Amendment SSA1-SB218

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:

SB218-SSA1,15,24 1. What diagnostic conditions constitute high-risk medical conditions for purposes of the definition of a high-risk individual.

SB218-SSA1,16,2 2. How to determine an insurer's highest premium rate level for purposes of the definition of a high-risk individual.

SB218-SSA1,16,4 3. What percentage of an insurer's total enrollment under group health benefit plans issued by the insurer constitutes the threshold level for purposes of par. (b) 1.

SB218-SSA1, s. 36 Section 36. 632.747 (title) of the statutes is amended to read:

SB218-SSA1,16,7 632.747 (title) Guaranteed acceptance under group health benefit plans.

SB218-SSA1, s. 37 Section 37. 632.748 (title) of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,16,10 632.748 Prohibiting discrimination under group health benefit plans.

SB218-SSA1, s. 38 Section 38. 632.748 (4) (c) of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,16,14 632.748 (4) (c) Provide an exception from, or limit, the rate regulation under s. 635.05 632.7497.

SB218-SSA1, s. 39 Section 39. 632.749 (title) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,16,18 632.749 (title) Contract termination and renewability for group health benefit plans.

SB218-SSA1, s. 40 Section 40. 632.749 (2) (e) of the statutes, as affected by 1997 Wisconsin Act 27, is amended to read:

SB218-SSA1,16,25 632.749 (2) (e) In the case of a group health benefit plan that the insurer offers through a network plan, there is no longer an enrollee under the plan who resides, lives or works in the service area of the insurer or in an area in which the insurer is authorized to do business and, in the case of the small group market, the insurer would deny enrollment under the plan under s. 635.19 (2) (a) 1.

SB218-SSA1, s. 41 Section 41. 632.7491 of the statutes is created to read:

SB218-SSA1,17,4 632.7491 Disclosure of rating factors and renewability provisions for group health benefit plans. (1) Before the sale of a group health benefit plan, an insurer shall disclose to an employer all of the following:

SB218-SSA1,17,6 (a) The insurer's right to increase premium rates and any factors limiting the amount of increase.

SB218-SSA1,17,8 (b) The extent to which benefit design characteristics and case characteristics affect premium rates.

SB218-SSA1,17,10 (c) The extent to which rating factors and changes in benefit design benefit design characteristics and case characteristics affect changes in premium rates.

SB218-SSA1,17,11 (d) The employer's renewability rights.

SB218-SSA1,17,13 (e) As part of the insurer's solicitation and sales materials, the availability of the information under par. (f).

SB218-SSA1,17,14 (f) Upon the request of the employer, the following information:

SB218-SSA1,17,16 1. The provisions, if any, of the plan or policy relating to preexisting condition exclusions.

SB218-SSA1,17,18 2. The benefits and premiums available under all health insurance coverage offered by the insurer for which the employer is qualified.

SB218-SSA1,17,22 (2) Information required to be disclosed under this section shall be provided in a manner that is understandable to an employer and shall be sufficient to reasonably inform an employer of the employer's rights and obligations under the health insurance coverage.

SB218-SSA1,17,24 (3) An insurer is not required under this section to disclose information that is proprietary or trade secret information under applicable law.

SB218-SSA1, s. 42 Section 42. 632.7492 of the statutes is created to read:

SB218-SSA1,18,7 632.7492 Annual certification of compliance for group health benefit plans. (1) Records. An insurer that issues group health benefit plans to employers, as defined in s. 632.7497 (1), shall maintain at its principal place of business complete and detailed records with respect to those group health benefit plans relating to its rating methods and practices and its renewal underwriting methods and practices, and shall make the records available to the commissioner upon request.

SB218-SSA1,18,12 (2) Certification. An insurer that issues group health benefit plans to employers, as defined in s. 632.7497 (1), 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 with respect to those group health benefit plans:

SB218-SSA1,18,13 (a) That the insurer is in compliance with the rate provisions of s. 632.7497.

SB218-SSA1,18,15 (b) That the insurer's rating methods are based on generally accepted and sound actuarial principles, policies and procedures.

SB218-SSA1,18,18 (c) That the opinion is based on the actuary's examination of the insurer's records and a review of the insurer's actuarial assumptions and statistical methods used in setting rates and procedures used in implementing rating plans.

SB218-SSA1, s. 43 Section 43. 632.7494 of the statutes is created to read:

SB218-SSA1,18,23 632.7494 Preexisting conditions and portability for individual health benefit plans. (1) (a) An individual health benefit plan may not impose a preexisting condition exclusion with respect to a covered individual for losses incurred more than 12 months after the individual's enrollment date under the plan.

SB218-SSA1,18,25 (b) An individual health benefit plan may not define a preexisting condition more restrictively than any of the following:

SB218-SSA1,19,4 1. A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 18 months immediately preceding the individual's enrollment date under the plan and for which the individual did not seek medical advice, diagnosis, care or treatment.

SB218-SSA1,19,7 2. A condition for which medical advice, diagnosis, care or treatment was recommended or received during the 18 months immediately preceding the individual's enrollment date under the plan.

SB218-SSA1,19,10 (c) Notwithstanding pars. (a) and (b), an individual health benefit plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition.

SB218-SSA1,19,15 (2) An individual health benefit plan shall waive any period applicable to a preexisting condition exclusion period with respect to particular services for the period that the individual was covered with respect to those services under creditable coverage, if the creditable coverage terminated not more than 31 days before the individual applied for coverage under the individual health benefit plan.

SB218-SSA1, s. 44 Section 44. 632.7497 of the statutes is created to read:

SB218-SSA1,19,24 632.7497 Rate regulation for individual and 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-SSA1,20,2 (2) Notwithstanding ch. 625, the commissioner shall promulgate rules that do all of the following:

SB218-SSA1,20,7 (a) Establish restrictions on premium rates that an insurer may charge an employer for coverage under a group health benefit plan such that the premium rates charged to employers with similar case characteristics for the same or similar benefit design characteristics do not vary from the midpoint rate for those employers by more than 30% of that midpoint rate.

SB218-SSA1,20,12 (b) Establish restrictions on premium rates that an insurer may charge an individual for coverage under an individual health benefit plan such that the premium rates charged to individuals with similar case characteristics for the same or similar benefit design characteristics do not vary from the midpoint rate for those individuals by more than 35% of that midpoint rate.