Amendment SSA3-AB365

AB365-SSA3,28,18 1. The benefit design is not comparable to a typical comprehensive individual health insurance policy offered in the private sector market in this state.

AB365-SSA3,28,21 2. The benefit levels are not generally reflective of and commensurate with comprehensive health insurance coverage offered in the private individual market in this state.

AB365-SSA3,28,23 3. The copayments, deductibles, and coinsurance are not actuarially equivalent to comprehensive individual plans and would create undue financial hardship.

AB365-SSA3,28,25 4. It is inconsistent with the purpose of providing health care coverage to those unable to obtain coverage in the private market.

AB365-SSA3,82 Section 82. 631.36 (7) (c) of the statutes is created to read:

AB365-SSA3,29,4 631.36 (7) (c) Notice of cancellation or nonrenewal required under sub. (2) (b) or (4) is not effective unless the notice contains the notice required under s. 632.784, if applicable.

AB365-SSA3,83 Section 83. 632.7495 (4) (c) of the statutes is amended to read:

AB365-SSA3,29,13 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods. This paragraph does not apply if provisions of the federal Patient Protection and Affordable Care Act, P.L. 111-148, under 42 USC 300gg to 300gg-4 are no longer enforceable or no longer preempt state law relating to individual health insurance policies.

AB365-SSA3,84 Section 84. 632.784 of the statutes is created to read:

AB365-SSA3,29,21 632.784 Notice of Health Insurance Risk-Sharing Plan. (1) If an insurer issues one or more of the following or takes any other action based wholly or partially on medical underwriting considerations which is likely to render any person eligible under s. 656.12 for coverage under ch. 656, the insurer shall notify all persons affected of the existence of the mandatory health insurance risk-sharing plan under ch. 656, as well as the eligibility requirements and method of applying for coverage under the plan:

AB365-SSA3,29,22 (a) A notice of rejection or cancellation of coverage.

AB365-SSA3,30,2 (b) A notice of reduction or limitation of coverage, including restrictive riders, if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.

AB365-SSA3,30,5 (c) A notice of increase in premium exceeding the premium then in effect for the insured person by 50 percent or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.

AB365-SSA3,30,8 (d) A notice of premium for a policy not yet in effect which exceeds the premium applicable to a person considered a standard risk by 50 percent or more for the types of coverage provided by the plan.

AB365-SSA3,30,10 (2) Any notice issued under sub. (1) shall also state the reasons for the rejection, termination, cancellation, or imposition of underwriting restrictions.

AB365-SSA3,85 Section 85. 646.01 (1) (a) 2. k. of the statutes is amended to read:

AB365-SSA3,30,12 646.01 (1) (a) 2. k. Risk-sharing plans under ch. chs. 619 and 656.

AB365-SSA3,86 Section 86 . Chapter 656 of the statutes is created to read:

AB365-SSA3,30,15 Chapter 656 Health insurance risk-sharing plans

AB365-SSA3,30,17 SUBCHAPTER I general provisions

AB365-SSA3,30,18 656.01 Definitions. In this chapter:

AB365-SSA3,30,19 (1) “Authority” means the Health Insurance Risk-Sharing Plan Authority.

AB365-SSA3,30,20 (2) “Board” means the board of directors of the authority.

AB365-SSA3,30,21 (3) “Church plan” has the meaning given in 29 USC 1002 (33).

AB365-SSA3,30,22 (4) “Commissioner” means the commissioner of insurance.

AB365-SSA3,30,23 (5) “Creditable coverage” has the meaning given in s. 632.745 (4).

AB365-SSA3,31,3 (6) “Eligible person” means a person who is certified as eligible under s. 656.12 (1), whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.

AB365-SSA3,31,4 (7) “Federal continuation provision” has the meaning given in s. 632.745 (8).

AB365-SSA3,31,7 (8) “Federal governmental plan” means a benefit program established or maintained for its employees by the government of the United States or by any agency or instrumentality of the government of the United States.

AB365-SSA3,31,9 (9) “Fund” means the Health Insurance Risk-Sharing Plan fund under s. 656.10 (2).

