AB100: Bill Text Engrossed

AB100-engrossed,2108,12 149.18 Chapters 600 to 645 applicable. Except as otherwise provided in this subchapter chapter, the plan shall comply and be administered in compliance with chs. 600 to 645.

AB100-engrossed, s. 4910c Section 4910c. 628.34 (3) (a) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

AB100-engrossed,2108,21 628.34 (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 and, 632.745 and 632.748. 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.

AB100-engrossed, s. 4910e Section 4910e. 628.34 (3) (b) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

AB100-engrossed,2109,5 628.34 (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. 632.745, 632.747, 632.749, 635.09 and 635.26 632.746 to 632.7495.

AB100-engrossed, s. 4910g Section 4910g. 628.36 (2) (b) 1. of the statutes is amended to read:

AB100-engrossed,2109,12 628.36 (2) (b) 1. Except for health maintenance organizations, preferred provider plans, and limited service health organizations and the small employer health insurance plan under subch. II of ch. 635, no health care plan may prevent any person covered under the plan from choosing freely among providers who have agreed to participate in the plan and abide by its terms, except by requiring the person covered to select primary providers to be used when reasonably possible.

AB100-engrossed, s. 4910i Section 4910i. 628.36 (2) (b) 3. of the statutes is amended to read:

AB100-engrossed,2109,18 628.36 (2) (b) 3. Except as provided in subd. 4., no provider may be denied the opportunity to participate in a health care plan, other than a health maintenance organization, a limited service health organization, or a preferred provider plan or the small employer health insurance plan under subch. II of ch. 635, under the terms of the plan.

AB100-engrossed, s. 4910k Section 4910k. 628.36 (2) (b) 5. of the statutes is amended to read:

AB100-engrossed,2109,24 628.36 (2) (b) 5. Except for the small employer health insurance plan under subch. II of ch. 635 to the extent determined by the small employer insurance board under s. 635.23 (1) (b), all All health care plans, including health maintenance organizations, limited service health organizations and preferred provider plans are subject to s. 632.87 (3).

AB100-engrossed, s. 4910m Section 4910m. 631.01 (4) of the statutes is amended to read:

AB100-engrossed,2110,11 631.01 (4) Annuities and group policies for eleemosynary institutions. This chapter, and ch. 632 and the health insurance mandates under ch. 632 that apply to the plan under subch. II of ch. 635 do not apply to annuities or group policies that are provided on a basis as uniform nationally as state statutes permit to educational, scientific research, religious or charitable institutions organized without profit to any person, for the benefit of employes of such institutions. The commissioner may by order subject such contracts issued by a particular insurer to this chapter, or ch. 632 or the health insurance mandates under ch. 632 that apply to the plan under subch. II of ch. 635 or any portion of those provisions upon a finding, after a hearing, that the interests of Wisconsin insureds or creditors or the public of this state so require.

AB100-engrossed, s. 4912 Section 4912. 631.36 (7) (a) 2. of the statutes is amended to read:

AB100-engrossed,2110,16 631.36 (7) (a) 2. Unless the notice contains adequate instructions to the policyholder for applying for insurance through a risk-sharing plan under subch. I of ch. 619, if a risk-sharing plan exists under subch. I of ch. 619 for the kind of coverage being canceled or nonrenewed, except as provided in par. (b).

AB100-engrossed, s. 4915m Section 4915m. 632.70 of the statutes is repealed.

AB100-engrossed, s. 4916m Section 4916m. 632.745 of the statutes, as affected by 1995 Wisconsin Acts 289 and 453, is repealed and recreated to read:

AB100-engrossed,2110,21 632.745 Coverage requirements for group and individual health benefit plans; definitions. In this section and ss. 632.746 to 632.7495:

AB100-engrossed,2110,24 (1) "Affiliation period" means the period which, under the terms of health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective.

AB100-engrossed,2111,2 (2) "Beneficiary" has the meaning given in section 3 (8) of the federal Employee Retirement Income Security Act of 1974.

AB100-engrossed,2111,4 (3) "Bona fide association" means an association that satisfies all of the following:

AB100-engrossed,2111,5 (a) The association has been actively in existence for at least 5 years.

AB100-engrossed,2111,7 (b) The association has been formed and maintained in good faith for purposes other than obtaining insurance.

AB100-engrossed,2111,10 (c) The association does not condition membership in the association on any health status-related factor of an individual, including an employe of an employer or a dependent of an employe.

AB100-engrossed,2111,13 (d) The association makes health insurance coverage offered through the association available to all members, regardless of any health status-related factor of those members or individuals eligible for coverage through a member.

AB100-engrossed,2111,15 (e) The association does not make health insurance coverage offered through the association available other than in connection with a member of the association.

AB100-engrossed,2111,18 (f) The association meets any additional requirements that are imposed by a rule of the commissioner designed to prevent the use of an association for risk segmentation.

AB100-engrossed,2111,20 (4) (a) Except as provided in par. (b), "creditable coverage" means coverage under any of the following:

AB100-engrossed,2111,21 1. A group health plan.

AB100-engrossed,2111,22 2. Health insurance.

AB100-engrossed,2111,23 3. Part A or part B of title XVIII of the federal Social Security Act.

AB100-engrossed,2111,25 4. Title XIX of the federal Social Security Act, except for coverage consisting solely of benefits under section 1928 of that act.

AB100-engrossed,2112,1 5. Chapter 55 of title 10 of the United States Code.

AB100-engrossed,2112,3 6. A medical care program of the federal Indian health service or of an American Indian tribal organization.

AB100-engrossed,2112,4 7. A state health benefits risk pool.

AB100-engrossed,2112,5 8. A health plan offered under chapter 89 of title 5 of the United States Code.

AB100-engrossed,2112,7 9. A public health plan, as defined in regulations issued by the federal department of health and human services.

AB100-engrossed,2112,9 10. A health coverage plan under section 5 (e) of the federal Peace Corps Act, 22 USC 2504 (e).

AB100-engrossed,2112,11 (b) "Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in section 2791 (c) of P.L. 104-191.

AB100-engrossed,2112,18 (5) (a) Except as provided in par. (b), "eligible employe" means an employe who works on a permanent basis and has a normal work week of 30 or more hours. The term includes a sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership and a member of a limited liability company if the sole proprietor, business owner, partner or member is included as an employe under a health benefit plan of an employer, but the term does not include an employe who works on a temporary or substitute basis.

AB100-engrossed,2112,21 (b) For purposes of a group health benefit plan, or a self-insured health plan, that is offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7), "eligible employe" has the meaning given in s. 40.02 (25).

AB100-engrossed,2112,22 (6) (a) "Employer" means any of the following:

AB100-engrossed,2112,25 1. 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.

AB100-engrossed,2113,1 2. A municipality, as defined in s. 16.70 (8).

AB100-engrossed,2113,2 3. The state.

AB100-engrossed,2113,3 (b) For purposes of this definition, all of the following apply:

AB100-engrossed,2113,5 1. All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer.

AB100-engrossed,2113,6 2. "Employer" includes any predecessor of an employer.

AB100-engrossed,2113,10 (7) "Enrollment date" means, with respect to an individual covered under a 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.

AB100-engrossed,2113,11 (8) "Federal continuation provision" means any of the following:

AB100-engrossed,2113,13 (a) Section 4980B of the Internal Revenue Code of 1986, except for section 4980B (f) (1) of that code insofar as it relates to pediatric vaccines.

AB100-engrossed,2113,15 (b) Part 6 of subtitle B of title I of the federal Employee Retirement Income Security Act of 1974, except for section 609 of that act.

AB100-engrossed,2113,16 (c) Title XXII of P.L. 104-191.

AB100-engrossed,2113,21 (9) "Group health benefit plan" means a health benefit plan that is issued by an insurer to or through an employer on behalf of a group consisting of at least 2 employes or a group including at least 2 eligible employes. The term includes individual health benefit plans covering eligible employes when 3 or more are sold to or through an employer.

AB100-engrossed,2113,22 (10) "Group health plan" means any of the following:

AB100-engrossed,2114,2 (a) An employe welfare plan, as defined in section 3 (1) of the federal Employee Retirement Security Act of 1974, to the extent that the employe welfare plan provides medical care, including items and services paid for as medical care, to employes or to their dependents, as defined under the terms of the employe welfare plan, directly or through insurance, reimbursement or otherwise.

AB100-engrossed,2114,8 (b) Any program that would not otherwise be an employe welfare benefit plan and that is established or maintained by a partnership, to the extent that the program provides medical care, including items and services paid for as medical care, to present or former partners of the partnership or to their dependents, as defined under the terms of the program, directly or through insurance, reimbursement or otherwise.

AB100-engrossed,2114,10 (11) (a) Except as provided in par. (b), "health benefit plan" means any hospital or medical policy or certificate.

