SB218,36,77 5. Medical history.
SB218,36,88 6. Genetic information.
SB218,36,109 7. Evidence of insurability, including conditions arising out of acts of domestic
10violence.
SB218,36,1111 8. Disability.
SB218,36,1312 (b) For purposes of par. (a), rules for eligibility to enroll under a group health
13benefit plan include rules defining any applicable waiting periods for enrollment.
SB218,36,18 14(2) An insurer offering a group health benefit plan may not require any
15individual, as a condition of enrollment or continued enrollment under the plan, to
16pay, on the basis of any health status-related factor with respect to the individual
17or a dependent of the individual, a premium or contribution that is greater than the
18premium or contribution for a similarly situated individual enrolled under the plan.
SB218,36,20 19(3) To the extent consistent with s. 635.03, sub. (1) shall not be construed to do
20any of the following:
SB218,36,2221 (a) Require a group health benefit plan to provide particular benefits other
22than those provided under the terms of the plan.
SB218,36,2523 (b) Prevent a group health benefit plan from establishing limitations or
24restrictions on the amount, level, extent or nature of benefits or coverage for
25similarly situated individuals enrolled under the plan.
SB218,37,1
1(4) Nothing in sub. (1) shall be construed to do any of the following:
SB218,37,32 (a) Restrict the amount that an insurer may charge an employer for coverage
3under a group health benefit plan.
SB218,37,74 (b) Prevent an insurer offering a group health benefit plan from establishing
5premium discounts or rebates, or from modifying otherwise applicable copayments
6or deductibles, in return for adherence to programs of health promotion and disease
7prevention.
SB218,37,88 (c) Provide an exception from, or limit, the rate regulation under s. 635.09.
SB218, s. 45 9Section 45. 635.06 of the statutes is created to read:
SB218,37,14 10635.06 Guaranteed issue for group health benefit plans. (1) Except as
11provided in subs. (3) and (4), an insurer shall provide coverage under a group health
12benefit plan to an employer and to all of the employer's eligible employes and their
13dependents, regardless of health condition or claims experience, if all of the following
14apply:
SB218,37,1515 (a) The insurer has in force a group health benefit plan.
SB218,37,1716 (b) The employer agrees to pay the premium required for coverage under the
17group health benefit plan.
SB218,37,2018 (c) The employer agrees to comply with all other provisions of the group health
19benefit plan that apply generally to a policyholder or an insured without regard to
20health condition or claims experience.
SB218,37,22 21(2) An insurer that provides coverage under sub. (1) may impose payment
22security provisions that are reasonably related to the risk covered.
SB218,38,2 23(3) (a) An insurer that is otherwise required to provide coverage under sub. (1)
24may refuse to issue a group health benefit plan to an employer if all of the individuals

1in the employer group that are to be covered under the group health benefit plan may
2be covered under one individual health benefit plan providing family coverage.
SB218,38,53 (b) Subsection (1) does not require an insurer to issue coverage that the insurer
4is not authorized to issue under its bylaws, charter or certificate of incorporation or
5authority.
SB218,38,96 (c) Subsection (1) does not require an insurer that provides coverage to an
7employer under a group health benefit plan to issue a different group health benefit
8plan to the employer before the expiration of the agreed term of the group health
9benefit plan under which the employer has coverage.
SB218,38,1310 (d) An insurer that offers health care coverage exclusively to a single category
11or limited categories of employers may, with prior approval of the commissioner, limit
12its compliance with sub. (1) to that single category or those limited categories of
13employers.
SB218,38,1714 (e) The commissioner may exempt an insurer from the requirements of sub. (1)
15if the commissioner determines that it is in the public interest to exempt the insurer
16from the requirements under sub. (1) because the insurer is in financially hazardous
17condition.
SB218,38,2218 (f) If an employer loses coverage under a group health benefit plan for failure
19to pay a premium when due, an insurer that is otherwise required to provide
20coverage under sub. (1) may refuse to issue a group health benefit plan to that
21employer during the 12-month period beginning on the day on which the employer
22lost coverage.
