Wisconsin Legislature: 27,4930

632.7495 Guaranteed renewability of individual health insurance coverage. (1) (a) Except as provided in subs. (2) and (3) and notwithstanding s. 631.36 (2) to (4m), an insurer that provides individual health benefit plan coverage shall renew such coverage or continue such coverage in force at the option of the insured individual and, if applicable, the association through which the individual has coverage.

(b) At the time of coverage renewal, the insurer may modify the individual health benefit plan coverage policy form as long as the modification is consistent with state law and effective on a uniform basis among all individuals with coverage under that policy form.

(2) Notwithstanding s. 631.36 (2) to (4m), an insurer may nonrenew or discontinue the individual health benefit plan coverage of an individual, but only if any of the following applies:

(a) The individual or, if applicable, the association through which the individual has coverage has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or in a timely manner.

(b) The individual or, if applicable, the association through which the individual has coverage has performed an act or engaged in a practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the health insurance coverage.

(c) The insurer is ceasing to offer individual health benefit plan coverage in accordance with sub. (3) and any other applicable state law.

(d) In the case of individual health benefit plan coverage that the insurer offers through a network plan, the individual no longer resides, lives or works in the service area or in an area in which the insurer is authorized to do business. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of covered individuals.

(e) In the case of individual health benefit plan coverage that the insurer offers only through one or more bona fide associations, the individual ceases to be a member of the association on which the coverage is based. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of covered individuals.

(f) The individual is eligible for medicare and the commissioner by rule permits coverage to be terminated.

(3) (a) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue offering in this state a particular type of individual health benefit plan coverage, but only if all of the following apply:

1. The insurer provides notice of the discontinuance to each individual for whom the insurer provides coverage of this type in this state and, if applicable, to the association through which the individual has coverage at least 90 days before the date on which the coverage will be discontinued.

2. The insurer offers to each individual for whom the insurer provides coverage of this type in this state and, if applicable, to the association through which the individual has coverage the option to purchase any other type of individual health insurance coverage that the insurer offers for individuals.

3. In electing to discontinue coverage of this particular type and in offering the option to purchase coverage under subd. 2., the insurer acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for the type of coverage described under subd. 2.

(b) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue offering individual health benefit plan coverage in this state, but only if all of the following apply:

1. The insurer provides notice of the discontinuance to the commissioner and to each individual for whom the insurer provides individual health benefit plan coverage in this state and, if applicable, to the association through which the individual has coverage at least 180 days before the date on which the coverage will be discontinued.

2. All individual health benefit plan coverage issued or delivered for issuance in this state is discontinued and coverage under such coverage is not renewed.

3. The insurer does not issue or deliver for issuance in this state any individual health benefit plan coverage before 5 years after the day on which the last individual health benefit plan coverage is discontinued under subd. 2.

27,4929m Section 4929m. 632.755 (title) of the statutes is amended to read:

632.755 (title) Public assistance and early intervention services.

27,4929n Section 4929n. 632.755 (1g) (a) of the statutes is amended to read:

632.755 (1g) (a) A disability insurance policy may not exclude a person or a person's dependent from coverage because the person or the dependent is eligible for assistance under ch. 49 or because the dependent is eligible for early intervention services under s. 51.44.

27,4929p Section 4929p. 632.755 (1g) (b) of the statutes is amended to read:

632.755 (1g) (b) A disability insurance policy may not terminate its coverage of a person or a person's dependent because the person or the dependent is eligible for assistance under ch. 49 or because the dependent is eligible for early intervention services under s. 51.44.

27,4929r Section 4929r. 632.755 (1g) (c) of the statutes is amended to read:

632.755 (1g) (c) A disability insurance policy may not provide different benefits of coverage to a person or the person's dependent because the person or the dependent is eligible for assistance under ch. 49 or because the dependent is eligible for early intervention services under s. 51.44 than it provides to persons and their dependents who are not eligible for assistance under ch. 49 or for early intervention services under s. 51.44.

27,4929t Section 4929t. 632.755 (2) of the statutes is amended to read:

632.755 (2) Benefits provided by a disability insurance policy shall be primary to those benefits provided under ch. 49 or under s. 51.44 or 253.05.

27,4929w Section 4929w. 632.76 (2) (a) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

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 (1) (c) (9), which is subject to s. 632.745 (2) 632.746.

27,4930 Section 4930 . 632.785 (1) (intro.) of the statutes is amended to read:

632.785 (1) (intro.) 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. 619.12 149.12 for coverage under subch. II of ch. 619 149, the insurer shall notify all persons affected of the existence of the mandatory health insurance risk-sharing plan under subch. II of ch. 619 149, as well as the eligibility requirements and method of applying for coverage under the plan:

27,4930d Section 4930d. 632.89 (2) (a) 2. of the statutes is amended to read:

632.89 (2) (a) 2. Except as provided in pars. (b) to (e), coverage of conditions under subd. 1. by a policy may not be subject to exclusions or limitations, including deductibles, that are not generally applicable to other conditions covered under the policy.

27,4930f Section 4930f. 632.89 (2) (c) 2. a. of the statutes is amended to read:

632.89 (2) (c) 2. a. The expenses of the first 30 days as an inpatient in a hospital.

27,4930h Section 4930h. 632.89 (2) (c) 2. b. of the statutes is amended to read:

632.89 (2) (c) 2. b. The first $7,000 Seven thousand dollars minus a copayment of up to 10% for inpatient hospital services or, if the coverage is provided by a health maintenance organization, as defined in s. 609.01 (2), the first $6,300 or the equivalent benefits measured in services rendered.

27,4930pm Section 4930pm. 632.89 (2) (d) 2. of the statutes is amended to read:

632.89 (2) (d) 2. Except as provided in par. (b), a policy under subd. 1. shall provide coverage in every policy year for not less than the first $2,000 minus a copayment of up to 10% for outpatient services or, if the coverage is provided by a health maintenance organization, as defined in s. 609.01 (2), the first $1,800 or the equivalent benefits measured in services rendered.

27,4930rm Section 4930rm. 632.89 (2) (dm) 2. of the statutes is amended to read:

632.89 (2) (dm) 2. Except as provided in par. (b), a policy under subd. 1. shall provide coverage in every policy year for not less than the first $3,000 minus a copayment of up to 10% for transitional treatment arrangements or, if the coverage is provided by a health maintenance organization, as defined in s. 609.01 (2), the first $2,700 or the equivalent benefits measured in services rendered.

27,4930t Section 4930t. 632.895 (11) of the statutes is created to read:

632.895 (11) Treatment for the correction of temporomandibular disorders. (a) 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 any diagnostic or surgical procedure involving a bone, joint, muscle or tissue shall provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders , including medically necessary surgery for the correction of functional deformities of the maxilla or mandible, if all of the following apply:

1. The condition is caused by congenital, developmental or acquired deformity, disease or injury.

2. Under the accepted standards of the profession of the health care provider rendering the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of the condition.

3. The purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction.

(b) 1. The coverage required under this subsection for nonsurgical treatment includes coverage for prescribed intraoral splint therapy devices.

2. The coverage required under this subsection does not include coverage for cosmetic or elective orthodontic care, periodontic care or general dental care.

(c) The coverage required under this subsection may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan.

27,4930u Section 4930u. 632.895 (12) of the statutes is created to read:

632.895 (12) Hospital and ambulatory surgery center charges and anesthetics for dental care. (a) In this subsection, “ambulatory surgery center" has the meaning given in s. 49.45 (6r) (a) 1.

(b) Every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, shall cover hospital or ambulatory surgery center charges incurred, and anesthetics provided, in conjunction with dental care that is provided to a covered individual in a hospital or ambulatory surgery center, if any of the following applies:

1. The individual is a child under the age of 5.

2. The individual has a chronic disability that meets all of the conditions under s. 230.04 (9r) (a) 2. a., b. and c.

3. The individual has a medical condition that requires hospitalization or general anesthesia for dental care.

27,4930v Section 4930v. 632.895 (13) of the statutes is created to read:

632.895 (13) Breast reconstruction. (a) 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 breast reconstruction of the affected tissue incident to a mastectomy.

(b) The coverage required under par. (a) may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan.

27,4931m Section 4931m. 632.896 (4) of the statutes, as affected by 1995 Wisconsin Act 289, is amended to read:

632.896 (4) Preexisting conditions. Notwithstanding ss. 632.745 (2) 632.746 and 632.76 (2) (a), a disability insurance policy that is subject to sub. (2) and that is in effect when a court makes a final order granting adoption or when the child is placed for adoption may not exclude or limit coverage of a disease or physical condition of the child on the ground that the disease or physical condition existed before coverage is required to begin under sub. (3).

27,4932 Section 4932 . 632.897 (10) (am) 2. of the statutes is amended to read:

632.897 (10) (am) 2. Provide family coverage under the group policy or individual policy for the individual's child, if eligible for coverage, upon application by the individual, the child's other parent, the department of health and family services workforce development or the county designee child support agency under s. 59.53 (5).

27,4932bm Section 4932bm. 632.898 (1), (2), (3), (4), (5) and (6) of the statutes are repealed.

27,4932br Section 4932br. 632.898 (7) of the statutes is renumbered 632.899 and amended to read:

632.899 (title) Medical savings accounts study. If the federal government enacts legislation providing for a federal income tax exemption for amounts deposited in an a medical savings account established under this section and for any interest, dividends or other gain that accrues in the account if redeposited in the account, the commissioner shall conduct a study, to be completed within 4 years after the enactment of the federal legislation, of individuals and groups that had coverage under a high cost-share health plan, as defined in s. 632.898 (1) (c), 1995 stats., and that terminated that coverage in order to enroll in a health benefit plan that was not a high cost-share health plan. If as a result of the study the commissioner determines that s. 632.745 (1) (f) 2. is not necessary for the purpose for which it was intended, the commissioner shall certify that determination to the revisor of statutes. Upon the certification, the revisor of statutes shall publish notice in the Wisconsin administrative register of the determination, the date of the certification and that after 30 days after the date of the certification s. 632.745 (1) (f) 2. is not effective, as defined in s. 632.898 (1) (c), 1995 stats. The commissioner shall submit a report of all findings, conclusions and recommendations to the appropriate standing committees in the manner provided under section 13.172 (3) of the statutes.

27,4932d Section 4932d. Subchapter I (title) of chapter 635 [precedes 635.01] of the statutes is repealed.

27,4932f Section 4932f. 635.01 of the statutes is amended to read:

635.01 Scope. This subchapter chapter applies to all group health insurance plans, policies or certificates, written on risks or operations in this state, providing coverage for employes of a small employer, or employes of a small employer and the employer, and to individual health insurance policies, written on risks or operations in this state, providing coverage for employes of a small employer, or employes of a small employer and the employer when 3 or more are sold to or through a small employer.

27,4932h Section 4932h. 635.02 (intro.) of the statutes is amended to read:

635.02 Definitions. (intro.) In this subchapter chapter:

27,4932j Section 4932j. 635.02 (1c) of the statutes is repealed.

27,4932L Section 4932L. 635.02 (1p) of the statutes is created to read:

635.02 (1p) “Bona fide association" has the meaning given in s. 632.745 (3).

27,4932p Section 4932p. 635.02 (3c) of the statutes is repealed.

27,4932q Section 4932q. 635.02 (3f) of the statutes is repealed.

27,4932r Section 4932r. 635.02 (3g) of the statutes is created to read:

635.02 (3g) “Employer" has the meaning given in s. 632.745 (6).

27,4932s Section 4932s. 635.02 (3k) of the statutes is created to read:

635.02 (3k) “Group health benefit plan" has the meaning given in s. 632.745 (9).

27,4932t Section 4932t. 635.02 (3m) of the statutes is repealed and recreated to read:

635.02 (3m) “Health benefit plan" has the meaning given in s. 632.745 (11).

27,4932u Section 4932u. 635.02 (4t) of the statutes is created to read:

635.02 (4t) “Network plan" has the meaning given in s. 632.745 (19).

27,4932v Section 4932v. 635.02 (7) of the statutes is repealed and recreated to read:

635.02 (7) “Small employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 2 but not more than 50 employes on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 2 but not more than 50 employes on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 employes on the first day of the plan year.

27,4932w Section 4932w. 635.02 (9) of the statutes is created to read:

635.02 (9) “Small group market" has the meaning given in s. 632.745 (26).

27,4932x Section 4932x. 635.09 of the statutes is repealed.