SB466: Bill Text

Under current law, a city, village, town, county, or school district may offer a self-insured health plan (self-insured governmental health plan) to its employees. The Office of the Commissioner of Insurance (OCI) may enforce laws that specify some of the coverage a self-insured governmental health plan must offer. Current law requires that a self-insured governmental health plan must offer coverage to all eligible employees and their dependents and dictates other requirements for plan participation. Current law also mandates coverage that a self-insured governmental health plan must offer, such as drugs for treatment of human immunodeficiency virus (HIV), lead poisoning screening, treatment for the correction of temporomandibular disorders, anesthetic and surgery center charges in conjunction with dental care, breast reconstruction if the plan also covers mastectomy, certain immunizations, and health care for students on medical leave. Current law requires that if a self-insured governmental health plan covers dependent children, the plan must also cover adopted children. Among other requirements, self-insured governmental health plans must develop procedures for physicians to request an exception for a plan participant for drugs or devices that are routinely not covered under the plan, must specify any limits on coverage of experimental treatment, may not require preauthorization for emergency services if the plan covers emergency services, and may not exclude coverage for treatment of a condition by a dentist if the treatment is covered when performed by another health care provider.

This bill expands the authority of OCI to regulate a self-insured health plan of a city, village, town, county, or school district (governmental body), similar to the way OCI currently regulates insurers offering a health insurance policy or group health benefit plan. The bill allows OCI to require a governmental body that provides a self-insured health plan to provide reports pertaining to the self-insured health plan and to reply to requests for information made to a person with authority over the self-insured health plan. OCI may examine the affairs of the governmental body as they relate to the self-insured health plan. The bill allows OCI to seek an injunction or temporary restraining order for a violation of the statutes pertaining to a self-insured governmental health plan and allows forfeitures and criminal penalties to be imposed for those violations. OCI must promulgate rules regarding the level of reserves and surpluses that the governmental body must maintain with respect to its self-insured health plan. The governmental body may reinsure the self-insured health plan under this bill but must report the name of the reinsurer to OCI. The bill applies laws pertaining to rehabilitation and liquidation of insurers and the insurance security fund to governmental bodies, with respect to a self-insured health plan.

The bill imposes coverage requirements on self-insured governmental health plans similar to requirements imposed on health insurance policies and group health benefit plans. Self-insured governmental health plans, under the bill, may not limit coverage of HIV treatment if limits are not imposed on other illnesses or medical conditions, may not refuse to provide or renew coverage based on the health plan participant being a victim of domestic violence, must establish an internal grievance procedure and an independent review plan for the review of adverse and experimental treatment determinations, may not exclude coverage of treatment by a licensed chiropractor, must provide an explanation for a restriction or termination of coverage, must cover home care in certain circumstances, must cover skilled nursing care meeting certain requirements, must cover maternity and newborn children, must cover diabetes treatment and diabetic supplies, may not deny coverage based on possible coverage under a liability policy, and must cover mammograms, among other requirements.

Because this bill creates a new crime or revises a penalty for an existing crime, the Joint Review Committee on Criminal Penalties may be requested to prepare a report concerning the proposed penalty and the costs or savings that are likely to result if the bill is enacted.

For further information see the state and local fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB466, s. 1 Section 1. 66.0137 (4) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

SB466,4,3 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 631.95, 632.726, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.857, 632.86, 632.87 (4), (5), and (6), 632.875, 632.88, 632.885, 632.89, 632.895 (9) to (17), 632.896, 632.897, and 767.513 (4).

SB466, s. 2 Section 2. 120.13 (2) (g) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

SB466,4,10 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 631.95, 632.726, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.857, 632.86, 632.87 (4), (5), and (6), 632.875, 632.88, 632.885, 632.89, 632.895 (9) to (17), 632.896, 632.897, and 767.513 (4).

SB466, s. 3 Section 3. 153.01 (5m) of the statutes is amended to read:

SB466,4,14 153.01 (5m) "Insurer" has the meaning given under s. 632.745 (15) but does not include a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan.

SB466, s. 4 Section 4. 601.41 (8) (a) 1. of the statutes is amended to read:

SB466,4,17 601.41 (8) (a) 1. "Group health benefit plan" has the meaning given in s. 632.745 (9) (a) and (b).

