27,4882
Section 4882
. 619.16 (3) (a) of the statutes is renumbered 149.16 (3) (a) and amended to read:
149.16 (3) (a) The administering carrier plan administrator shall perform all eligibility and administrative claims payment functions relating to the plan.
27,4883
Section
4883. 619.16 (3) (b) of the statutes is renumbered 149.16 (3) (b) and amended to read:
149.16 (3) (b) The administering carrier plan administrator shall establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the board department.
27,4884c
Section 4884c. 619.16 (3) (c) of the statutes is renumbered 149.16 (3) (c), and 149.16 (3) (c) (intro.), as renumbered, is amended to read:
149.16 (3) (c) (intro.) The administering carrier plan administrator shall perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
27,4885
Section 4885
. 619.16 (3) (d) of the statutes is repealed.
27,4886
Section 4886
. 619.16 (3) (e) of the statutes is renumbered 149.16 (3) (e) and amended to read:
149.16 (3) (e) The administering carrier plan administrator, under the direction of the department, shall pay claims expenses from the premium payments received from or on behalf of covered persons under the plan. If the administering carrier's plan administrator's payments for claims expenses exceed the portion of premiums allocated by the board for payment of claims expenses premium payments, the board shall forward to the department, and the department shall provide to the carrier plan administrator, additional funds for payment of claims expenses.
27,4887
Section 4887
. 619.16 (3) (em) of the statutes is repealed.
27,4888
Section 4888
. 619.16 (3) (f) of the statutes is repealed.
27,4889
Section 4889
. 619.165 (title) of the statutes is renumbered 149.165 (title).
27,4890
Section 4890
. 619.165 (1) (a) of the statutes is renumbered 149.165 (1) and amended to read:
149.165 (1) The board Except as provided in s. 149.146 (2) (a), the department shall reduce the premiums established by the commissioner under s.
619.11 149.11 in conformity with ss. 619.14 (5) 149.143 and 619.17 149.17, for the eligible persons and in the manner set forth in pars. (b) to (d) subs. (2) and (3).
27,4891
Section 4891
. 619.165 (1) (b) of the statutes is renumbered 149.165 (2), and 149.165 (2) (intro.), as renumbered, is amended to read:
149.165 (2) (intro.) If the household income, as defined in s. 71.52 (5) and as determined under par. (d) sub. (3), of an eligible person is equal to or greater than the first amount and less than the 2nd amount listed in any of the following, the board department shall reduce the premium for the eligible person, as established by the commissioner, to the rate shown after the amounts:
27,4891c
Section 4891c. 619.165 (1) (d) of the statutes is renumbered 619.165 (1) (d) 1. and amended to read:
619.165 (1) (d) 1. The Subject to subd. 2., the board shall establish and implement the method for determining the household income of an eligible person under par. (b).
27,4891r
Section 4891r. 619.165 (1) (d) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.165 (3), and 149.165 (3) (a) and (b) (intro.), as renumbered, are amended to read:
149.165 (3) (a) Subject to subd. 2., the board par. (b), the department shall establish and implement the method for determining the household income of an eligible person under par. (b) sub. (2).
(b) (intro.) In determining household income under par. (b), the board sub. (2), the department shall consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:
27,4891t
Section 4891t. 619.165 (1) (d) 2. of the statutes is created to read:
619.165 (1) (d) 2. In determining household income under par. (b), the board shall consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:
a. The person is a farmer, as defined in s. 102.04 (3).
b. The person was not eligible to claim the homestead credit under subch. VIII of ch. 71 in the preceding taxable year.
27,4893
Section 4893
. 619.165 (2) of the statutes is repealed.
27,4894
Section 4894
. 619.165 (3) of the statutes is renumbered 149.165 (4) and amended to read:
149.165 (4) The commissioner shall forward to the board moneys received under s. 20.145 (7) (a) and (g) in an amount sufficient to department shall reimburse the plan for premium reductions under sub. (1) (2) and deductible reductions under s. 619.14 149.14 (5) (a) with moneys from the appropriation under s. 20.435 (5) (ah).
27,4895
Section 4895
. 619.167 of the statutes is repealed.
27,4896
Section 4896
. 619.17 (intro.) of the statutes is renumbered 149.17 (intro.).
27,4897
Section 4897
. 619.17 (1) of the statutes is renumbered 149.17 (1) and amended to read:
149.17 (1) Subject to s. 619.14 (5) (a) ss. 149.143 and 149.146 (2) (b), a rating plan calculated in accordance with generally accepted actuarial principles.
27,4898
Section 4898
. 619.17 (2) of the statutes is renumbered 149.17 (2) and amended to read:
149.17 (2) A schedule of premiums, deductibles and coinsurance payments which complies with all requirements of this subchapter chapter.
27,4899
Section 4899
. 619.17 (3) of the statutes is renumbered 149.17 (3).
27,4900
Section 4900
. 619.17 (4) (a) of the statutes is renumbered 149.17 (4) and amended to read:
149.17 (4) Cost containment provisions established by the commissioner department by rule, including managed care requirements.
27,4901
Section 4901
. 619.175 of the statutes is renumbered 149.175 and amended to read:
149.175 Waiver or exemption from provisions prohibited. Except as provided in s. 619.13 (1) (a) 149.13 (1), the commissioner
department may not waive, or authorize the board to waive, any of the requirements of this subchapter chapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter
chapter.
27,4902
Section 4902
. 619.18 of the statutes is renumbered 149.18 and amended to read:
149.18 Chapters 600 to 645 applicable. Except as otherwise provided in this subchapter chapter, the plan shall comply and be administered in compliance with chs. 600 to 645.
27,4910c
Section 4910c. 628.34 (3) (a) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:
628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365 and, 632.745 and 632.748. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.
27,4910e
Section 4910e. 628.34 (3) (b) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:
628.34 (3) (b) No insurer may refuse to insure or refuse to continue to insure, or limit the amount, extent or kind of coverage available to an individual, or charge an individual a different rate for the same coverage because of a mental or physical disability except when the refusal, limitation or rate differential is based on either sound actuarial principles supported by reliable data or actual or reasonably anticipated experience, subject to ss. 632.745, 632.747, 632.749, 635.09 and 635.26
632.746 to 632.7495.
27,4910g
Section 4910g. 628.36 (2) (b) 1. of the statutes is amended to read:
628.36 (2) (b) 1. Except for health maintenance organizations, preferred provider plans, and limited service health organizations and the small employer health insurance plan under subch. II of ch. 635, no health care plan may prevent any person covered under the plan from choosing freely among providers who have agreed to participate in the plan and abide by its terms, except by requiring the person covered to select primary providers to be used when reasonably possible.
27,4910i
Section 4910i. 628.36 (2) (b) 3. of the statutes is amended to read:
628.36 (2) (b) 3. Except as provided in subd. 4., no provider may be denied the opportunity to participate in a health care plan, other than a health maintenance organization, a limited service health organization,
or a preferred provider plan or the small employer health insurance plan under subch. II of ch. 635, under the terms of the plan.
27,4910k
Section 4910k. 628.36 (2) (b) 5. of the statutes is amended to read:
628.36 (2) (b) 5. Except for the small employer health insurance plan under subch. II of ch. 635 to the extent determined by the small employer insurance board under s. 635.23 (1) (b), all All health care plans, including health maintenance organizations, limited service health organizations and preferred provider plans are subject to s. 632.87 (3).