SB218,39,323 (g) An insurer that previously issued group health benefit plans but, prior to
24the effective date of this paragraph .... [revisor inserts date], discontinued offering
25such plans to small employers, shall within 60 days after the effective date of this

1paragraph .... [revisor inserts date], again offer group health benefit plans to small
2employers or be subject to the requirements under s. 635.16 as if the insurer had
3elected to not renew a group health benefit plan.
SB218,39,6 4(4) (a) In this subsection, "high-risk individual" means an individual with a
5high-risk medical condition who has coverage under a group health benefit plan
6with a premium rate at the insurer's highest premium rate level.
SB218,39,97 (b) An insurer that is otherwise required to provide coverage under sub. (1)
8shall be exempt from the requirement under sub. (1) for the remainder of a calendar
9year after all of the following occur:
SB218,39,1110 1. The number of high-risk individuals covered by the insurer at least equals
11the threshold level determined under par. (e) 3.
SB218,39,1812 2. The insurer applies for exemption from the requirement under sub. (1) by
13certifying its qualification under subd. 1. to the commissioner and the commissioner,
14within 30 days after the insurer submits its certifying information, makes no
15objection and does not request additional information. If the commissioner does
16timely object or request additional information, the insurer shall be exempt from the
17requirements under sub. (1) 30 days after the commissioner objects or the insurer
18submits the additional information if the commissioner takes no further action.
SB218,39,2219 (c) Whenever an insurer becomes exempt from the requirement under sub. (1)
20by satisfying the criteria under par. (b), the commissioner shall provide notice of that
21exemption to all insurers offering group health benefit plans to employers in this
22state and to all insurance agents listed under s. 628.11 by those insurers.
SB218,39,2523 (d) An insurer that satisfies the criterion under par. (b) 1. is not required to
24apply for exemption from the requirement under sub. (1). An insurer that does not
25apply for exemption shall remain subject to the requirement under sub. (1).
SB218,40,3
1(e) In consultation with the committee on risk adjustment, the commissioner
2shall promulgate rules for the operation of the risk adjustment mechanism under
3this subsection, including rules that specify at least all of the following:
SB218,40,54 1. What diagnostic conditions constitute high risk medical conditions for
5purposes of the definition of a high-risk individual.
SB218,40,76 2. How to determine an insurer's highest premium rate level for purposes of
7the definition of a high-risk individual.
SB218,40,98 3. What percentage of an insurer's total enrollment under group health benefit
9plans issued by the insurer constitutes the threshold level for purposes of par. (b) 1.
SB218, s. 46 10Section 46. 635.08 of the statutes is created to read:
SB218,40,13 11635.08 Coverage requirements for individual health benefit plans. (1)
12(a) In this section, "qualifying coverage" means benefits or coverage provided under
13any of the following:
SB218,40,1614 1. A group health benefit plan, group health plan or self-insured health plan
15that provides benefits similar to or exceeding benefits provided under the health
16benefit plan for which the individual is applying.
SB218,40,2017 2. An individual health benefit plan that provides benefits similar to or
18exceeding benefits provided under the health benefit plan for which the individual
19is applying, if the individual health benefit plan has been in effect for at least one
20year.
SB218,41,221 (b) Notwithstanding par. (a), "qualifying coverage" does not include a high
22cost-share health plan, as defined in s. 632.898 (1) (c), that is linked to a medical
23savings account, as described in s. 632.898, if the employer that provides the
24individual's new coverage offers its eligible employes a choice of health benefit plan

1options that includes a high cost-share health plan, as defined in s. 632.898 (1) (c),
2and the individual's new coverage is not a high cost-share health plan.
SB218,41,5 3(2) (a) An individual health benefit plan may not impose a preexisting
4condition exclusion with respect to a covered individual for losses incurred more than
512 months after the individual's enrollment date under the plan.
SB218,41,76 (b) An individual health benefit plan may not define a preexisting condition
7more restrictively than any of the following:
SB218,41,118 1. A condition that would have caused an ordinarily prudent person to seek
9medical advice, diagnosis, care or treatment during the 18 months immediately
10preceding the individual's enrollment date under the plan and for which the
11individual did not seek medical advice, diagnosis, care or treatment.
