I. Protected Health Information
By signing this form, I authorize certain organizations and persons to use or disclose my, my spouse's and my dependent child(ren)'s protected health information. Protected health information includes, but is not limited to, hospital records, physician records, lab results, mental health records, and alcohol and/or drug abuse records. Protected health information may be written, oral, or electronic. This form does not permit the use or disclosure of psychotherapy notes or the disclosure of information concerning whether I, my spouse or my dependent child(ren) have 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 were.
II. Purpose of this Authorization Form
By signing this form, I, my spouse and my dependent child(ren) authorize the use and disclosure of protected health information for the purposes of pre-enrollment underwriting or risk-rating of health insurance coverage for me, my spouse and my dependent child(ren), to determine eligibility for enrollment or benefits under a health plan or to allow the insurer to conduct utilization review and quality improvement activities (“Purpose").
III. Entities Authorized to Use and Disclose My Protected Health Information
Insurers: I hereby authorize the following insurers, their reinsurers, and their legal representatives (“Insurers") to receive, use, and disclose my, my spouse's and my dependent child(ren)'s protected health information for the Purpose listed above:
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
I authorize the Insurers to disclose my, my spouse's and my dependent child(ren)'s protected health information: between themselves, to reinsuring companies, and to the plan administrator (if other than the employer), plan sponsor (if other than the employer), insurance intermediaries, or other persons or organizations performing business or legal services in connection with the Purpose above.
I further authorize any licensed physician, medical practitioner, health care provider, hospital, clinic, or other medical or medically related facility, insurance or reinsuring company, Medical Information Bureau, Inc., consumer reporting agency, or other organization, institution, or person that has any record or knowledge of me, my spouse or my dependent(s), to give to Insurers any and all protected health information about me, my spouse, or my dependent(s) to be covered concerning diagnosis, treatment and prognosis for any physical or mental condition, history or character, general reputation, personal trait, and mode of living, including, but not limited to, all medical and health care records, but not including whether I, my spouse or my dependent(s) obtained a test for the presence of HIV antigen or nonantigenic products of HIV or what the results of this test were.
I, my spouse and my dependent child(ren) understand that protected health information described in this form may be used by, or disclosed to or by, organizations and persons who are not subject to federal or state privacy laws.
IV. Term of Authorization
I agree this Authorization shall be valid for two and one half (2
½) years from the latest signature date below.
V. Right to Revoke
I understand I, my spouse or my dependent child(ren) may revoke this authorization at any time by giving advance written notice to Insurers. Revocation of this authorization form will not affect actions Insurers and others took in reliance on this form prior to the written notice of revocation.
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY SIGNING THIS FORM, I AUTHORIZE THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I UNDERSTAND THAT I MAY ONLY REVOKE AUTHORIZATION FOR MYSELF OR MY MINOR CHILD(REN) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW. (CONTINUED ON THE NEXT PAGE.)
_________________________________ ________________ _________________________________
Signature of Adult Applicant Date signed Printed Name
_________________________________ ________________ _________________________________
I have had full opportunity to read and consider this form. I understand that, by signing this form, I authorize the uses and disclosures of protected health information described in this form. I understand that I may only revoke authorization for myself or my minor child(ren) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW.
___________________________________ ________________ _________________________________
Signature of Adult Dependent Date signed Printed Name
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child(ren) (if applicable)
If signing for more than one child, please list the names of each child for whom you are signing:
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent:
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child (if minor received
treatment with knowledge of parent)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
Uniform Employee Application
OCI 26-501 (R 6/2010)
Ins 8.50
Ins 8.50
Underwriting restriction. In determining whether to issue or continue to provide coverage to a small employer, a small employer insurer may not consider the occupation of the employees of the small employer or the type of business in which the small employer is engaged.
Ins 8.50 History
History: Cr.
Register, October, 1992, No. 442, eff. 11-1-92.