AB365-SSA3,31,10 (10) “Governmental plan” has the meaning given under 29 USC 1002 (32).

AB365-SSA3,31,11 (11) “Group health plan” has the meaning given in s. 632.745 (10).

AB365-SSA3,31,13 (12) “Health care coverage revenue” means any of the following, but does not include payments to health maintenance organizations under s. 49.45 (59) (a):

AB365-SSA3,31,14 (a) Premiums received for health care coverage.

AB365-SSA3,31,15 (b) Subscriber contract charges received for health care coverage.

AB365-SSA3,31,17 (c) Health maintenance organization, limited service health organization, or preferred provider plan charges received for health care coverage.

AB365-SSA3,31,19 (d) The sum of benefits paid and administrative costs incurred for health care coverage under a medical reimbursement plan.

AB365-SSA3,31,25 (13) “Health insurance” means surgical, medical, hospital, major medical, and other health service coverage provided on an expense-incurred basis and fixed indemnity policies. “Health insurance” does not include ancillary coverage such as income continuation, short-term, accident only, credit insurance, automobile medical payment coverage, coverage issued as a supplement to liability coverage, loss of time, or accident benefits.

AB365-SSA3,32,1 (14) “Health maintenance organization” has the meaning given in s. 609.01 (2).

AB365-SSA3,32,3 (15) “HIV” means any strain of human immunodeficiency virus, which causes acquired immunodeficiency syndrome.

AB365-SSA3,32,4 (16) “Insurance” has the meaning given in s. 600.03 (25).

AB365-SSA3,32,6 (17) “Insurer” has the meaning given in s. 600.03 (27) and does not include a plan under ch. 613 which offers only dental care.

AB365-SSA3,32,8 (18) “Limited service health organization” has the meaning given in s. 609.01 (3).

AB365-SSA3,32,10 (19) “Medical Assistance program” means the health care benefit program provided under subch. IV of ch. 49.

AB365-SSA3,32,11 (20) “Policy” has the meaning given in s. 600.03 (35).

AB365-SSA3,32,16 (21) “Preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage, whether or not the individual received any medical advice or recommendation, diagnosis, care, or treatment related to the condition before that date.

AB365-SSA3,32,17 (22) “Preferred provider plan” has the meaning given in s. 609.01 (4).

AB365-SSA3,32,18 (23) “Premium” has the meaning given in s. 600.03 (38).

AB365-SSA3,32,22 656.03 Applicability. This chapter applies only if provisions of the federal Patient Protection and Affordable Care Act, P.L. 111-148, under 42 USC 300gg to 300gg-4 are no longer enforceable or no longer preempt state law relating to individual health insurance policies.

AB365-SSA3,33,2 656.05 Immunity. No liability may be imposed on any of the following for an act or omission in the performance of any powers and duties under this chapter, unless the person asserting liability proves the act or omission constitutes willful misconduct:

AB365-SSA3,33,3 (1) The authority, plan, or board.

AB365-SSA3,33,4 (2) Any agent, employee, or director of the authority, plan, or board.

AB365-SSA3,33,5 (3) Any participating insurer.

AB365-SSA3,33,6 (4) The commissioner.

AB365-SSA3,33,7 (5) Any of the commissioner's agents, employees, or representatives.

AB365-SSA3,33,10 SUBCHAPTER II health insurance risk-sharing plan provisions

AB365-SSA3,33,13 656.10 Administration of plan. (1) Authority. The authority shall be responsible for the operation of the plan and, subject to ss. 656.43 (3) and 656.47, may enter into contracts for the plan's administration.

AB365-SSA3,33,16 (2) Fund. (a) The authority shall pay the operating administrative expenses of the plan from the fund, which shall be outside the state treasury and which shall consist of all of the following:

AB365-SSA3,33,17 1. Insurer assessments paid under s. 656.15.

AB365-SSA3,33,18 2. Premiums paid by eligible persons.

AB365-SSA3,33,19 3. Moneys received from the federal government as grants for high-risk pools.

AB365-SSA3,33,20 4. The earnings resulting from investments under par. (b).

