SB218: Bill Text

SB218, s. 17 Section 17. 619.123 of the statutes is repealed.

SB218, s. 18 Section 18. 625.12 (2) of the statutes is amended to read:

SB218,10,24 625.12 (2) Classification. Risks Subject to s. 635.09, 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 635.09, 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, s. 19 Section 19. 628.34 (3) (a) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

SB218,11,10 628.34 (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 , 635.03, 635.05, 635.08 and 635.09. 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, s. 20 Section 20. 628.34 (3) (b) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

SB218,11,19 628.34 (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 635.26 635.03 to 635.09, 635.16 and 635.165.

SB218, s. 21 Section 21. 628.36 (2) (b) 1. of the statutes is amended to read:

SB218,12,2 628.36 (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.

SB218, s. 22 Section 22. 628.36 (2) (b) 3. of the statutes is amended to read:

SB218,12,8 628.36 (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.

SB218, s. 23 Section 23. 628.36 (2) (b) 5. of the statutes is amended to read:

SB218,12,14 628.36 (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).

SB218, s. 24 Section 24. 631.01 (4) of the statutes is amended to read:

SB218,13,2 631.01 (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.

SB218, s. 25 Section 25. 632.70 of the statutes is repealed.

SB218, s. 26 Section 26. 632.745 of the statutes, as affected by 1995 Wisconsin Acts 289 and 453, is repealed.

SB218, s. 27 Section 27. 632.747 (title) of the statutes, as created by 1995 Wisconsin Act 289, is renumbered 635.04 (title) and amended to read:

SB218,13,8 635.04 (title) Guaranteed acceptance under group plans.

SB218, s. 28 Section 28. 632.747 (1) of the statutes, as created by 1995 Wisconsin Act 289, is renumbered 635.04 (1), and 635.04 (1) (intro.), as renumbered, is amended to read:

SB218,13,17 635.04 (1) Employe becomes eligible after commencement of coverage. (intro.) If Unless otherwise permitted by rule of the commissioner, if an insurer provides coverage under a group health benefit plan, the insurer shall provide coverage under the group health benefit plan to an eligible employe who becomes eligible for coverage after the commencement of the employer's coverage, and to the eligible employe's dependents, regardless of health condition or claims experience, if all of the following apply:

SB218, s. 29 Section 29. 632.747 (2) of the statutes, as created by 1995 Wisconsin Act 289, is repealed.

SB218, s. 30 Section 30. 632.747 (3) (intro.) of the statutes, as created by 1995 Wisconsin Act 289, is renumbered 635.04 (2) (intro.).

SB218, s. 31 Section 31. 632.747 (3) (a) of the statutes, as created by 1995 Wisconsin Act 289, is renumbered 635.04 (2) (a) and amended to read:

SB218,14,3 635.04 (2) (a) The eligible employe was covered as a dependent under qualifying creditable coverage when he or she waived coverage under the self-insured health plan.

SB218, s. 32 Section 32. 632.747 (3) (b) of the statutes, as created by 1995 Wisconsin Act 289, is renumbered 635.04 (2) (b) and amended to read:

SB218,14,11 635.04 (2) (b) The eligible employe's coverage under the qualifying creditable coverage has terminated or will terminate due to a divorce from the insured under the qualifying creditable coverage, the death of the insured under the qualifying creditable coverage, loss of employment by the insured under the qualifying creditable coverage or involuntary loss of coverage under the qualifying creditable coverage by the insured under the qualifying creditable coverage.

SB218, s. 33 Section 33. 632.747 (3) (c) of the statutes, as created by 1995 Wisconsin Act 289, is renumbered 635.04 (2) (c) and amended to read:

SB218,14,16 635.04 (2) (c) The eligible employe applies for coverage under the self-insured health plan not more than 30 days after termination of his or her coverage under the qualifying creditable coverage.

SB218, s. 34 Section 34. 632.749 of the statutes, as created by 1997 Wisconsin Act 289, is repealed.

SB218, s. 35 Section 35. 632.76 (2) (a) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

SB218,15,2 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (1) (c) 635.02 (14), which is subject to s. 632.745 (2) 635.03 or 635.08 (2).

SB218, s. 36 Section 36. 632.896 (4) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

SB218,15,10 632.896 (4) Preexisting conditions. Notwithstanding ss. 632.745 (2) and 632.76 (2) (a), 635.03 and 635.08 (2), a disability insurance policy that is subject to sub. (2) and that is in effect when a court makes a final order granting adoption or when the child is placed for adoption may not exclude or limit coverage of a disease or physical condition of the child on the ground that the disease or physical condition existed before coverage is required to begin under sub. (3).

