in the self-insured health plan or group health plan or who is potentially covered by the health insurance coverage, the period that must pass with respect to the individual before the individual is eligible for benefits under the terms of the plan or coverage.

SB218-SSA1, s. 29 Section 29. 632.746 (title) of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,9,6 632.746 (title) Preexisting condition conditions; portability; restrictions; and special enrollment periods for group health benefit plans.

SB218-SSA1, s. 30 Section 30. 632.746 (1) (a) of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,9,15 632.746 (1) (a) Subject to subs. (2) and (3), a self-insured health plan or an insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant's or beneficiary's enrollment date under the plan.

SB218-SSA1, s. 31 Section 31. 632.746 (2) of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,9,20 632.746 (2) An A self-insured health plan or an insurer offering a group health benefit plan may not treat genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

SB218-SSA1,9,23 (b) An A self-insured health plan or an insurer offering a group health benefit plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition.

SB218-SSA1,9,25 (c) Subject to par. (e), a self-insured health plan or an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is born.

SB218-SSA1,10,9 (d) Subject to par. (e), a self-insured health plan or an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is adopted or placed for adoption before attaining the age of 18 years and who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is adopted or placed for adoption. This paragraph does not apply to coverage before the day on which the individual is adopted or placed for adoption.

SB218-SSA1,10,16 (e) Paragraphs (c) and (d) do not apply to an individual after the end of the first continuous period during which the individual was not covered under any creditable coverage for at least 63 days. For purposes of this paragraph, any waiting period or affiliation period for coverage under a self-insured health plan, group health plan or group health benefit plan shall not be taken into account in determining the period before enrollment in the self-insured health plan, group health plan or group health benefit plan.

SB218-SSA1, s. 32 Section 32. 632.746 (3) (a), (b) and (d) 1., of the statutes, as created by 1997 Wisconsin Act 27, are amended to read:

SB218-SSA1,10,22 632.746 (3) (a) The length of time during which any preexisting condition exclusion under sub. (1) may be imposed shall be reduced by the aggregate of the participant's or beneficiary's periods of creditable coverage on his or her enrollment date under the self-insured health plan or group health benefit plan.

SB218-SSA1,11,6 (b) With respect to enrollment of an individual under a self-insured health plan, a group health plan or a group health benefit plan, a period of creditable coverage after which the individual was not covered under any creditable coverage for a period of at least 63 days before enrollment in the self-insured health plan, group health plan or group health benefit plan may not be counted. For purposes of this paragraph, any waiting period or affiliation period for coverage under the self-insured health plan, group health plan or group health benefit plan shall not be taken into account in determining the period before enrollment in the self-insured health plan, group health plan or group health benefit plan.

SB218-SSA1,11,9 (d) 1. An A self-insured health plan or an insurer offering a group health benefit plan shall count a period of creditable coverage without regard to the specific benefits for which the individual had coverage during the period.

SB218-SSA1, s. 33 Section 33. 632.746 (6) of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,11,17 632.746 (6) An A self-insured health plan or an insurer offering a group health benefit plan shall permit an employe who is not enrolled but who is eligible for coverage under the terms of the self-insured health plan or group health benefit plan, or a participant's or employe's dependent who is not enrolled but who is eligible for coverage under the terms of the self-insured health plan or group health benefit plan, to enroll for coverage under the terms of the plan if all of the following apply:

SB218-SSA1,11,20 (a) The employe or dependent was covered under a self-insured health plan or group health plan or had health insurance coverage at the time coverage was previously offered to the employe or dependent.

SB218-SSA1,12,3 (b) The employe or participant stated in writing at the time coverage was previously offered that coverage under a self-insured health plan or group health plan or health insurance coverage was the reason for declining enrollment under the self-insured health plan or insurer's group health benefit plan. This paragraph applies only if the self-insured health plan or insurer required such a statement at the time coverage was previously offered and provided the employe or participant, at the time coverage was previously offered, with notice of the requirement and the consequences of the requirement.

SB218-SSA1,12,8 (c) The employe or dependent is currently covered under the self-insured health plan, group health plan or health insurance or, under the terms of the self-insured health plan or group health benefit plan, the employe or participant requests enrollment no later than 30 days after the date on which the coverage under par. (a) is exhausted or terminated.

SB218-SSA1, s. 34 Section 34. 632.746 (7) (a) (intro.), (b) (intro.) and 1. and (c) 1., of the statutes, as created by 1997 Wisconsin Act 27, are amended to read:

SB218-SSA1,12,13 632.746 (7) (a) (intro.) If par. (b) applies, a self-insured health plan or an insurer offering a group health benefit plan shall provide for a special enrollment period during which any of the following may occur:

SB218-SSA1,12,15 (b) (intro.) An A self-insured health plan or an insurer under par. (a) is required to provide for a special enrollment period if all of the following apply:

SB218-SSA1,12,17 1. The self-insured health plan or group health benefit plan makes coverage available for dependents of participants under the plan.

SB218-SSA1,12,19 (c) 1. The date dependent coverage is made available under the self-insured health plan or group health benefit plan.

SB218-SSA1, s. 35 Section 35. 632.7465 of the statutes is created to read:

SB218-SSA1,13,3 632.7465 Guaranteed issue for group health benefit plans. (1) In this section, "employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 2 but not more than 100 employes on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 2 but not more than 100 employes on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 employes on the first day of the plan year.

SB218-SSA1,13,7 (2) Except as provided in subs. (4) and (5), an insurer shall provide coverage under a group health benefit plan 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:

SB218-SSA1,13,8 (a) The insurer has in force a group health benefit plan.

SB218-SSA1,13,10 (b) The employer agrees to pay the premium required for coverage under the group health benefit plan.

SB218-SSA1,13,13 (c) 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.

SB218-SSA1,13,15 (3) An insurer that provides coverage under sub. (2) may impose payment security provisions that are reasonably related to the risk covered.

SB218-SSA1,13,19 (4) (a) An insurer that is otherwise required to provide coverage under sub. (2) 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 one individual health benefit plan providing family coverage.

SB218-SSA1,13,22 (b) Subsection (2) does 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.

SB218-SSA1,14,2 (c) Subsection (2) does not require an insurer that provides coverage to an employer under a group health benefit plan to issue a different group health benefit plan to the employer before the expiration of the agreed term of the group health benefit plan under which the employer has coverage.

SB218-SSA1,14,6 (d) 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 sub. (2) to that single category or those limited categories of employers.

SB218-SSA1,14,10 (e) The commissioner may exempt an insurer from the requirements of sub. (2) if the commissioner determines that it is in the public interest to exempt the insurer from the requirements under sub. (2) because the insurer is in financially hazardous condition.

SB218-SSA1,14,15 (f) If an employer loses coverage under a group health benefit plan for failure to pay a premium when due, an insurer that is otherwise required to provide coverage under sub. (2) may refuse to issue a group health benefit plan to that employer during the 12-month period beginning on the day on which the employer lost coverage.

SB218-SSA1,14,21 (g) An insurer that previously issued group health benefit plans but, prior to the effective date of this paragraph .... [revisor inserts date], discontinued offering such plans to small employers shall within 60 days after the effective date of this paragraph .... [revisor inserts date], again offer group health benefit plans to small employers or be subject to the requirements under s. 632.749 as if the insurer had elected to discontinue offering a group health benefit plan.

SB218-SSA1,14,24 (5) (a) In this subsection, "high-risk individual" means an individual with a high-risk medical condition who has coverage under a group health benefit plan with a premium rate at the insurer's highest premium rate level.

SB218-SSA1,15,3 (b) An insurer that is otherwise required to provide coverage under sub. (2) shall be exempt from the requirement under sub. (2) for the remainder of a calendar year after all of the following occur:

SB218-SSA1,15,5 1. The number of high-risk individuals covered by the insurer at least equals the threshold level determined under par. (e) 3.

SB218-SSA1,15,12 2. The insurer applies for exemption from the requirement under sub. (2) by certifying its qualification under subd. 1. to the commissioner and the commissioner, within 30 days after the insurer submits its certifying information, makes no objection and does not request additional information. If the commissioner does timely object or request additional information, the insurer shall be exempt from the requirements under sub. (2) 30 days after the commissioner objects or the insurer submits the additional information if the commissioner takes no further action.

SB218-SSA1,15,16 (c) Whenever an insurer becomes exempt from the requirement under sub. (2) by satisfying the criteria under par. (b), the commissioner shall provide notice of that exemption to all insurers offering group health benefit plans to employers in this state and to all insurance agents listed under s. 628.11 by those insurers.

SB218-SSA1,15,19 (d) An insurer that satisfies the criterion under par. (b) 1. is not required to apply for exemption from the requirement under sub. (2). An insurer that does not apply for exemption shall remain subject to the requirement under sub. (2).

SB218-SSA1,15,22 (e) In consultation with the committee on risk adjustment, the commissioner shall promulgate rules for the operation of the risk adjustment mechanism under this subsection, including rules that specify at least all of the following: