Wisconsin Legislature: 27,4932L

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.

27,4932y Section 4932y. 635.11 of the statutes is renumbered 635.11 (1m), and 635.11 (1m) (intro.), as renumbered, is amended to read:

635.11 (1m) (intro.) Before the sale of a plan or policy subject to this subchapter chapter, a small employer insurer shall disclose to a small employer all of the following:

27,4933c Section 4933c. 635.11 (1m) (e) of the statutes is created to read:

635.11 (1m) (e) As part of the small employer insurer's solicitation and sales materials, the availability of the information under par. (f).

27,4933e Section 4933e. 635.11 (1m) (f) of the statutes is created to read:

635.11 (1m) (f) Upon the request of the small employer, the following information:

1. The provisions, if any, of the plan or policy relating to preexisting condition exclusions.

2. The benefits and premiums available under all health insurance coverage offered by the small employer insurer for which the small employer is qualified.

27,4933g Section 4933g. 635.11 (2m) of the statutes is created to read:

635.11 (2m) Information required to be disclosed under this section shall be provided in a manner that is understandable to a small employer and shall be sufficient to reasonably inform a small employer of the small employer's rights and obligations under the health insurance coverage.

27,4933i Section 4933i. 635.11 (3m) of the statutes is created to read:

635.11 (3m) A small employer insurer is not required under this section to disclose information that is proprietary or trade secret information under applicable law.

27,4934c Section 4934c. 635.13 (1) of the statutes is amended to read:

635.13 (1) Records. A small employer insurer shall maintain at its principal place of business complete and detailed records relating to its rating methods and practices and its renewal underwriting methods and practices, and shall make the records available to the commissioner and the small employer insurance board upon request.

27,4935m Section 4935m. 635.18 (1) of the statutes is amended to read:

635.18 (1) Every small employer insurer shall actively market health benefit plan coverage, including basic health benefit plans, to small employers in the state. If a small employer insurer denies coverage to a small employer under a health benefit plan that is not a basic health benefit plan on the basis of the health status or claims experience of the small employer or its eligible employes or their dependents, the small employer insurer shall offer the small employer the opportunity to purchase a basic health benefit plan.

27,4935p Section 4935p. 635.18 (3) (c) of the statutes is repealed.

27,4935r Section 4935r. 635.18 (7) of the statutes is amended to read:

635.18 (7) A 3rd-party administrator that enters into a contract, agreement or other arrangement with a small employer insurer to provide administrative, marketing or other services related to the offering of health benefit plans to small employers in this state is subject to this subchapter chapter as if it were a small employer insurer.

27,4936c Section 4936c. 635.19 of the statutes is created to read:

635.19 Issuance of coverage in small group market. (1) (a) Except as provided in subs. (2) to (6), a small employer insurer that offers a group health benefit plan in the small group market shall do all of the following:

1. Accept any small employer in the state that applies for such coverage.

2. Accept for enrollment under such coverage any eligible individual who applies for enrollment during the period in which the individual first becomes eligible to enroll under the terms of the group health benefit plan.

3. Place no restriction on an eligible individual under par. (b) that is inconsistent with s. 632.746 or 632.748.

(b) For purposes of this section, whether an individual is an “eligible individual" in relation to a small employer shall be determined in accordance with all of the following:

1. The terms of the group health benefit plan under which the individual is applying for enrollment.

2. Rules of the small employer insurer offering the group health benefit plan under which the individual is applying for enrollment, which rules must apply uniformly in this state to small employers in the small group market.

3. All state laws that apply to small employer insurers and the small group market.

(2) (a) A small employer insurer that offers a group health benefit plan in the small group market through a network plan may do any of the following:

1. Limit the small employers that may apply for such coverage to those with eligible individuals who reside, live or work in the service area of the network plan.

2. Within the service area of the network plan, deny such coverage to small employers if the small employer insurer demonstrates to the commissioner all of the following:

a. That the insurer does not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees.

b. That the insurer is applying this subdivision uniformly to all small employers without regard to the claims experience of those small employers or their employes or employes' dependents or any other health status-related factor of those employes or their dependents.

(b) A small employer insurer that denies coverage under par. (a) 2. in any service area may not offer coverage in the small group market in that service area for 180 days after the date on which the coverage was denied.

(3) (a) A small employer insurer that offers a group health benefit plan in the small group market may deny small employers coverage under such a plan in the small group market if the small employer insurer demonstrates to the commissioner all of the following:

1. That the insurer does not have the financial reserves necessary to underwrite additional coverage.

2. That the insurer is applying this paragraph uniformly to all small employers in the small group market in the state in accordance with applicable state law and without regard to the claims experience of those small employers or their employes or employes' dependents or any other health status-related factor of those employes or their dependents.

(b) A small employer insurer that denies coverage under par. (a) may not offer a group health benefit plan in the small group market in the state for 180 days after the date on which the coverage was denied or until the insurer demonstrates to the commissioner that the insurer has sufficient financial reserves to underwrite additional coverage, whichever is later.

(4) Subsection (1) shall not be construed to preclude a small employer insurer from establishing, for the offering of a group health benefit plan in the small group market, any of the following:

(a) Rules or requirements relating to the minimum level or amount of small employer contribution toward the premium for the enrollment of participants and beneficiaries.

(b) Rules or requirements relating to the minimum number or percentage of participants or beneficiaries that must be enrolled in relation to a specified number or percentage of eligible individuals or employes of a small employer.

(5) Subsection (1) does not apply to a group health benefit plan offered by a small employer insurer in the small group market if all of the following apply:

(a) The group health benefit plan is offered in the small group market only through one or more bona fide associations.