SB218, s. 37 Section 37. 632.898 (1) (b) of the statutes is repealed and recreated to read:

SB218,15,15 632.898 (1) (b) "Dependent" means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.

SB218, s. 38 Section 38. 632.898 (7) of the statutes is amended to read:

SB218,16,5 632.898 (7) If the federal government enacts legislation providing for a federal income tax exemption for amounts deposited in an account established under this section and for any interest, dividends or other gain that accrues in the account if redeposited in the account, the commissioner shall conduct a study, to be completed within 4 years after the enactment of the federal legislation, of individuals and groups that had coverage under a high cost-share health plan and that terminated that coverage in order to enroll in a health benefit plan that was not a high cost-share health plan. If as a result of the study the commissioner determines that s. 632.745 (1) (f) 2. 635.08 (1) (b) is not necessary for the purpose for which it was intended, the commissioner shall certify that determination to the revisor of statutes. Upon the certification, the revisor of statutes shall publish notice in the Wisconsin administrative register of the determination, the date of the certification and that after 30 days after the date of the certification s. 632.745 (1) (f) 2. 635.08 (1) (b) is not effective.

SB218, s. 39 Section 39. Chapter 635 (title) of the statutes is amended to read:

SB218,16,7 CHAPTER 635

SB218,16,9 SMALL EMPLOYER regulation of HEALTH INSURANCE

SB218, s. 40 Section 40. Subchapter I (title) of chapter 635 [precedes 635.01] of the statutes is repealed.

SB218, s. 41 Section 41. 635.01 of the statutes is repealed.

SB218, s. 42 Section 42. 635.02 of the statutes, as affected by 1995 Wisconsin Act 289, is repealed and recreated to read:

SB218,16,15 635.02 Definitions. In this chapter, unless otherwise specified:

SB218,16,18 (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.

SB218,16,21 (2) "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.

SB218,16,23 (3) "Beneficiary" has the meaning given in section 3 (8) of the federal Employee Retirement Income Security Act of 1974.

SB218,17,3 (4) "Benefit design characteristics" means covered services, cost sharing, utilization management, managed care networks and other features that differentiate plan or coverage designs.

SB218,17,5 (5) "Bona fide association" means an association that satisfies all of the following:

SB218,17,6 (a) The association has been actively in existence for at least 5 years.

SB218,17,8 (b) The association has been formed and maintained in good faith for purposes other than obtaining insurance.

SB218,17,11 (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.

SB218,17,14 (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.

SB218,17,16 (e) The association does not make health insurance coverage offered through the association available other than in connection with a member of the association.

SB218,17,19 (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.

SB218,17,21 (6) "Case characteristics" means the age, gender, geographic location and tobacco use of the individuals covered under a health benefit plan.

SB218,17,23 (7) (a) Except as provided in par. (b), "creditable coverage" means coverage under any of the following:

SB218,17,24 1. A group health plan.

SB218,17,25 2. Health insurance.

SB218,18,1 3. Part A or part B of title XVIII of the federal Social Security Act.

SB218,18,3 4. Title XIX of the federal Social Security Act, except for coverage consisting solely of benefits under section 1928 of that act.

SB218,18,4 5. Chapter 55 of title 10 of the United States Code.

SB218,18,6 6. A medical care program of the federal Indian health service or of an American Indian tribal organization.

SB218,18,7 7. A state health benefits risk pool.

SB218,18,8 8. A health plan offered under chapter 89 of title 5 of the United States Code.

SB218,18,10 9. A public health plan, as defined in regulations issued by the federal department of health and human services.

SB218,18,12 10. A health coverage plan under section 5 (e) of the federal Peace Corps Act, 22 USC 2504 (e).

SB218,18,14 (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.

SB218,18,21 (8) (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.

SB218,18,24 (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).

SB218,18,25 (9) (a) "Employer" means any of the following:

SB218,19,3 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.

SB218,19,4 2. A municipality, as defined in s. 16.70 (8).

SB218,19,5 3. The state.

SB218,19,6 (b) For purposes of this definition, all of the following apply:

SB218,19,8 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.

SB218,19,9 2. "Employer" includes any predecessor of an employer.

SB218,19,13 (10) "Enrollment date" means, with respect to an individual covered under a group health plan, self-insured 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.

SB218,19,14 (11) "Federal continuation provision" means any of the following:

SB218,19,16 (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.

SB218,19,18 (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.

SB218,19,19 (c) Title XXII of P.L. 104-191.

SB218,19,24 (12) "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.

SB218,19,25 (13) "Group health plan" means any of the following:

SB218,20,5 (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.

SB218,20,11 (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.

SB218,20,13 (14) (a) Except as provided in par. (b), "health benefit plan" means any hospital or medical policy or certificate.

SB218,20,14 (b) "Health benefit plan" does not include any of the following: