SB206: Bill Text

SB206, s. 43 Section 43. 632.758 of the statutes is created to read:

SB206,17,25 632.758 Special treatment of grandfathered health plans. (1) Definition. In this section, "grandfathered health plan" means any group health plan or group or individual health insurance coverage in which an individual was enrolled on March 23, 2010.

SB206,18,6 (2) Preexisting condition exclusion. (a) No claim or loss incurred or disability commencing after 12 months from the date of issue of a grandfathered health plan that provides individual health insurance coverage may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

SB206,18,11 (b) A grandfathered health plan that provides individual health insurance coverage may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

SB206, s. 44 Section 44. 632.76 (2) (a) of the statutes is amended to read:

SB206,18,20 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.745 (24).

SB206, s. 45 Section 45. 632.76 (2) (ac) 1. of the statutes is amended to read:

SB206,19,2 632.76 (2) (ac) 1. Notwithstanding par. (a) and except as provided in subd. 4., no claim or loss incurred or disability commencing after 12 months from the date of issue of an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

SB206, s. 46 Section 46. 632.76 (2) (ac) 1. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is renumbered 632.76 (2) (am) and amended to read:

SB206,19,12 632.76 (2) (am) Notwithstanding par. (a) and except as provided in subd. 4., no claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss. This paragraph does not apply to a grandfathered health plan, as defined in s. 632.758 (1), that provides individual health insurance coverage.

SB206, s. 47 Section 47. 632.76 (2) (ac) 2. of the statutes is amended to read:

SB206,19,19 632.76 (2) (ac) 2. Except as provided in subd. subds. 3. and 4., an individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

SB206, s. 48 Section 48. 632.76 (2) (ac) 2. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

SB206, s. 49 Section 49. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

SB206,20,2 632.76 (2) (ac) 3. (intro.) Except as provided in subd. 4. and except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy subject to s. 632.7495 (4) and (5):

SB206, s. 50 Section 50. 632.76 (2) (ac) 3. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

SB206, s. 51 Section 51. 632.76 (2) (ac) 4. of the statutes is created to read:

SB206,20,12 632.76 (2) (ac) 4. No individual disability insurance policy, as defined in s. 632.895 (1) (a), or self-insured health plan, as defined in 632.745 (24), may reduce or deny a claim for loss by a participant or beneficiary under the policy or plan who is under the age of 19 on the ground that a disease or physical condition existed prior to the effective date of coverage. This subdivision does not apply to a grandfathered health plan, as defined in s. 632.758 (1), that provides individual health insurance coverage.

SB206, s. 52 Section 52. 632.76 (2) (ac) 4. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

SB206, s. 53 Section 53. 632.76 (2) (b) of the statutes is amended to read:

SB206,21,8 632.76 (2) (b) Notwithstanding par. (a), no claim for loss incurred or disability commencing after 6 months from the date of issue of a medicare supplement policy, medicare replacement policy or long-term care insurance policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage. Notwithstanding par. (ac) 2., a A medicare supplement policy, medicare replacement policy, or long-term care insurance policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. Notwithstanding par. (a), if on the basis of information contained in an application for insurance a medicare supplement policy, medicare replacement policy, or long-term care insurance policy excludes from coverage a condition by name or specific description, the exclusion must terminate no later than 6 months after the date of issue of the medicare supplement policy, medicare replacement policy, or long-term care insurance policy. The commissioner may by rule exempt from this paragraph certain classes of medicare supplement policies, medicare replacement policies, and long-term care insurance policies, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.

SB206, s. 54 Section 54. 632.795 (4) (a) of the statutes is amended to read:

SB206,21,21 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods , or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.

SB206, s. 55 Section 55. 632.85 (2) of the statutes is amended to read:

SB206,22,3 632.85 (2) If a health care plan or a self-insured health plan provides coverage of any emergency medical services, the health care plan or self-insured health plan shall provide coverage of emergency medical services that are provided in a hospital emergency facility, regardless whether that facility is a participating provider with respect to the plan, and that are needed to evaluate or stabilize, as defined in section 1867 of the federal Social Security Act, an emergency medical condition.

SB206, s. 56 Section 56. 632.85 (4) of the statutes is created to read:

SB206,22,10 632.85 (4) A health care plan or self-insured health plan that is required to provide the coverage under sub. (2) shall impose the same cost-sharing requirements on coverage for emergency medical services provided by a nonparticipating provider as it imposes for services provided by a participating provider. This subsection does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

SB206, s. 57 Section 57. 632.865 of the statutes is created to read:

SB206,22,18 632.865 Choice of primary care provider. A group or individual health benefit plan, as defined in s. 632.745 (11), that requires or provides for the designation by any individual or beneficiary covered under the plan of a participating primary care provider shall allow each individual or beneficiary to designate any participating primary care provider who is available to accept that individual or beneficiary. This section does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

SB206, s. 58 Section 58. 632.87 (5m) of the statutes is created to read:

SB206,22,23 632.87 (5m) (a) 1. Except as provided in subd. 2. and par. (d), no health care plan, as defined in s. 628.36 (2) (a) 1., that provides coverage for hospital lengths of stay in connection with childbirth for a mother or a newborn child may do any of the following:

SB206,23,3 a. Restrict benefits under the plan for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours.

SB206,23,6 b. Restrict benefits under the plan for any hospital length of stay in connection with childbirth for the mother or newborn child, following a cesarean section, to less than 96 hours.

SB206,23,8 c. Require that a provider obtain authorization from the plan for prescribing any length of stay required under subd. 1. a. or b.

SB206,23,12 2. Subdivision 1. does not apply to a health care plan in any case in which the decision to discharge the mother or her newborn child before the minimum length of stay described under subd. 1. a. or b. is made by an attending provider in consultation with the mother.

SB206,23,14 (b) No health care plan, as defined in s. 628.36 (2) (a) 1., may do any of the following:

SB206,23,17 1. Deny to the mother or her newborn child eligibility, or continued eligibility, to enroll in or renew coverage under the plan solely for the purpose of avoiding the requirements of this subsection.

SB206,23,19 2. Provide monetary payments or rebates to mothers to encourage mothers to accept less than the minimum protections available under this subsection.

SB206,23,22 3. Penalize a provider or reduce or limit the reimbursement of a provider because the provider provided care to an individual in accordance with this subsection.

SB206,23,25 4. Subject to par. (c), restrict benefits for any portion of a hospital length of stay under subd. 1. a. or b. in a manner that is less favorable than the benefits provided for any preceding portion of the stay.

SB206,24,5 (c) A health care plan may impose cost-sharing requirements in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child, except that those cost-sharing requirements for any portion of a hospital length of stay may not be greater than the cost-sharing requirements for any preceding portion of the stay.

SB206,24,7 (d) This subsection does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

SB206, s. 59 Section 59. 632.883 of the statutes is created to read:

SB206,24,13 632.883 Lifetime and annual limits. (1) No insurer may impose a lifetime limit on the dollar value of benefits under a group or individual health care plan, as defined in s. 628.36 (2) (a) 1., and no self-insured health plan, as defined in s. 632.745 (24), may impose a lifetime limit on the dollar value of benefits under the self-insured health plan.

SB206,24,20 (2) For plan years beginning before January 1, 2014, an insurer under a group or individual health care plan, as defined in s. 628.36 (2) (a) 1., and a self-insured health plan, as defined in s. 632.745 (24), may impose only a restricted annual limit on the dollar value of benefits, as restricted annual limit is defined by the secretary of the federal department of health and human services under 42 USC 300gg-11 (a). This subsection does not apply to a grandfathered health plan, as defined in s. 632.758 (1), that provides individual health insurance coverage.

SB206, s. 60 Section 60 . 632.883 (2) of the statutes, as created by 2011 Wisconsin Act .... (this act), is amended to read:

SB206,25,5 632.883 (2) For plan years beginning before January 1, 2014, an No insurer under a group or individual health care plan, as defined in s. 628.36 (2) (a) 1., and a no self-insured health plan, as defined in s. 632.745 (24), may impose only a restricted an annual limit on the dollar value of benefits, as restricted annual limit is defined by the secretary of the federal department of health and human services under 42 USC 300gg-11 (a). This subsection does not apply to a grandfathered health plan, as defined in s. 632.758 (1), that provides individual health insurance coverage.

SB206, s. 61 Section 61. 632.895 (13) (a) of the statutes is renumbered 632.895 (13) (a) (intro.) and amended to read:

SB206,25,12 632.895 (13) (a) (intro.) Every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, that provides coverage of the surgical procedure known as a mastectomy shall provide coverage of all of the following in a manner determined in consultation with the attending physician and the patient:

SB206,25,14 1. All stages of breast reconstruction of the affected tissue incident to a mastectomy.

SB206, s. 62 Section 62. 632.895 (13) (a) 2. of the statutes is created to read:

SB206,25,17 632.895 (13) (a) 2. Surgery and reconstruction of the other breast than the one on which the mastectomy was performed to produce a symmetrical appearance.

SB206, s. 63 Section 63. 632.895 (13) (a) 3. of the statutes is created to read:

SB206,25,20 632.895 (13) (a) 3. Prostheses and physical complications of mastectomy, including lymphademas.

SB206, s. 64 Section 64. 632.895 (13) (c) of the statutes is created to read:

SB206,25,24 632.895 (13) (c) The disability insurance policy and self-insured health plan shall provide written notice of the available coverage under par. (a) upon enrollment in the policy or plan and annually thereafter.

SB206, s. 65 Section 65. 632.895 (13m) of the statutes is created to read:

SB206,26,2 632.895 (13m) Preventive care copayments prohibited. (a) In this subsection, "preventive care service" means any service described under 42 USC 300gg-13 (a).

SB206,26,6 (b) Except as provided in par. (d), every group health plan, every insurer providing a disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, shall provide coverage for all preventive care services.

SB206,26,8 (c) No insurer or plan described under par. (b) may subject the coverage of a preventive care service to a copayment or coinsurance.

SB206,26,10 (d) This subsection does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

SB206, s. 66 Section 66. 632.895 (15) (a) of the statutes is renumbered 632.895 (15) (a) (intro.) and amended to read:

SB206,26,19 632.895 (15) (a) (intro.) Subject to pars. (b) and (c), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a person as a dependent of the insured because the person is a full-time student, including the coverage under s. 632.885 (2) (b), shall continue to provide dependent coverage for the person if, due to a medically necessary leave of absence, he or she ceases to be a full-time student., if the leave of absence meets all of the following criteria:

SB206, s. 67 Section 67. 632.895 (15) (a) 1., 2. and 3. of the statutes are created to read:

SB206,26,22 632.895 (15) (a) 1. The leave of absence commences while the person is suffering from a serious illness or injury.

SB206,26,23 2. The leave of absence is medically necessary.

SB206,26,25 3. The leave of absence causes the person to lose student status for purposes of coverage under the terms of the plan or coverage.

SB206, s. 68 Section 68. 632.895 (15) (b) of the statutes is amended to read:

SB206,27,8 632.895 (15) (b) A policy or plan is not required to continue coverage under par. (a) unless the person submits documentation and written certification of the medical necessity of by a treating physician that states the person is suffering from a serious illness or injury and that the leave of absence from the person's attending physician is medically necessary. The date on which the person ceases to be a full-time student due to the medically necessary leave of absence shall be the date on which the coverage continuation under par. (a) begins.

SB206, s. 69 Section 69. 632.895 (15) (c) 1. to 4. of the statutes are repealed.

SB206, s. 70 Section 70. 632.895 (15) (c) 5. of the statutes is amended to read:

SB206,27,14 632.895 (15) (c) 5. Except for a person who has coverage as a dependent under s. 632.885 (2) (b), the person reaches the age at which coverage as a dependent who is a full-time student would otherwise end under the terms and conditions of the policy or plan.

SB206, s. 71 Section 71. 632.895 (15) (c) 6. of the statutes is repealed.

SB206, s. 72 Section 72. 632.895 (15) (d) of the statutes is created to read:

SB206,27,23 632.895 (15) (d) Every disability insurance policy and every self-insured health plan that provides coverage under par. (a) shall include with any notice regarding a requirement for certification of student status for coverage under the plan or coverage a description of the terms of this subsection for continued coverage during a medically necessary leave of absence. The policy or plan shall provide the description in language that is understandable to the typical insured or plan participant.

SB206, s. 73 Section 73. 632.895 (15) (e) of the statutes is created to read:

SB206,28,4 632.895 (15) (e) A person whose benefits are continued under par. (a) is entitled to the same benefits as if, during the medically necessary leave of absence, the person continued to be covered under the policy or plan as a full-time student who is not on a leave of absence.

SB206, s. 74 Section 74. 632.897 (11) (a) of the statutes is amended to read:

SB206,28,14 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may promulgate rules establishing standards requiring insurers to provide continuation of coverage for any individual covered at any time under a group policy who is a terminated insured or an eligible individual under any federal program that provides for a federal premium subsidy for individuals covered under continuation of coverage under a group policy, including rules governing election or extension of election periods, notice, rates, premiums, premium payment, application of preexisting condition exclusions, election of alternative coverage, and status as an eligible individual, as defined in s. 149.10 (2t).

SB206, s. 75 Section 75. 635.02 (2) of the statutes is amended to read:

SB206,28,21 635.02 (2) "Case characteristics" means the demographic, actuarially based characteristics ages, geographic locations, and tobacco usage of the employees of a small employer, and the employer, if covered, such as age, sex, and geographic location, used by a small employer insurer to determine premium rates for a small employer. "Case characteristics" does not include loss or claim history, health status, occupation, duration of coverage, or other factors related to claim experience.

SB206, s. 76 Section 76 . Initial applicability.

SB206,29,7 (1) The treatment of sections 40.51 (8) (by Section 1 ) and (8m) (by Section 3 ), 66.0137 (4) (by Section 5 ), 120.13 (2) (g) (by Section 7 ), 185.983 (1) (intro.) (by Section 9), 632.758, 632.85 (2), and 632.895 (15) (b), (c) 5., (d), and (e) of the statutes, the renumbering and amendment of section 632.895 (13) (a) and (15) (a) of the statutes, and the creation of sections 609.845, 632.723, 632.746 (2) (dm), 632.753, 632.76 (2) (ac) 4., 632.85 (4), 632.865, 632.87 (5m), 632.883, and 632.895 (13) (a) 2. and 3. and (c), (13m), and (15) (a) 1., 2., and 3., (d), and (e) of the statutes first apply to policies or plans that are newly issued or renewed, or self-insured governmental or school district health plans that are established, extended, modified, or renewed, on the effective date of this subsection.

SB206,29,17 (2) The treatment of sections 40.51 (8) (by Section 2) and (8m) (by Section 4), 66.0137 (4) (by Section 6 ), 120.13 (2) (g) (by Section 8 ), 185.983 (1) (intro.) (by Section 10), 609.845 (by Section 13 ), 625.12 (1) (a) and (e) and (2), 625.15 (1), 628.34 (3) (a), 632.746 (8) (a) (intro.) and (10) (a) 1., 632.795 (4) (a), 632.883 (2) (by Section 60), 632.897 (11) (a), and 635.02 (2) of the statutes, the renumbering of section 632.7497 (3) (a) of the statutes, the renumbering and amendment of sections 632.746 (1) (a) and 632.76 (2) (ac) 1. of the statutes, and the creation of sections 632.728 and 632.7493 of the statutes first apply to policies or plans that are newly issued or renewed, or self-insured governmental or school district health plans that are established, extended, modified, or renewed, on the effective date of this subsection.

SB206, s. 77 Section 77 . Effective dates. This act takes effect on the day after publication, except as follows:

SB206,30,5 (1) The treatment of sections 40.51 (8) (by Section 2 ) and (8m) (by Section 4 ), 66.0137 (4) (by Section 6 ), 120.13 (2) (g) (by Section 8 ), 185.983 (1) (intro.) (by Section 10), 609.845 (by Section 13 ), 625.12 (1) (a) and (e) and (2), 625.15 (1), 628.34 (3) (a), 632.746 (5) (a), (8) (a) (intro.), and (10) (a) 1., 632.76 (2) (b), 632.795 (4) (a), 632.883 (2) (by Section 60 ), 632.897 (11) (a), and 635.02 (2) of the statutes, the repeal of sections 631.95 (3) (a), 632.746 (1) (b), (2) (a), (b), and (dm), (3) (a) and (d) 2. and 3., and (10) (a) 4., 632.7497 (3) (b), and 632.76 (2) (ac) 2., 3., and 4. of the statutes, the renumbering of sections 632.746 (3) (d) 1. and 632.7497 (3) (a) of the statutes, the renumbering and amendment of sections 632.746 (1) (a) and 632.76 (2) (ac) 1. of the statutes, and the creation of sections 632.728 and 632.7493 of the statutes, and Section 76 (2) of this act take effect on January 1, 2014.

SB206,30,6 (End)