27,4910m
Section 4910m. 631.01 (4) of the statutes is amended to read:
631.01 (4) Annuities and group policies for eleemosynary institutions. This chapter, and ch. 632 and the health insurance mandates under ch. 632 that apply to the plan under subch. II of ch. 635 do not apply to annuities or group policies that are provided on a basis as uniform nationally as state statutes permit to educational, scientific research, religious or charitable institutions organized without profit to any person, for the benefit of employes of such institutions. The commissioner may by order subject such contracts issued by a particular insurer to this chapter, or ch. 632
or the health insurance mandates under ch. 632 that apply to the plan under subch. II of ch. 635 or any portion of those provisions upon a finding, after a hearing, that the interests of Wisconsin insureds or creditors or the public of this state so require.
27,4912
Section 4912
. 631.36 (7) (a) 2. of the statutes is amended to read:
631.36 (7) (a) 2. Unless the notice contains adequate instructions to the policyholder for applying for insurance through a risk-sharing plan under subch. I of ch. 619, if a risk-sharing plan exists under subch. I of ch. 619 for the kind of coverage being canceled or nonrenewed, except as provided in par. (b).
27,4915m
Section 4915m. 632.70 of the statutes is repealed.
27,4916m
Section 4916m. 632.745 of the statutes, as affected by 1995 Wisconsin Acts 289 and 453, is repealed and recreated to read:
632.745 Coverage requirements for group and individual health benefit plans; definitions. In this section and ss. 632.746 to 632.7495:
(1) “Affiliation period" means the period which, under the terms of health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective.
(2) “Beneficiary" has the meaning given in section 3 (8) of the federal Employee Retirement Income Security Act of 1974.
(3) “Bona fide association" means an association that satisfies all of the following:
(a) The association has been actively in existence for at least 5 years.
(b) The association has been formed and maintained in good faith for purposes other than obtaining insurance.
(c) The association does not condition membership in the association on any health status-related factor of an individual, including an employe of an employer or a dependent of an employe.
(d) The association makes health insurance coverage offered through the association available to all members, regardless of any health status-related factor of those members or individuals eligible for coverage through a member.
(e) The association does not make health insurance coverage offered through the association available other than in connection with a member of the association.
(f) The association meets any additional requirements that are imposed by a rule of the commissioner designed to prevent the use of an association for risk segmentation.
(4) (a) Except as provided in par. (b), “creditable coverage" means coverage under any of the following:
1. A group health plan.
2. Health insurance.
3. Part A or part B of title XVIII of the federal Social Security Act.
4. Title XIX of the federal Social Security Act, except for coverage consisting solely of benefits under section 1928 of that act.
5. Chapter 55 of title 10 of the United States Code.
6. A medical care program of the federal Indian health service or of an American Indian tribal organization.
7. A state health benefits risk pool.
8. A health plan offered under chapter 89 of title 5 of the United States Code.
9. A public health plan, as defined in regulations issued by the federal department of health and human services.
10. A health coverage plan under section 5 (e) of the federal Peace Corps Act, 22 USC 2504 (e).
(b) “Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in section 2791 (c) of P.L. 104-191.
(5) (a) Except as provided in par. (b), “eligible employe" means an employe who works on a permanent basis and has a normal work week of 30 or more hours. The term includes a sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership and a member of a limited liability company if the sole proprietor, business owner, partner or member is included as an employe under a health benefit plan of an employer, but the term does not include an employe who works on a temporary or substitute basis.
(b) For purposes of a group health benefit plan, or a self-insured health plan, that is offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7), “eligible employe" has the meaning given in s. 40.02 (25).
(6) (a) “Employer" means any of the following:
1. An individual, firm, corporation, partnership, limited liability company or association that is actively engaged in a business enterprise in this state, including a farm business.
2. A municipality, as defined in s. 16.70 (8).
3. The state.
(b) For purposes of this definition, all of the following apply:
1. All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer.
2. “Employer" includes any predecessor of an employer.
(7) “Enrollment date" means, with respect to an individual covered under a group health plan or health insurance, the date of enrollment of the individual under the plan or insurance or, if earlier, the first day of the waiting period for such enrollment.