Ins 8.52
Ins 8.52
Regulation of rates and rate changes. Ins 8.52(1)(1)
Identification of the set of midpoint rates. Ins 8.52(1)(a)
(a) Each small employer insurer shall identify a set of rates applicable to all combinations of case characteristics and benefit design characteristics that serves as the set of midpoint rates for policies issued to small employers. These rates shall be represented by any combination of rates and rating factors that satisfy the following:
Ins 8.52(1)(a)1.
1. All differences among rates in the set shall be in accordance with the insurer's rate manual or rating procedures and shall be based on the actuarially determined values of the differences in case characteristics and benefit design characteristics.
Ins 8.52(1)(a)2.
2. The differences among the rates may not reflect any differences due to such factors as the claim experience, health status and duration of coverage of an individual policy or a collection of policies grouped according to anything other than case characteristics or benefit design.
Ins 8.52(1)(b)
(b) The set of midpoint rates identified in par.
(a) shall apply during a specified period which shall not be less than one calendar month.
Ins 8.52(2)(a)
(a) For a new policy issued on or after March 15, 1992, the following table lists the maximum percent a rate may vary from the midpoint rate applicable to policies with the same case characteristics and benefit design characteristics according to the effective date of any rate applied to that policy:
-
See PDF for table 
Ins 8.52(2)(b)
(b) For a policy issued before March 15, 1992, an insurer shall comply with the rate variance restriction specified in
par.
(a) 2 no later than August 15, 1994.
Ins 8.52(3)
(3) Premium rate changes; documentation and restrictions. Ins 8.52(3)(a)(a) For the purpose of complying with s.
635.02 (2), Stats., and this subsection,“class of business" means a group of policies with the same or similar benefit design whose rates are based wholly or partly on their aggregate loss experience.
Ins 8.52(3)(b)
(b) For a policy renewed on or after March 15, 1993, an insurer shall maintain sufficient documentation so that each of the following distinct components can be identified:
Ins 8.52(3)(b)1.
1. The percentage change in the new business premium rate measured from the rating period in which the small employer was last rated to the current rating period or, in the case of a class of business for which the insurer is not issuing new policies, the corresponding change in the base premium rate.
Ins 8.52(3)(b)2.
2. The percentage change due to adjustments in case characteristics, determined in accordance with the insurer's rate manual or rating procedures.
Ins 8.52(3)(b)3.
3. The percentage change due to adjustments in benefit design, determined in accordance with the insurer's rate manual or rating procedures.
Ins 8.52(3)(b)4.
4. The percentage change due to such rating factors as claim experience, health status and duration of coverage, determined in accordance with the insurer's rate manual or rating procedures.
Ins 8.52(3)(c)
(c) Each renewal rate, regardless of whether the rate represents an increase, shall be limited to the previous rate adjusted by the combination of the 4 components specified in par.
(b) with the following restrictions on the experience component specified in par.
(b) 4.:
Ins 8.52(3)(c)1.
1. For a policy issued on or after March 15, 1992, the experience component shall be limited to 15% per year, adjusted proportionately for rating periods of less than one year.
Ins 8.52(3)(c)2.
2. For a policy issued before March 15, 1992, subd.
1. applies, except if the premium rate exceeds the midpoint rate by more than the percentage specified in sub.
(2) (a) for the applicable period for policies with the same case characteristics and benefit design characteristics, the experience component may not exceed 0%.
Ins 8.52(3)(d)
(d) For a rate change made before the end of the policy term due to the addition of a new entrant, late enrollee, underwritten individual or a new dependent of an insured employee, par.
(c) applies, except that:
Ins 8.52(3)(d)1.
1. The new business rate change component specified in par.
(b) 1. may not be applied at that time.
Ins 8.52(3)(d)2.
2. The experience component specified in par.
(b) 4. may not exceed 15% per year, adjusted proportionately to the time remaining in the policy term.
Ins 8.52(3)(d)3.
3. The experience component specified in par.
(b) 4., when combined with the experience component of the last scheduled rate renewal and any other subsequent rate changes during the current policy term, shall not exceed the limit specified in par.
(c) 1. or
2., whichever applies.
