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2011 - 2012 LEGISLATURE
July 29, 2011 - Introduced by Representative Petersen. Referred to Committee on
Insurance.
AB210,1,12 1An Act to repeal 609.755, 632.83, 632.835 and 632.885; to renumber 625.02 (1);
2to renumber and amend 625.03 (1m) (e); to amend 40.51 (8), 40.51 (8), 40.51
3(8m), 40.51 (8m), 49.67 (3) (am) 2. b., 66.0137 (4), 66.0137 (4), 111.91 (2) (n),
4111.91 (2) (nm), 111.91 (2) (s), 111.998 (2) (n), 111.998 (2) (s), 120.13 (2) (g),
5120.13 (2) (g), 185.983 (1) (intro.), 185.983 (1) (intro.), 600.01 (2) (b), 601.31 (1)
6(Lp), 601.31 (1) (Lr), 601.42 (4), 609.655 (4) (b), 625.13 (1), 625.14, 632.76 (2) (ac)
71., 632.76 (2) (ac) 2., 632.76 (2) (ac) 3. (intro.) and 632.895 (15) (c) (intro.); and
8to create 601.465 (1m) (d), 625.02 (1h), 625.02 (1p), 625.02 (2f), 625.02 (2s),
9625.03 (1m) (e) 2., 625.03 (1m) (e) 3., 625.13 (3), 632.76 (2) (ac) 4. and chapter
10636 of the statutes; relating to: implementing health insurance reform,
11providing an exemption from emergency rule procedures, and granting
12rule-making authority.
Analysis by the Legislative Reference Bureau
This bill incorporates the health insurance coverage requirements of the
federal Patient Protection and Affordable Care Act (PPACA) into the Wisconsin

statutes. The bill requires insurers to comply with PPACA provisions that went into
effect for plan years beginning on or after March 23, 2010, relating to all of the
following: 1) standards relating to benefits for mothers and newborns; 2) required
coverage for reconstructive surgery following a mastectomy; and 3) coverage of a
dependent student on a medically necessary leave of absence. The bill requires
insurers to comply with PPACA provisions that went into effect for plan years
beginning on or after September 23, 2010, relating to all of the following: 1)
prohibiting annual or lifetime limits; 2) prohibiting coverage rescissions; 3)
prohibiting preexisting condition exclusions for individuals under age 19; 4)
coverage of certain preventive health services without cost-sharing; 5) extension of
coverage to dependents up to age 26; 6) the provision of additional information; 7)
giving plan enrollees choice as to a primary care provider; and 8) coverage of
emergency services without prior authorization. In addition, the bill requires
insurers to comply with PPACA provisions for plan years beginning on or after March
23, 2012, relating to all of the following: 1) the development and use of uniform
explanation of coverage documents and standardized definitions; and 2)
requirements for ensuring the quality of care. The bill also requires insurers to
comply with the PPACA requirement to file a report for each plan year concerning
the ratio of incurred loss, plus loss adjustment expense, to earned premiums and to
provide a rebate to enrollees under certain circumstances. Under PPACA, the
provisions apply to insurers offering medical care benefits under any hospital or
medical service policy or plan contract.
A health care policy or plan that was in effect when PPACA was enacted is
called a grandfathered health plan. The bill specifically requires a grandfathered
health plan to comply, when the grandfathered health plan is renewed, with the
following PPACA provisions: 1) coverage of a dependent student on a medically
necessary leave of absence; 2) coverage of certain preventive health services without
cost-sharing; 3) coverage of emergency services without prior authorization; and 4)
at renewal on or after March 23, 2012, requirements for ensuring the quality of care.
The bill provides that the additional requirements under the bill with which insurers
must comply apply to grandfathered health plans only with respect to those
requirements that apply to grandfathered health plans under PPACA.
Current law requires health insurers to cover emergency services without prior
authorization, breast reconstruction after a mastectomy, dependent coverage of a
student while on a medically necessary leave of absence, and colorectal screening.
These coverage provisions are consistent with, and therefore duplicative of, the
relevant PPACA requirements and are not repealed in the bill. Current law also
requires health insurers to provide coverage of a dependent up to age 27, or up to any
age if the dependent is a student and had to leave school previously because he or she
was called to active duty in the armed forces. PPACA requires coverage of a
dependent up to age 26 and has no additional requirement related to a student
previously called to active duty. Because of this inconsistency, the current law
dependent coverage provision is repealed in the bill. The bill specifies that, if PPACA
is found by a final decision of a federal court of competent jurisdiction to be
unconstitutional in its entirety and unenforceable in this state, after all appeals have