SB218,41,1412 2. A condition for which medical advice, diagnosis, care or treatment was
13recommended or received during the 18 months immediately preceding the
14individual's enrollment date under the plan.
SB218,41,1715 (c) Notwithstanding pars. (a) and (b), an individual health benefit plan may not
16impose a preexisting condition exclusion relating to pregnancy as a preexisting
17condition.
SB218,41,20 18(3) (a) Except as provided in pars. (b) and (g), an insurer shall provide coverage
19under an individual health benefit plan to an individual who is a resident of this
20state, regardless of health condition or claims experience, if all of the following apply:
SB218,41,2121 1. The insurer has in force an individual health benefit plan.
SB218,41,2322 2. The individual agrees to pay the premium required for coverage under the
23individual health benefit plan.
SB218,42,3
13. The individual agrees to comply with all other provisions of the individual
2health benefit plan that apply generally to a policyholder or an insured without
3regard to health condition or claims experience.
SB218,42,54 4. The individual was covered under qualifying coverage that terminated not
5more than 31 days before the individual applied for the new coverage.
SB218,42,116 5. If the individual's qualifying coverage under subd. 4. was coverage under
7sub. (1) (a) 1., the individual had been covered under continuation coverage, as
8defined in s. 252.16 (1) (a), for the maximum allowable period; the individual is not
9now eligible for coverage under any group health benefit plan, group health plan or
10self-insured health plan; and the individual was an eligible employe for at least 6
11months immediately before applying for the new coverage.
SB218,42,1412 (b) 1. Paragraph (a) does not require an insurer to issue coverage that the
13insurer is not authorized to issue under its bylaws, charter or certificate of
14incorporation or authority.
SB218,42,1815 2. Paragraph (a) does not require an insurer that provides coverage to an
16individual under an individual health benefit plan to issue a different individual
17health benefit plan to the individual before the expiration of the agreed term of the
18individual health benefit plan under which the individual has coverage.
SB218,42,2219 3. An insurer that offers health care coverage exclusively to a single category
20or limited categories of individuals may, with prior approval of the commissioner,
21limit its compliance with par. (a) to the single category or those limited categories of
22individuals.
SB218,43,223 4. The commissioner may exempt an insurer from the requirement under par.
24(a) if the commissioner determines that it is in the public interest to exempt the

1insurer from the requirement under par. (a) because the insurer is in financially
2hazardous condition.
SB218,43,63 (c) An insurer that issues an individual health benefit plan to an individual
4described in par. (a) shall provide coverage under the individual health benefit plan
5for any dependents of the individual who had coverage under the individual's
6qualifying coverage under par. (a) 4.
SB218,43,107 (d) An individual health benefit plan that is issued to an individual described
8in par. (a) may not restrict or modify coverage with respect to the individual except
9to the extent that the individual's qualifying coverage under par. (a) 4. was restricted
10or modified.
SB218,43,1311 (e) The maximum lifetime benefits available under an individual health benefit
12plan that is issued to an individual described in par. (a) may be reduced by the total
13benefits paid under the individual's qualifying coverage under par. (a) 4.
SB218,43,1814 (f) An individual health benefit plan that is issued to an individual described
15in par. (a) shall waive any period applicable to a preexisting condition exclusion
16period with respect to particular services for the period that the individual was
17covered with respect to such services under the individual's qualifying coverage
18under par. (a) 4.
SB218,43,2119 (g) An insurer that is otherwise required to provide coverage under par. (a)
20shall be exempt from the requirement under par. (a) for the remainder of a calendar
21year after all of the following occur:
SB218,44,222 1. The total number of individuals described under par. (a) and their
23dependents who are covered by the insurer equals at least 1% of the total number of
24individuals and their dependents covered under all individual health benefit plans

1issued by the insurer that were in effect on December 31 of the preceding year and
2that were qualifying coverage under sub. (1) (a) 2.
SB218,44,43 2. The insurer applies for exemption from the requirement under par. (a) by
4submitting to the commissioner certification that includes all of the following:
SB218,44,75 a. The total number of individuals and their dependents covered under all
6individual health benefit plans issued by the insurer that were in effect on December
731 of the preceding year and that were qualifying coverage under sub. (1) (a) 2.