AB100-engrossed,2114,11 (b) "Health benefit plan" does not include any of the following:

AB100-engrossed,2114,13 1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.

AB100-engrossed,2114,14 2. Coverage issued as a supplement to liability insurance.

AB100-engrossed,2114,16 3. Liability insurance, including general liability insurance and automobile liability insurance.

AB100-engrossed,2114,17 4. Worker's compensation or similar insurance.

AB100-engrossed,2114,18 5. Automobile medical payment insurance.

AB100-engrossed,2114,19 6. Credit-only insurance.

AB100-engrossed,2114,20 7. Coverage for on-site medical clinics.

AB100-engrossed,2114,23 8. Other similar insurance coverage, as specified in regulations issued by the federal department of health and human services, under which benefits for medical care are secondary or incidental to other insurance benefits.

AB100-engrossed,2115,4 9. If provided under a separate policy, certificate or contract of insurance, or if otherwise not an integral part of the policy, certificate or contract of insurance: limited-scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those benefits; and such other similar, limited benefits as are specified in regulations issued by the federal department of health and human services under section 2791 of P.L. 104-191.

AB100-engrossed,2115,6 10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply:

AB100-engrossed,2115,8 a. The benefits are provided under a separate policy, certificate or contract of insurance.

AB100-engrossed,2115,11 b. There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.

AB100-engrossed,2115,14 c. Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.

AB100-engrossed,2115,20 11. Benefits that are provided under a separate policy, certificate or contract of insurance and that are medicare supplemental health insurance, as defined in section 1882 (g) (1) of the federal Social Security Act, coverage supplemental to the coverage provided under chapter 55 of title 10 of the United States Code or similar supplemental coverage provided as supplemental to coverage under a group health plan.

AB100-engrossed,2115,21 12. Other insurance exempted by rule of the commissioner.

AB100-engrossed,2115,23 (12) "Health insurance" includes health benefit plans but does not include group health plans.

AB100-engrossed,2115,24 (13) "Health maintenance organization" has the meaning given in s. 609.01 (2).

AB100-engrossed,2116,2 (14) "Health status-related factor" means any of the factors listed in s. 632.748 (1) (a).

AB100-engrossed,2116,9 (15) "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 health benefit plans covering individuals in this state or eligible employes of one or more employers in this state. The term includes a health maintenance organization, a preferred provider plan, as defined in s. 609.01 (4), an insurer operating as a cooperative association organized under ss. 185.981 to 185.985 and a limited service health organization, as defined in s. 609.01 (3).

AB100-engrossed,2116,15 (16) "Large employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 51 employes on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 51 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.

AB100-engrossed,2116,19 (17) "Large group market" means the health insurance market under which individuals obtain health insurance coverage on behalf of themselves and their dependents, directly or through any arrangement, under a group health benefit plan maintained by a large employer.

AB100-engrossed,2116,22 (18) "Late enrollee" means, with respect to coverage under 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:

AB100-engrossed,2116,24 (a) The first period in which the individual is eligible to enroll under the plan or coverage.

AB100-engrossed,2116,25 (b) A special enrollment period under s. 632.746 (7).

AB100-engrossed,2117,4 (19) "Network plan" means health insurance coverage of an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer.

AB100-engrossed,2117,9 (20) "Participant" has the meaning given in section 3 (7) of the federal Employee Retirement Income Security Act of 1974. "Participant" includes an individual who is, or may become, eligible to receive a benefit, or whose beneficiaries may be eligible to receive any such benefit, in connection with a group health plan or group health benefit plan if the individual is any of the following:

AB100-engrossed,2117,11 (a) A partner in relation to a partnership and the group health plan or group health benefit plan is maintained by the partnership.

AB100-engrossed,2117,14 (b) A self-employed individual with one or more employes who are participants in the group health plan or group health benefit plan and the group health plan or group health benefit plan is maintained by the self-employed individual.

AB100-engrossed,2117,19 (21) "Placed for adoption" or "placement for adoption" means, with respect to the placement for adoption of a child with a person, the assumption and retention by the person of a legal obligation for the total or partial support of the child in anticipation of the adoption of the child. A child's placement for adoption with a person terminates upon the termination of the person's legal obligation for support.

AB100-engrossed,2117,21 (22) "Plan sponsor" has the meaning given in section 3 (16) (B) of the federal Employee Retirement Income Security Act of 1974.