AB365-SSA3,33,21 5. Any other moneys received by the authority.

AB365-SSA3,33,23 (b) The authority controls assets of the fund, including investment of assets of the fund.

AB365-SSA3,33,25 (c) Moneys in the fund may be expended only for the purposes specified in par. (a).

AB365-SSA3,34,5 656.11 Rules relating to creditable coverage. The commissioner shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 656.12 (1) (c) 1. and that determine the creditable coverage to which s. 656.12 (1) (c) 2. and 4. applies. The rules shall comply with any applicable federal law regarding creditable coverage.

AB365-SSA3,34,8 656.12 Eligibility determination. (1) Eligible persons. Except as provided in sub. (3) and subject to subs. (2) and (4), the authority shall certify as eligible a person who is a resident of this state and is any of the following:

AB365-SSA3,34,10 (a) A person who is covered by the Medicare program under 42 USC 1395 et seq. because he or she is disabled under 42 USC 423.

AB365-SSA3,34,12 (b) A person who submits evidence that he or she has a positive, validated HIV test result, as defined in s. 252.01 (8).

AB365-SSA3,34,13 (c) A person for whom all of the following apply:

AB365-SSA3,34,15 1. The aggregate of the individual's periods of creditable coverage is 18 months or more.

AB365-SSA3,34,18 2. The individual's most recent period of creditable coverage was under a group health plan, governmental plan, federal governmental plan, church plan, or under any health insurance offered in connection with any of those plans.

AB365-SSA3,34,22 3. The individual does not have creditable coverage and is not eligible for coverage under a group health plan; part A, B, or D of the Medicare program under 42 USC 1395 et seq.; or a state plan under the Medicaid program under 42 USC 1396 et seq.

AB365-SSA3,34,25 4. The individual's most recent period of creditable coverage was not terminated for any reason related to fraud or intentional misrepresentation of material fact or a failure to pay premiums.

AB365-SSA3,35,3 5. If the individual was offered the option of continuation coverage under a federal continuation provision or similar state program, the individual elected the continuation coverage.

AB365-SSA3,35,4 6. The individual has exhausted any continuation coverage under subd. 5.

AB365-SSA3,35,8 (d) A person who receives and submits any of the following notices based wholly or partially on medical underwriting considerations within 9 months before making an application for coverage by the plan and issued by a person acting as an administrator, as defined in s. 633.01 (1):

AB365-SSA3,35,9 1. A notice of rejection of coverage from one or more insurers.

AB365-SSA3,35,10 2. A notice of cancellation of coverage from one or more insurers.

AB365-SSA3,35,14 3. A notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.

AB365-SSA3,35,17 4. A notice of increase in premium exceeding the premium then in effect for the insured person by 50 percent or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.

AB365-SSA3,35,20 5. A notice of premium for a policy not yet in effect from 2 or more insurers which exceeds the premium applicable to a person considered a standard risk by 50 percent or more for the types of coverage provided by the plan.

AB365-SSA3,35,25 (e) A person not otherwise eligible under this subsection who meets eligibility criteria set by the authority. The authority shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.

AB365-SSA3,36,6 (2) Resident status. (a) For purposes of eligibility under sub. (1) (a), (b), (d), and (e), a resident is a person who has been legally domiciled in this state for a period of at least 3 months. Except for any of the following circumstances, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return:

AB365-SSA3,36,9 1. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state.

AB365-SSA3,36,13 2. A person with a developmental disability or another disability that prevents him or her from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return is legally domiciled in this state by living in this state.

AB365-SSA3,36,15 (b) For purposes of eligibility under sub. (1) (c), a resident is a person who legally resides in this state.

AB365-SSA3,36,21 (3) Exceptions to eligibility. (a) No person who is covered under the plan and who voluntarily terminates the coverage under the plan is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan. This paragraph does not apply to a person who is eligible under sub. (1) (c) or who terminates coverage under the plan because he or she is eligible to receive benefits under the Medical Assistance program.

AB365-SSA3,36,23 (b) No person on whose behalf the plan has paid out the lifetime limit under s. 656.20 (2) (a) or more is eligible for coverage under the plan.