Ins 8.52(4)(a)
(a) On or before December 1, every small employer insurer shall annually file with the commissioner the small employer insurer's lowest available monthly new business premium
rates which will be in effect the following January 1. The filing shall be made on a form provided by the commissioner and shall require all of the following information as may apply to the type of plan offered:
Ins 8.52(4)(a)1.
1. For an indemnity plan
, the rates shall be based on the insurer's plan that is closest to a plan that features a $500.00 annual deductible and 80%/20% coinsurance.
Ins 8.52(4)(a)2.
2. For a defined network plan, the rates shall be based on a plan which is actuarially equivalent to the features described in subd.
1. Ins 8.52(4)(a)3.
3. For all plans
, the rates shall be specified for family and single plans, by group size and by the geographical criteria that are used by the insurer.
Ins 8.52(4)(a)4.
4. The commissioner may require additional information be provided in the form as appropriate to implement this subsection.
Ins 8.52 Note
Note: OCI 26-500, the form described in this subsection may be obtained without charge by contacting the Office of the Commissioner of Insurance PO Box 7873, Madison WI. 53707-7873. The form is also available on the OCI website at oci.wi.gov
Ins 8.52(4)(b)
(b) Small employer insurers who file rates with the commissioner as described in this subsection
will be in compliance with the requirements of s.
635.12, Stats.
Ins 8.52 History
History: Cr.
Register, October, 1992, No. 442, eff. 11-1-92; am. (3) (d) (intro.),
Register, November, 1993, No. 455, eff. 2-1-94;
CR 02-043: cr. (4),
Register October 2002 No. 562, eff. 11-1-02.
Ins 8.54
Ins 8.54
Guaranteed renewability; cancellation and renewal restrictions. Ins 8.54(1)(a)(a) In this section, “medically underwritten policy" means a policy that is issued after the small employer insurer has, for purposes of risk selection, used information about the group's claim experience or the health history or medical records of one or more persons eligible for coverage.
Ins 8.54(1)(b)
(b) Notwithstanding par.
(a), a small employer insurer may apply medical underwriting standards to an individual who originally declined and later applies for coverage under a nonmedically underwritten policy without converting that policy to a medically underwritten policy.
Ins 8.54(2)(a)
(a) In this section, each of the following is a separate class of business, regardless of variations in policy forms, marketing methods or duration of coverage among small employers in the class of business:
Ins 8.54(2)(a)2.
2. All small employers with policies that are not medically underwritten.
Ins 8.54(2)(a)3.
3. All small employers whose policies constitute a block of business assumed by the small employer insurer under a specific assumption treaty with an insurer that is not an affiliate.
Ins 8.54(2)(b)
(b) No small employer insurer may establish a class of business other than one specified in par.
(a).
Ins 8.54(3)
(3) Guaranteed renewability. Except as provided in s.
635.07, Stats., a policyholder has the right to renew a policy on the same terms subject to the premium rate restrictions specified in s.
Ins 8.52 (3). The subsection does not prohibit a small employer insurer from offering a policyholder renewal with altered benefit design characteristics if the offer is available to all policyholders in the same class of business without regard to claim experience.
Ins 8.54 Note
Note: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749, Stats.
Ins 8.54(4)
(4) Nonrenewal or termination based on participation requirements. Ins 8.54(4)(a)(a) A small employer insurer that intends to nonrenew a policy or terminate a policy under s.
635.07 (1) (d), Stats., because the number of eligible employees is less than the number required to keep the policy in force shall do all of the following:
Ins 8.54 Note
Note: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (2), Stats.
Ins 8.54(4)(a)1.
1. Notify the small employer of its intent to nonrenew or terminate and the reason for the nonrenewal or termination. The notice shall be given as required under s.
631.36, Stats., for a nonrenewal or at least 20 days before the termination date for a termination.
Ins 8.54(4)(a)2.
2. Offer to continue the small employer's coverage for not less than 60 days after the nonrenewal or termination date in order to allow the small employer to increase the number of eligible employees to the required number.