SB466, s. 5 Section 5. 601.42 (1g) (intro.) of the statutes is amended to read:

SB466,4,22 601.42 (1g) Reports. (intro.) The commissioner may require any of the following from any person subject to regulation under chs. 600 to 655 and from any city, village, town, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan:

SB466, s. 6 Section 6. 601.42 (4) of the statutes is amended to read:

SB466,5,11 601.42 (4) Replies. Any officer, manager or general agent of any insurer authorized to do or doing an insurance business in this state, any person controlling or having a contract under which the person has a right to control such an insurer, whether exclusively or otherwise, any person with executive authority over or in charge of any segment of such an insurer's affairs, any person with authority over or in charge of a self-insured health plan of a city, town, village, county or school district, any individual practice association or officer, director or manager of an individual practice association, any insurance agent or other person licensed under chs. 600 to 646, any provider of services under a continuing care contract, as defined in s. 647.01 (2), any independent review organization certified or recertified under s. 632.835 (4) or any health care provider, as defined in s. 655.001 (8), shall reply promptly in writing or in other designated form, to any written inquiry from the commissioner requesting a reply.

SB466, s. 7 Section 7. 601.43 (1) (a) of the statutes is amended to read:

SB466,5,21 601.43 (1) (a) Insurers, other licensees and other persons subject to regulation. Whenever the commissioner deems it necessary in order to inform himself or herself about any matter related to the enforcement of chs. 600 to 647, the commissioner may examine the affairs and condition of any licensee or permittee under chs. 600 to 647 or applicant for a license or permit, of any person or organization of persons doing or in process of organizing to do an insurance business in this state, of any city, village, town, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan, and of any advisory organization serving any of the foregoing in this state.

SB466, s. 8 Section 8. 601.43 (1) (d) of the statutes is amended to read:

SB466,6,2 601.43 (1) (d) Delivery of records to the office. On order of the commissioner any licensee or permittee under chs. 600 to 647, or a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan, shall bring to the office for examination such records as the order reasonably requires.

SB466, s. 9 Section 9. 601.64 (1) of the statutes is amended to read:

SB466,6,10 601.64 (1) Injunctions and restraining orders. The commissioner may commence an action in circuit court in the name of the state to restrain by temporary or permanent injunction or by temporary restraining order any violation of chs. 600 to 655 or s. 59.52 (11) (c), 66.0137 (4) or (4m), 120.13 (2) (b) to (g), or 149.13, any rule promulgated under chs. 600 to 655, or any order issued under s. 601.41 (4). The commissioner need not show irreparable harm or lack of an adequate remedy at law in an action commenced under this subsection.

SB466, s. 10 Section 10. 601.64 (3) (a) of the statutes is amended to read:

SB466,6,16 601.64 (3) (a) Restitutionary forfeiture. Whoever violates an effective order issued under s. 601.41 (4), any insurance statute or rule, or s. 59.52 (11) (c), 66.0137 (4) or (4m), 120.13 (2) (b) to (g), or 149.13 shall forfeit to the state twice the amount of any profit gained from the violation, in addition to any other forfeiture or penalty imposed.

SB466, s. 11 Section 11. 601.64 (3) (c) of the statutes is amended to read:

SB466,6,24 601.64 (3) (c) Forfeiture for violation of statute or rule. Whoever violates an insurance statute or rule or s. 149.13, intentionally aids a person in violating an insurance statute or rule or s. 59.52 (11) (c), 66.0137 (4) or (4m), 120.13 (2) (b) to (g), or 149.13, or knowingly permits a person over whom he or she has authority to violate an insurance statute or rule or s. 149.13 shall forfeit to the state not more than $1,000 for each violation. If the statute or rule imposes a duty to make a report to the commissioner, each week of delay in complying with the duty is a new violation.

SB466, s. 12 Section 12. 601.64 (4) of the statutes is amended to read:

SB466,7,6 601.64 (4) Criminal penalty. Whoever intentionally violates or intentionally permits any person over whom he or she has authority to violate or intentionally aids any person in violating any insurance statute or rule of this state, s. 59.52 (11) (c), 66.0137 (4) or (4m), 120.13 (2) (b) to (g), or 149.13, or any effective order issued under s. 601.41 (4) is guilty of a Class I felony, unless a specific penalty is provided elsewhere in the statutes. Intent has the meaning expressed under s. 939.23.