been exhausted or the time for appeal has expired insurers are exempt from the
PPACA coverage requirements incorporated into the bill, with the exception of the
provision related to dependent coverage. Thus, if PPACA were found
unconstitutional, in addition to the dependent coverage requirement, insurers would
be subject to the coverage requirements in current law that are consistent with
PPACA and that have not been repealed in the bill.
Under current law, a health insurer must have an internal grievance procedure
and an independent review procedure whereby an insured person may appeal
certain types of coverage denials to an independent review organization. The
statutes set out criteria for both procedures and provide for certification of
independent review organizations by the commissioner of insurance (commissioner).
The bill repeals these provisions and requires the commissioner to establish
standards by rule for both internal and external appeals that are consistent with
requirements under PPACA. The requirements for internal appeals apply to all
group and individual health insurance policies, grandfathered health plans, policies
providing limited-scope dental or vision benefits, and hospital or fixed indemnity
policies. The requirements for external appeals apply to all group and individual
health insurance policies, grandfathered health plans, hospital or fixed indemnity
policies, and Medicare supplement or replacement polices, excluding Medicare
advantage plans. An independent review organization performing external appeals
must be certified by the commissioner, who may revoke, suspend, or limit the
certification or refuse to recertify under specified conditions. An independent review
organization must have a quality assurance mechanism to ensure timely and
independent reviews and may charge reasonable fees, which must be approved by
the commissioner. The commissioner has authority to examine and audit an
independent review organization's books and records. A decision of an independent
review organization is binding on the insured and the insurer. An independent
review organization is immune from any liability that may result from an
independent review determination, and an insurer is not liable for any damages
attributable to actions taken in compliance with an independent review organization
determination.
Under current law, rates for insurance must be filed with the commissioner
within 30 days after they become effective, and the commissioner may disapprove a
rate after it has been filed. Certain types of insurance, including group and blanket
accident and sickness insurance, are exempt from the rating requirement provisions,
including the requirement to file rates. The bill provides that, beginning on
September 1, 2011, group health insurance offered to employers with not more than
50 employees (small employer health insurance) and group and blanket accident and
sickness insurance offered in the individual market are not exempt from the rating
requirement provisions. In addition, the bill requires that rates for individual health
insurance, small employer health insurance, and group and blanket accident and
sickness insurance offered in the individual market be filed with the commissioner
before, rather than after, they become effective.

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:
AB210, s. 1 1Section 1 . 40.51 (8) of the statutes is amended to read:
AB210,4,62 40.51 (8) Every health care coverage plan offered by the state under sub. (6)
3shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8)
4and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855,
5632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896 and, so
6far as applicable, ch. 636
.
AB210, s. 2 7Section 2 . 40.51 (8) of the statutes, as affected by 2011 Wisconsin Act .... (this
8act), is amended to read:
AB210,4,139 40.51 (8) Every health care coverage plan offered by the state under sub. (6)
10shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8)
11and (10), 632.747, 632.748, 632.798, 632.85, 632.853, 632.855, 632.87 (3) to (6),
12632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896 and, so far as applicable,
13ch. 636.
AB210, s. 3 14Section 3 . 40.51 (8m) of the statutes is amended to read:
AB210,4,1815 40.51 (8m) Every health care coverage plan offered by the group insurance
16board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
17632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.885, 632.89, and
18632.895 (11) to (17) and, so far as applicable, ch. 636.
AB210, s. 4 19Section 4 . 40.51 (8m) of the statutes, as affected by 2011 Wisconsin Act .... (this
20act), is amended to read:
AB210,5,4
140.51 (8m) Every health care coverage plan offered by the group insurance
2board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
3632.748, 632.798, 632.85, 632.853, 632.855, 632.885, 632.89, and 632.895 (11) to (17)
4and, so far as applicable, ch. 636.
AB210, s. 5 5Section 5. 49.67 (3) (am) 2. b. of the statutes, as affected by 2011 Wisconsin
6Act 32
, is amended to read:
AB210,5,117 49.67 (3) (am) 2. b. If the applicant is under 26 years of age, notice that he or
8she may be eligible for coverage as a dependent under his or her parent's health care
9plan in accordance with s. 632.885 636.25 (1) (h) or (3) (b), and that his or her parent's
10plan must include coverage for services that are not covered under the plan under
11this section.
AB210, s. 6 12Section 6 . 66.0137 (4) of the statutes is amended to read:
AB210,5,1913 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
14a village provides health care benefits under its home rule power, or if a town
15provides health care benefits, to its officers and employees on a self-insured basis,
16the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
17632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87
18(4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4) and, so
19far as applicable, ch. 636
.
AB210, s. 7 20Section 7 . 66.0137 (4) of the statutes, as affected by 2011 Wisconsin Act ....
21(this act), is amended to read:
AB210,6,322 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
23a village provides health care benefits under its home rule power, or if a town
24provides health care benefits, to its officers and employees on a self-insured basis,
25the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),

