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2011 - 2012 LEGISLATURE
October 7, 2011 - Introduced by Representatives Richards, Pasch, Berceau,
Bernard Schaber, Bewley, Clark, E. Coggs, Grigsby, Hebl, Hintz, Milroy,
Pocan, Pope-Roberts, Roys, Seidel, Sinicki, C. Taylor, Toles
and Turner,
cosponsored by Senators Erpenbach, C. Larson, Jauch, Taylor, Holperin,
Hansen, Carpenter
and S. Coggs. Referred to Committee on Insurance.
AB312,2,4 1An Act to repeal 631.95 (3) (a), 632.746 (1) (b), 632.746 (2) (a) and (b), 632.746
2(2) (c), (d) and (e), 632.746 (2) (dm), 632.746 (3) (a), 632.746 (3) (d) 2. and 3.,
3632.746 (10) (a) 4., 632.7497 (3) (b), 632.76 (2) (ac) 2., 632.76 (2) (ac) 3., 632.76
4(2) (ac) 4., 632.895 (15) (c) 1. to 4. and 632.895 (15) (c) 6.; to renumber 632.746
5(3) (d) 1. and 632.7497 (3) (a); to renumber and amend 632.746 (1) (a), 632.76
6(2) (ac) 1., 632.895 (13) (a) and 632.895 (15) (a); to amend 40.51 (8), 40.51 (8),
740.51 (8m), 40.51 (8m), 66.0137 (4), 66.0137 (4), 120.13 (2) (g), 120.13 (2) (g),
8185.983 (1) (intro.), 185.983 (1) (intro.), 609.22 (3), 609.845, 625.12 (1) (a) and
9(e), 625.12 (2), 625.15 (1), 628.34 (3) (a), 631.11 (4) (a) and (b), 631.22 (2), 631.22
10(5), 632.746 (5) (a), 632.746 (8) (a) (intro.), 632.746 (10) (a) 1., 632.76 (2) (a),
11632.76 (2) (ac) 1., 632.76 (2) (ac) 2., 632.76 (2) (ac) 3. (intro.), 632.76 (2) (b),
12632.795 (4) (a), 632.85 (2), 632.883 (2), 632.895 (15) (b), 632.895 (15) (c) 5.,
13632.897 (11) (a) and 635.02 (2); and to create 609.845, 632.723, 632.7252,
14632.7254, 632.728, 632.746 (2) (dm), 632.7493, 632.753, 632.758, 632.76 (2) (ac)

14., 632.85 (4), 632.865, 632.87 (5m), 632.883, 632.895 (13) (a) 2., 632.895 (13)
2(a) 3., 632.895 (13) (c), 632.895 (13m), 632.895 (15) (a) 1., 2. and 3., 632.895 (15)
3(d) and 632.895 (15) (e) of the statutes; relating to: implementing federal
4health insurance law changes.
Analysis by the Legislative Reference Bureau
On March 23, 2010, the federal government enacted the Patient Protection and
Affordable Care Act (PPACA), which, among other things, imposes requirements and
limitations on health insurance policies and health plans. This bill incorporates
some of those requirements and limitations of PPACA into state law.
Under current law, no insurer may rescind an insurance policy for a
misrepresentation made by a policyholder if the insurer had constructive or active
knowledge of the fact. An insurer may rescind a policy if it acquires knowledge of
sufficient facts to constitute grounds for rescission after the policy was issued only
if the insurer notifies the insured within 60 days after acquiring the knowledge of its
intent to rescind or within 120 days if the insurer needs to gather additional medical
information. This bill prohibits an insurer from rescinding a health benefit plan, or
a self-insured governmental health plan from recinding a self-insured plan, unless
the applicant for coverage committed fraud or made an intentional
misrepresentation of material fact with regard to obtaining coverage. The insurer
or governmental entity must provide notice before rescinding the plan.
Under current law, a policy or plan providing individual health insurance may
not reduce or deny coverage based on a preexisting disease or condition (preexisting
condition exclusion) after 12 months after the date of issue of the policy or plan unless
the condition was specifically excluded from coverage. The preexisting condition
that is excluded from coverage must have been one for which the individual received
or was recommended medical advice, diagnosis, care, or treatment within 12 months
before the coverage under the plan became effective. A group health benefit plan,
under current law may impose a preexisting condition exclusion on an individual's
coverage only if the condition being excluded was one for which the individual was
recommended or received medical advice, diagnosis, care, or treatment within six
months before the individual's enrollment date under the plan. This bill prohibits
an insurer under a group health benefit plan or an individual health insurance
policy, except for a grandfathered health plan providing individual health coverage,
from imposing a preexisting condition exclusion on a participant or beneficiary
under the plan who is under 19 years of age. A grandfathered health plan is a health
policy or plan in existence on March 23, 2010. As of January 1, 2014, this bill
prohibits an insurer that offers a group health benefit plan or an individual health
insurance policy, except for a grandfathered health plan providing individual health
coverage, from imposing a preexisting condition exclusion on any participant or
beneficiary under the plan, regardless of age.

Under the bill, every group health plan, except for a grandfathered health plan,
and every insurer providing a health insurance policy, and every self-insured
governmental health plan must provide coverage for all preventive care services as
defined in PPACA. The bill prohibits a plan or insurer from subjecting the coverage
of a preventive care service to a copayment or coinsurance.
This bill requires an individual or group health plan, except a grandfathered
health plan, to provide in plain language to the secretary of the federal department
of health and human services (DHHS), the commissioner of insurance, any insurance
exchange if the plan is sold through an exchange, and the public certain disclosures
including claims payment policies and practices, data on enrollment and
disenrollment in the plan, and enrollee and participant rights. A health benefit plan,
except a grandfathered health plan, is also required to make available upon request
on its Internet Web site, and through another means for those without Internet
access, a means to permit individuals to learn the amount of cost sharing required
under the plan for a specific item or service.
This bill requires that a group or individual health benefit plan, except for a
grandfathered health plan, that requires or provides for an individual or beneficiary
to designate a primary care provider must allow each individual or beneficiary to
designate any participating primary care provider who is available to accept that
individual or beneficiary.
Under current law, a health care plan or a self-insured governmental health
plan that provides coverage of any emergency medical services must provide
coverage of emergency medical services that are provided in a hospital emergency
facility and that are needed to evaluate or stabilize an emergency medical condition.
Current law prohibits the health care plan or self-insured governmental health plan
from requiring prior authorization for those emergency medical services. This bill
specifies that the services must be covered regardless whether the hospital
emergency facility is a participating provider in the health care plan or self-insured
governmental health plan. This bill also requires that the health care plan or
self-insured governmental health plan, except for a grandfathered health plan,
impose the same cost-sharing requirements on coverage for emergency medical
services provided by a nonparticipating provider as it imposes for a participating
provider.
With some exceptions, this bill prohibits a self-insured governmental health
plan or a health care plan, except for a grandfathered health plan, from restricting
benefits for a hospital stay for a mother or newborn to less than 48 hours for a vaginal
delivery or less than 96 hours for a cesarean section.
Under current law, every health insurance policy and self-insured
governmental health plan that provides coverage of mastectomies must provide
coverage of breast reconstruction of the affected tissue incident to a mastectomy. The
policy or plan may impose cost-sharing provisions on the breast reconstruction
coverage that apply generally under the policy or plan. This bill specifies that all
stages of breast reconstruction must be covered by a policy or plan. Under the bill,
the policy or plan must also cover surgery and reconstruction of the other breast than
the one on which the mastectomy was performed to produce a symmetrical

appearance and prostheses and physical complications of mastectomy. The bill also
specifies that all procedures covered must be provided in a manner determined in
consultation with the attending physician and the patient. A policy or plan is
required under the bill to provide written notice of the available coverage upon
enrollment in the policy and annually thereafter.
Under current law, every health insurance policy and every self-insured
governmental health plan that provides coverage for a full-time student dependent
of the insured, must continue to provide coverage for that dependent if, due to a
medically necessary leave of absence, the dependent is no longer a full-time student.
The policy or plan is not required to continue coverage unless the medical necessity
of the leave of absence is documented and certified by the attending physician. The
coverage continues until the dependent advises the policy or plan that he or she no
longer intends to return to school full time, becomes employed full time, obtains other
health care coverage, marries and is eligible for coverage as a spouse, reaches an age
where he or she is no longer eligible for dependent coverage, or has not returned to
school full time after one year since the continuation began or until the coverage of
the insured under which the dependent has coverage is discontinued or not renewed.
This bill specifies that a policy or plan must continue coverage only if the leave
commences while the individual is suffering from a serious illness or injury, the leave
is medically necessary, and the leave causes the individual to lose student status.
The bill specifies that the physician must also document that the dependent is
suffering from a serious illness. The bill requires dependent coverage to continue
until the coverage would otherwise end or until one year has elapsed since the
continuation began and the dependent has not returned to school full time, and the
bill eliminates the other situations under which the continued coverage requirement
ends. The bill also requires that every policy and plan provide a description of the
continued coverage during a medically necessary leave of absence with any notice
regarding a requirement for certification of student status for the dependent's
coverage. The dependent whose coverage is being continued during a medically
necessary leave of absence is entitled under the bill to the same coverage as a
full-time student who is not on leave.
Under current law, an insurer is required to provide consumers policies that are
coherent, written in commonly understood language, legible, appropriately divided
and captioned, and presented in a meaningful sequence. The commissioner of
insurance must make rules establishing standards for the understandability of
policies and may exempt types of policies from the specific understandability
requirements if the commissioner determines that the type of policy is generally
understood by those receiving it or those individuals are adequately protected. This
bill additionally requires that, no later than March 23, 2012, each health insurer,
health plan, and self-insured governmental health plan comply with the standards
that the secretary of the federal DHHS will create regarding compiling and providing
a summary of benefits and coverage explanation that accurately describes the
benefits and coverage under the plan.
This bill requires that no later than March 23, 2012, every health care plan,
except for a grandfathered health care plan, and self-insured governmental health

plan must comply with the standards developed by the secretary of the federal DHHS
regarding reporting for reimbursement structures to improve health outcomes and
other quality measures.
This bill prohibits an insurer or self-insured governmental health plan from
imposing a lifetime limit on the dollar value of benefits under the group or individual
health care plan or self-insured plan. Before January 1, 2014, an insurer under a
group or an individual health care plan, except for a grandfathered health plan
providing individual coverage, or a self-insured governmental health plan may
impose only a certain annual limit on the dollar value of benefits as defined by the
secretary of the federal DHHS. Starting on January 1, 2014, an insurer under a
group or individual health care plan, except for a grandfathered health plan
providing individual coverage, and a self-insured governmental health plan may not
impose an annual limit on the dollar value of benefits.
Under current law, if an insurer provides coverage under a group health benefit
plan, the insurer must provide coverage to any eligible employee who becomes an
eligible employee after the group coverage commences, and his or her dependents,
regardless of health condition or claims experience, with certain exceptions. A
self-insured governmental health plan must similarly provide coverage to an
eligible employee who waived coverage during an enrollment period, regardless of
health condition or claims experience, with certain exceptions. With certain
exceptions, under current law, an insurer offering a group health benefit plan must
renew coverage at the option of the employer. Current law also requires an insurer
that provides an individual health benefit plan to renew the coverage for the insured
at the option of the insured, with certain exceptions, but modifications to the
individual health benefit plan that comply with the law are allowed. This bill
requires any insurer that offers an individual health benefit plan, except for a
grandfathered health plan, to offer coverage to any individual, and his or her
dependents, that apply for coverage.
Under current law, insurers offering individual or group health insurance
policies or plans are not limited in what factors they use to set rates, or premiums,
except that they may not discriminate on the basis of race, color, creed, or national
origin and they may not under a group health insurance policy or plan charge a
higher rate based on a health status-related factor. Rates, under current law, may
be modified for individual risks. As of January 1, 2014, health care plans, except for
grandfathered health plans, and self-insured governmental health plans, when
setting premium rates, may only consider whether the plan covers an individual or
a family and the age, tobacco use, and geographic location of any individual covered
under the plan. Rates based on age or tobacco use may only vary a certain amount
under the bill.
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:
AB312, s. 1
1Section 1 . 40.51 (8) of the statutes is amended to read:
AB312,6,62 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), 632.723,
4632.7252, 632.7254,
632.746 (1) to (8) and (10), 632.747, 632.748, 632.753, 632.798,
5632.83, 632.835, 632.85, 632.853, 632.855, 632.865, 632.87 (3) to (6), 632.883,
6632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.
AB312, s. 2 7Section 2 . 40.51 (8) of the statutes, as affected by 2011 Wisconsin Act .... (this
8act), is amended to read:
AB312,6,139 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), 632.723,
11632.7252, 632.7254, 632.728, 632.746 (1) (1m) to (8) and (10), 632.747, 632.748,
12632.753, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.865, 632.87 (3) to
13(6), 632.883, 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.
AB312, s. 3 14Section 3 . 40.51 (8m) of the statutes is amended to read:
AB312,6,1915 40.51 (8m) Every health care coverage plan offered by the group insurance
16board under sub. (7) shall comply with ss. 631.95, 632.723, 632.7252, 632.7254,
17632.746 (1) to (8) and (10), 632.747, 632.748, 632.753, 632.798, 632.83, 632.835,
18632.85, 632.853, 632.855, 632.865, 632.87 (5m), 632.883, 632.885, 632.89, and
19632.895 (11) to (17).
AB312, s. 4 20Section 4 . 40.51 (8m) of the statutes, as affected by 2011 Wisconsin Act .... (this
21act), is amended to read:
AB312,7,222 40.51 (8m) Every health care coverage plan offered by the group insurance
23board under sub. (7) shall comply with ss. 631.95, 632.723, 632.7252, 632.7254,
24632.728, 632.746 (1) (1m) to (8) and (10), 632.747, 632.753, 632.748, 632.798, 632.83,

1632.835, 632.85, 632.853, 632.855, 632.865, 632.87 (5m), 632.883, 632.885, 632.89,
2and 632.895 (11) to (17).
AB312, s. 5 3Section 5 . 66.0137 (4) of the statutes is amended to read:
AB312,7,104 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
5a village provides health care benefits under its home rule power, or if a town
6provides health care benefits, to its officers and employees on a self-insured basis,
7the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
8632.723, 632.7252, 632.7254, 632.746 (2) (dm) and (10) (a) 2. and (b) 2., 632.747 (3),
9632.753, 632.798, 632.85, 632.853, 632.855, 632.865, 632.87 (4), (5), and to (6),
10632.883, 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
AB312, s. 6 11Section 6 . 66.0137 (4) of the statutes, as affected by 2011 Wisconsin Act ....
12(this act), is amended to read:
AB312,7,1913 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),
17632.723, 632.7252, 632.7254, 632.728, 632.746 (2) (dm) (1m) and (10) (a) 2. and (b)
182., 632.747 (3), 632.753, 632.798, 632.85, 632.853, 632.855, 632.865, 632.87 (4) to (6),
19632.883, 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
AB312, s. 7 20Section 7 . 120.13 (2) (g) of the statutes is amended to read:
AB312,7,2521 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
2249.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.723, 632.7252, 632.7254, 632.746 (2)
23(dm) and
(10) (a) 2. and (b) 2., 632.747 (3), 632.753, 632.798, 632.85, 632.853,
24632.855, 632.865, 632.87 (4), (5), and to (6), 632.883, 632.885, 632.89, 632.895 (9) to
25(17), 632.896, and 767.513 (4).
AB312, s. 8
1Section 8 . 120.13 (2) (g) of the statutes, as affected by 2011 Wisconsin Act ....
2(this act), is amended to read:
AB312,8,73 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
449.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.723, 632.7252, 632.7254, 632.728,
5632.746 (2) (dm) (1m) and (10) (a) 2. and (b) 2., 632.747 (3), 632.753, 632.798, 632.85,
6632.853, 632.855, 632.865, 632.87 (4) to (6), 632.883, 632.885, 632.89, 632.895 (9) to
7(17), 632.896, and 767.513 (4).
AB312, s. 9 8Section 9 . 185.983 (1) (intro.) of the statutes is amended to read:
AB312,8,179 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
10cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
11646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
12601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
13631.95, 632.72 (2), 632.723, 632.7252, 632.7254, 632.745 to 632.749, 632.753,
14632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.865, 632.87 (2),
15(2m), (3), (4), (5), and
to (6), 632.883, 632.885, 632.89, 632.895 (5) and (8) to (17),
16632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the
17sponsoring association shall:
AB312, s. 10 18Section 10 . 185.983 (1) (intro.) of the statutes, as affected by 2011 Wisconsin
19Act .... (this act), is amended to read:
AB312,9,320 185.983 (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), 632.723, 632.7252, 632.7254, 632.728, 632.745 to 632.749,
25632.753, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.865,

1632.87 (2) to (6), 632.883, 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and
2632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association
3shall:
AB312, s. 11 4Section 11. 609.22 (3) of the statutes is amended to read:
AB312,9,125 609.22 (3) Primary provider selection. A Except as provided in s. 632.865,
6a
defined network plan that is not a preferred provider plan shall permit each
7enrollee to select his or her own primary provider from a list of participating primary
8care physicians and any other participating providers that are authorized by the
9defined network plan to serve as primary providers. The list shall be updated on an
10ongoing basis and shall include a sufficient number of primary care physicians and
11any other participating providers authorized by the plan to serve as primary
12providers who are accepting new enrollees.
AB312, s. 12 13Section 12. 609.845 of the statutes is created to read:
AB312,9,18 14609.845 Coverage requirements and limitations; preventive care;
15maternal and newborn care; quality; standardization.
Limited service health
16organizations, preferred provider plans, and defined network plans are subject to ss.
17632.723, 632.7252, 632.7254, 632.746 (2) (dm) or 632.76 (2) (ac) 4., 632.753, 632.865,
18632.87 (5m), 632.883, and 632.895 (13m).
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