SB466, s. 13 Section 13. 623.17 of the statutes is created to read:

SB466,7,12 623.17 Self-insured governmental health plans. (1) The commissioner shall promulgate rules regarding the level of reserves, compulsory surplus, and security surplus that must be maintained by a city, village, town, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan.

SB466,7,15 (2) The commissioner may order a city, village, town, county, or school district to adjust its reserves or surpluses if they do not bear an appropriate relation to its obligations with regard to a self-insured health plan.

SB466,7,17 (3) A city, village, town, county, or school district that provides a self-insured health plan shall do all of the following:

SB466,7,18 (a) Comply with rules promulgated and orders issued under this section.

SB466,7,20 (b) Report to the commissioner annually the levels of reserves and surpluses maintained with respect to a self-insured health plan.

SB466, s. 14 Section 14. 627.23 (2) of the statutes is amended to read:

SB466,8,5 627.23 (2) Power to cede reinsurance. Subject to s. 611.78, any authorized insurer or a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan, may cede to any insurer authorized to assume it under chs. 611 to 618 and sub. (1) any liability it has undertaken on risks lawfully written under its certificate of authority. It may also cede reinsurance to any authorized agency of the federal government or of this state. Subject to rules promulgated by the commissioner for calculation of its reserves and its surplus, and subject to sub. (3), an authorized insurer may also cede reinsurance to an unauthorized insurer.

SB466, s. 15 Section 15. 627.23 (6) of the statutes is created to read:

SB466,8,10 627.23 (6) Reinsurance of self-insured health plans. A city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan, shall report annually to the commissioner the name of any reinsurer.

SB466, s. 16 Section 16. 631.90 (2) (intro.) of the statutes is amended to read:

SB466,8,14 631.90 (2) (intro.) With regard to policies or plans issued or renewed on and after July 20, 1985, an insurer or self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., may not do any of the following:

SB466, s. 17 Section 17. 631.90 (2) (b) of the statutes is amended to read:

SB466,8,19 631.90 (2) (b) Condition the provision of insurance or plan coverage on whether an individual has obtained a test for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV or what the results of this test, if obtained by the individual, were.

SB466, s. 18 Section 18. 631.90 (2) (c) of the statutes is amended to read:

SB466,8,24 631.90 (2) (c) Consider in the determination of rates or any other aspect of insurance or plan coverage provided to an individual whether an individual has obtained a test for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV or what the results of this test, if obtained by the individual, were.

SB466, s. 19 Section 19. 631.93 (2) of the statutes is amended to read:

SB466,9,6 631.93 (2) Accident and health insurance. An accident or health insurance policy or self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., may not contain exclusions or limitations, including deductibles or copayments, for coverage of the treatment of HIV infection or any illness or medical condition arising from or related to HIV infection, unless the exclusions or limitations apply generally to other illnesses or medical conditions covered by the policy or plan.

SB466, s. 20 Section 20. 631.95 (2m) of the statutes is created to read:

SB466,9,11 631.95 (2m) Prohibitions and exceptions for self-insured health plans. (a) In this subsection, "self-insured governmental body" means a city, town, village, county, or school district that provides a self-insured health plan, with respect to the health plan.

SB466,9,13 (b) Except as provided in par. (c), a self-insured governmental body may not do any of the following:

SB466,9,20 1. Refuse to provide or renew coverage to a health plan participant under the self-insured health plan on the basis that the health plan participant has been, or the self-insured governmental body has reason to believe that the health plan participant is, a victim of abuse or domestic abuse or that a member of the health plan participant's family has been, or the self-insured governmental body has reason to believe that a member of the health plan participant's family is, a victim of abuse or domestic abuse.

SB466,9,25 2. Use as a factor in the determination of employee contributions or any other aspect of coverage under the self-insured health plan, the knowledge or suspicion that a health plan participant has been or is a victim of abuse or domestic abuse or that a member of the health plan participant's family has been or is a victim of abuse or domestic abuse.

SB466,10,7 3. Exclude or limit coverage of, or deny a claim for, health care services or items related to the treatment of injury or disease resulting from abuse or domestic abuse on the basis that a health plan participant has been, or the self-insured governmental body has reason to believe that a health plan participant is, a victim of abuse or domestic abuse or that a member of the health plan participant's family has been, or the self-insured governmental body has reason to believe that a member of the health plan participant's family is, a victim of abuse or domestic abuse.