1632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87
2(4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4) and, so
3far as applicable, ch. 636.
AB210, s. 8 4Section 8. 111.91 (2) (n) of the statutes is amended to read:
AB210,6,75 111.91 (2) (n) The provision to employees of the health insurance coverage
6required under s. 632.895 (11) to (14), (16), and (16m), and (17) and, so far as
7applicable, s. 636.25
.
AB210, s. 9 8Section 9. 111.91 (2) (nm) of the statutes is amended to read:
AB210,6,119 111.91 (2) (nm) The requirements related to providing coverage for a dependent
10under s. 632.885 and to
continuing coverage for a dependent student on a medical
11leave of absence under s. 632.895 (15).
AB210, s. 10 12Section 10. 111.91 (2) (s) of the statutes is amended to read:
AB210,6,1513 111.91 (2) (s) The requirements related to internal grievance procedures under
14s. 632.83 and independent review
and external appeals of certain health benefit plan
15determinations established under s. 632.835 636.12.
AB210, s. 11 16Section 11. 111.998 (2) (n) of the statutes is amended to read:
AB210,6,1817 111.998 (2) (n) The provision to employees of the health insurance coverage
18required under s. 632.895 (11) to (14) and, so far as applicable, s. 636.25.
AB210, s. 12 19Section 12. 111.998 (2) (s) of the statutes is amended to read:
AB210,6,2220 111.998 (2) (s) The requirements related to internal grievance procedures
21under s. 632.83 and independent review
and external appeals of certain health
22benefit plan determinations established under s. 632.835 636.12.
AB210, s. 13 23Section 13 . 120.13 (2) (g) of the statutes is amended to read:
AB210,7,224 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
2549.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),

1632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895
2(9) to (17), 632.896, and 767.513 (4) and, so far as applicable, ch. 636.
AB210, s. 14 3Section 14 . 120.13 (2) (g) of the statutes, as affected by 2011 Wisconsin Act ....
4(this act), is amended to read:
AB210,7,85 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
649.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
7632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895
8(9) to (17), 632.896, and 767.513 (4) and, so far as applicable, ch. 636.
AB210, s. 15 9Section 15 . 185.983 (1) (intro.) of the statutes is amended to read:
AB210,7,1710 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
11cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
12646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
13601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
14631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85,
15632.853, 632.855, 632.87 (2), (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (5)
16and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 625, 630, 635, 636, 645,
17and 646, but the sponsoring association shall:
AB210, s. 16 18Section 16 . 185.983 (1) (intro.) of the statutes, as affected by 2011 Wisconsin
19Act .... (this act), is amended to read:
AB210,8,220 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
21cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
22646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
23601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
24631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85,
25632.853, 632.855, 632.87 (2), (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (5)

1and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 625, 630, 635, 636, 645,
2and 646, but the sponsoring association shall:
AB210, s. 17 3Section 17. 600.01 (2) (b) of the statutes is amended to read:
AB210,8,54 600.01 (2) (b) Group or blanket insurance described in sub. (1) (b) 3. and 4. is
5not exempt from ss. 632.745 to 632.749, 632.83 or 632.835 or 636.12 or ch. 633 or 635.
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