SB218,44,108 b. The total number of individuals described under par. (a) and their
9dependents who have been accepted by the insurer for coverage under par. (a) during
10the current year.
SB218,44,1411 (h) Whenever an insurer becomes exempt from the requirement under par. (a)
12by satisfying the criteria under par. (g), the commissioner shall provide notice of that
13exemption to all insurers offering individual health benefit plans to individuals in
14this state and to all insurance agents listed under s. 628.11 by those insurers.
SB218, s. 47 15Section 47. 635.08 (1) (b) of the statutes, as created by 1997 Wisconsin Act ....
16(this act), is repealed.
SB218, s. 48 17Section 48. 635.09 of the statutes is repealed and recreated to read:
SB218,44,20 18635.09 Rate regulation for individual and group health benefit plans.
19Notwithstanding ch. 625, the commissioner shall promulgate rules that do all of the
20following:
SB218,44,25 21(1) Establish restrictions on premium rates that an insurer may charge an
22employer for coverage under a group health benefit plan such that the premium rates
23charged to employers with similar case characteristics for the same or similar benefit
24design characteristics do not vary from the midpoint rate for those employers by
25more than 30% of that midpoint rate.
SB218,45,5
1(2) Establish restrictions on premium rates that an insurer may charge an
2individual for coverage under an individual health benefit plan such that the
3premium rates charged to individuals with similar case characteristics for the same
4or similar benefit design characteristics do not vary from the midpoint rate for those
5individuals by more than 35% of that midpoint rate.
SB218,45,7 6(3) Establish restrictions on increases in premium rates that an insurer may
7charge an employer for coverage under a group health benefit plan such that:
SB218,45,98 (a) The percentage increase in the premium rate for a new rating period does
9not exceed the sum of the following:
SB218,45,1110 1. The percentage change in the new business premium rate measured from
11the first day of the prior rating period to the first day of the new rating period.
SB218,45,1612 2. An adjustment, not to exceed 15% per year for small employers or 25% per
13year for large employers, adjusted proportionally for rating periods of less than one
14year, for such rating factors as claims experience, health condition and duration of
15coverage, determined in accordance with the insurer's rate manual or rating
16procedures.
SB218,45,1917 3. An adjustment for a change in case characteristics or in benefit design
18characteristics, determined in accordance with the insurer's rate manual or rating
19procedures.
SB218,45,2320 (b) The percentage increase in the premium rate for a new rating period for a
21group health benefit plan issued before the effective date of this paragraph ....
22[revisor inserts date], does not exceed the sum of par. (a) 1. and 3., unless premium
23rates are in compliance with the rules promulgated under sub. (1).
SB218,46,2 24(4) Require the premium rate of a health benefit plan issued before the effective
25date of this subsection .... [revisor inserts date], to comply with the rules promulgated

1under sub. (1) or (2) no later than 2 years after the effective date of this subsection
2.... [revisor inserts date].
SB218,46,3 3(5) Define the terms necessary for compliance with this section.
SB218,46,4 4(6) Ensure that employers are classified using objective criteria.
SB218,46,6 5(7) Ensure that rating factors are applied objectively and consistently to small
6employers.
SB218, s. 49 7Section 49. 635.11 (title) of the statutes is amended to read:
SB218,46,9 8635.11 (title) Disclosure of rating factors and renewability provisions
9for group health benefit plans.
SB218, s. 50 10Section 50. 635.11 of the statutes is renumbered 635.11 (1m), and 635.11 (1m)
11(intro.), (a) and (d), as renumbered, are amended to read:
SB218,46,1412 635.11 (1m) (intro.) Before the sale of a group health benefit plan or policy
13subject to this subchapter, a small employer
, an insurer shall disclose to a small an
14employer all of the following:
SB218,46,1615 (a) The small employer insurer's right to increase premium rates and the
16factors limiting the amount of increase.
SB218,46,1717 (d) The small employer's renewability rights.
SB218, s. 51 18Section 51. 635.11 (1m) (e) of the statutes is created to read:
SB218,46,2019 635.11 (1m) (e) As part of the insurer's solicitation and sales materials, the
20availability of the information under par. (f).
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