SB466,10,13 (c) In establishing any employee contribution amounts for a self-insured health plan, a self-insured governmental body may inquire about a person's existing medical condition and, based on the opinion of a qualified actuary, as defined in s. 623.06 (1c), use information related to a person's existing medical condition, regardless of whether that condition is or may have been caused by abuse or domestic abuse.

SB466, s. 21 Section 21. 631.95 (4) of the statutes is amended to read:

SB466,10,19 631.95 (4) Immunity for insurers. An insurer or a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan, is immune from any civil or criminal liability for any action taken under sub. (2m) (c) or (3) or for the death of, or injury to, an insured or health plan participant that results from abuse or domestic abuse.

SB466, s. 22 Section 22. 631.95 (5) (a) of the statutes is renumbered 631.95 (5) (ar).

SB466, s. 23 Section 23. 631.95 (5) (ag) of the statutes is created to read:

SB466,10,22 631.95 (5) (ag) In this subsection, unless the context requires otherwise:

SB466,10,24 1. "Insurance" includes a self-insured health plan of a city, town, village, county, or school district.

SB466,11,2 2. "Insured" includes a person who participates in a self-insured health plan provided by a city, town, village, county, or school district.

SB466,11,4 3. "Insurer" includes a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan.

SB466, s. 24 Section 24. 631.95 (5) (c) (intro.) of the statutes is amended to read:

SB466,11,9 631.95 (5) (c) (intro.) Paragraphs (a) (ar) and (b) do not apply if the use, disclosure or transfer of the information is made with the consent of the individual to whom the information relates or if the use, disclosure or transfer satisfies any of the following:

SB466, s. 25 Section 25. 632.726 (2) of the statutes is amended to read:

SB466,11,17 632.726 (2) If an insurer or a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan, changes a current procedural terminology code that was submitted by a health care provider on a health insurance claim form, the insurer or city, town, village, county, or school district shall include on the explanation of benefits form the reason for the change to the current procedural terminology code and shall cite on the explanation of benefits form the source for the change.

SB466, s. 26 Section 26. 632.745 (intro.) of the statutes is amended to read:

SB466,11,21 632.745 Coverage requirements for group and individual health benefit plans; definitions. (intro.) In this section and ss. 632.746 to 632.7495, unless the context requires otherwise:

SB466, s. 27 Section 27. 632.745 (9) of the statutes is renumbered 632.745 (9) (intro.) and amended to read:

SB466,11,24 632.745 (9) (intro.) "Group health benefit plan" means a any of the following:

SB466,12,3 (a) 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 employees or a group including at least 2 eligible employees. The term includes individual

SB466,12,5 (b) Individual health benefit plans covering eligible employees when 3 or more are sold to or through an employer.

SB466, s. 28 Section 28. 632.745 (9) (c) of the statutes is created to read:

SB466,12,7 632.745 (9) (c) A self-insured health plan under sub. (24) (b) and (c).

SB466, s. 29 Section 29. 632.745 (15) of the statutes is amended to read:

SB466,12,17 632.745 (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 employees 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, a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan, and a limited service health organization, as defined in s. 609.01 (3).

SB466, s. 30 Section 30. 632.745 (24) of the statutes is renumbered 632.745 (24) (intro.) and amended to read:

SB466,12,21 632.745 (24) "Self-insured health plan" means a self-insured health plan of the any of the following:

SB466,12,22 (a) The state or a .

SB466,12,23 (b) A county, city, village, or town or.

SB466,12,24 (c) A school district.

SB466, s. 31 Section 31. 632.83 (1) of the statutes is renumbered 632.83 (1) (intro.) and amended to read:

SB466,13,3 632.83 (1) In this section, "health :

SB466,13,8 (a) "Health benefit plan" has the meaning given in s. 632.745 (11), except that "health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10. and includes a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., and a policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.

SB466, s. 32 Section 32. 632.83 (1) (b) of the statutes is created to read:

SB466,13,11 632.83 (1) (b) "Insured" includes a person who participates in a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3.

SB466, s. 33 Section 33. 632.83 (1) (c) of the statutes is created to read: