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).
SB218, s. 52 21Section 52. 635.11 (1m) (f) of the statutes is created to read:
SB218,46,2222 635.11 (1m) (f) Upon the request of the employer, the following information:
SB218,46,2423 1. The provisions, if any, of the plan or policy relating to preexisting condition
24exclusions.
SB218,47,2
12. The benefits and premiums available under all health insurance coverage
2offered by the insurer for which the employer is qualified.
SB218, s. 53 3Section 53. 635.11 (2m) of the statutes is created to read:
SB218,47,74 635.11 (2m) Information required to be disclosed under this section shall be
5provided in a manner that is understandable to an employer and shall be sufficient
6to reasonably inform an employer of the employer's rights and obligations under the
7health insurance coverage.
SB218, s. 54 8Section 54. 635.11 (3m) of the statutes is created to read:
SB218,47,109 635.11 (3m) An insurer is not required under this section to disclose
10information that is proprietary or trade secret information under applicable law.
SB218, s. 55 11Section 55. 635.13 (title) of the statutes is amended to read:
SB218,47,13 12635.13 (title) Annual certification of compliance for group health
13benefit plans
.
SB218, s. 56 14Section 56. 635.13 (1) of the statutes is amended to read:
SB218,47,2015 635.13 (1) Records. A small employer An insurer that issues group health
16benefit plans
shall maintain at its principal place of business complete and detailed
17records with respect to those group health benefit plans relating to its rating
18methods and practices and its renewal underwriting methods and practices, and
19shall make the records available to the commissioner and the small employer
20insurance board
upon request.
SB218,47,25 21(2) Certification. A small employer An insurer that issues group health
22benefit plans
shall file with the commissioner on or before May 1 annually an
23actuarial opinion by a member of the American academy of actuaries Academy of
24Actuaries
certifying all of the following with respect to those group health benefit
25plans
:
SB218,48,2
1(a) That the small employer insurer is in compliance with the rate provisions
2of s. 635.05 635.09.
SB218,48,43 (b) That the small employer insurer's rating methods are based on generally
4accepted and sound actuarial principles, policies and procedures.
SB218,48,85 (c) That the opinion is based on the actuary's examination of the small employer
6insurer's records and a review of the small employer insurer's actuarial assumptions
7and statistical methods used in setting rates and procedures used in implementing
8rating plans.
SB218, s. 57 9Section 57. 635.15 of the statutes is renumbered 635.10 and amended to read:
SB218,48,17 10635.10 (title) Temporary suspension of rate regulation for individual
11and group health benefit plans
. The commissioner may suspend the operation
12of all or any part of s. 635.05 635.09 with respect to one or more small employers or
13one or more individuals
for one or more rating periods upon the written request of
14a small employer an insurer and a finding by the commissioner that the suspension
15is necessary in light of the financial condition of the small employer insurer or that
16the suspension would enhance the efficiency and fairness of the small employer
17health insurance market.
SB218, s. 58 18Section 58. 635.16 of the statutes is created to read:
SB218,48,23 19635.16 Contract termination and renewability for group health
20benefit plans.
(1) (a) Except as provided in subs. (2) to (4) and notwithstanding
21s. 631.36 (2) to (4m), an insurer that offers a group health benefit plan shall renew
22such coverage or continue such coverage in force at the option of the employer and,
23if applicable, plan sponsor.
SB218,48,2524 (b) At the time of coverage renewal, the insurer may modify a group health
25benefit plan issued in the large group market.
SB218,49,2
1(2) Notwithstanding s. 631.36 (2) to (4m), an insurer may nonrenew or
2discontinue a group health benefit plan, but only if any of the following applies:
SB218,49,43 (a) The plan sponsor has failed to pay premiums or contributions in accordance
4with the terms of the group health benefit plan or in a timely manner.
SB218,49,75 (b) The plan sponsor has performed an act or engaged in a practice that
6constitutes fraud or made an intentional misrepresentation of material fact under
7the terms of the coverage.
SB218,49,108 (c) The plan sponsor has failed to comply with a material plan provision that
9is permitted under law relating to employer contribution or group participation
10rules.
SB218,49,1311 (d) The insurer is ceasing to offer coverage in the market in which the group
12health benefit plan is included in accordance with sub. (3) and any other applicable
13state law.
SB218,49,1714 (e) In the case of a group health benefit plan that the insurer offers through a
15network plan, there is no longer an enrollee under the plan who resides, lives or
16works in the service area of the insurer or in an area in which the insurer is
17authorized to do business.
SB218,49,2218 (f) In the case of a group health benefit plan that is made available only through
19one or more bona fide associations, the employer ceases to be a member of the
20association on which the coverage is based. Coverage may be terminated if this
21paragraph applies only if the coverage is terminated uniformly without regard to any
22health status-related factor of any covered individual.
SB218,50,2 23(3) (a) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue
24offering in this state a particular type of group health benefit plan offered in either

1the large group market or the group market other than the large group market, but
2only if all of the following apply:
SB218,50,63 1. The insurer provides notice of the discontinuance to each employer and, if
4applicable, plan sponsor for whom the insurer provides coverage of this type in this
5state, and to the participants and beneficiaries covered under the coverage, at least
690 days before the date on which the coverage will be discontinued.
SB218,50,137 2. The insurer offers to each employer and, if applicable, plan sponsor for whom
8the insurer provides coverage of this type in this state the option to purchase from
9among all of the other group health benefit plans that the insurer offers in the market
10in which is included the type of group health benefit plan that is being discontinued,
11except that in the case of the large group market, the insurer must offer each
12employer and, if applicable, plan sponsor the option to purchase one other group
13health benefit plan that the insurer offers in the large group market.
SB218,50,1814 3. In exercising the option to discontinue coverage of this particular type and
15in offering the option to purchase coverage under subd. 2., the insurer acts uniformly
16without regard to any health status-related factor of any covered participants or
17beneficiaries or any participants or beneficiaries who may become eligible for
18coverage.
SB218,50,2219 (b) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue offering
20in this state all group health benefit plans in the large group market or in the group
21market other than the large group market, or in both such group markets, but only
22if all of the following apply:
Loading...
Loading...