Amendment SSA1-AB416

AB416-SSA1, s. 37 Section 37. 619.14 (5) (a) of the statutes is amended to read:

AB416-SSA1,16,25 619.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter for major medical expense coverage required under this section. For coverage offered to those persons eligible for medicare, the plan shall offer a deductible equal to the deductible charged by part A of title XVIII of the federal social security act, as amended. The deductible amounts for all other eligible persons shall be dependent upon household income as determined under s. 619.165. For eligible persons under s. 619.165 (1) (b) 1., the deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2., the deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3., the deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4., the deductible shall be $800. For all other eligible persons who are not eligible for medicare, the deductible shall be $1,000. With respect to all eligible persons, expenses used to satisfy the deductible during the last 90 days of a calendar year shall also be applied to satisfy the deductible for the following calendar year. The schedule of premiums shall be promulgated by rule by the commissioner , subject to s. 619.15 (3) (f). The commissioner shall set rates at 60% of the operating and administrative costs of the plan premiums for eligible persons who have a household income, as defined in s. 71.52 (5) and as determined under s. 619.165 (1) (d), at or above the threshold amount established under s. 619.15 (3) (g) at a higher rate than premiums for eligible persons who have a household income below the threshold amount.

AB416-SSA1, s. 38 Section 38. 619.14 (5) (d) of the statutes is amended to read:

AB416-SSA1,17,8 619.14 (5) (d) Notwithstanding pars. (a) to (c), the board may establish different deductible amounts, a different coinsurance percentage and different covered costs and deductible aggregate amounts from those specified in pars. (a) to (c) in accordance with cost containment provisions established by the commissioner under s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under s. 619.145 or who are unable to enroll in an alternative plan because of the unavailability of such a plan in the individual's geographic area.

AB416-SSA1, s. 39 Section 39. 619.145 (1) of the statutes is amended to read:

AB416-SSA1,17,16 619.145 (1) The Except as provided in sub. (1m), the board may offer to persons eligible for coverage under s. 619.12 the opportunity to enroll, on a voluntary basis, in an alternative plan that uses managed care and that the commissioner determines provides benefits that are substantially equivalent to or greater than the benefits provided under the plan. A person who voluntarily enrolls in an alternative plan under this section is ineligible for coverage under the plan for 12 months after enrolling in the alternative plan.

AB416-SSA1, s. 40 Section 40. 619.145 (1m) of the statutes is created to read:

AB416-SSA1,17,22 619.145 (1m) (a) The board shall promulgate rules that implement the use of alternative plans that use managed care and capitation or other risk-sharing mechanisms and that the commissioner determines provide benefits for persons who use the services of providers designated by the alternative plan that are substantially equivalent to or greater than the benefits provided under the plan.

AB416-SSA1,17,25 (b) Beginning on July 1, 1997, the board shall offer to persons eligible for coverage under s. 619.12 the opportunity to enroll, and may require such persons to enroll, in an alternative plan.

AB416-SSA1,18,7 (c) Notwithstanding s. 619.14 (5) (a), the board may by rule establish premiums for persons who enroll in an alternative plan that are different from premiums for persons who do not enroll in an alternative plan to reflect the differences in the cost of covered services and articles. A person who is unable to enroll in an alternative plan because of the unavailability of such a plan in the person's geographic area, however, shall be allowed to pay the same premium rate as persons who do enroll in an alternative plan.

AB416-SSA1, s. 41 Section 41. 619.145 (3) (e) of the statutes is repealed.

AB416-SSA1, s. 42 Section 42. 619.145 (3) (e) of the statutes is created to read:

AB416-SSA1,18,13 619.145 (3) (e) Subject to sub. (4), a reduction in the alternative plan's assessment under s. 619.13 for operating and administrative, but not subsidy, expenses of the plan. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 43 Section 43. 619.145 (4) of the statutes is repealed.

AB416-SSA1, s. 44 Section 44. 619.145 (4) of the statutes is created to read:

AB416-SSA1,18,19 619.145 (4) A contract under sub. (3) may not provide for a reduction in the assessment under s. 619.13 against an alternative plan unless the assessment reduction has been adopted by rule under s. 619.15 (4) (e). This subsection does not apply after 2 years after the effective date of this subsection .... [revisor inserts date].

AB416-SSA1, s. 45 Section 45. 619.15 (1) of the statutes is amended to read:

AB416-SSA1,19,8 619.15 (1) The plan shall operate subject to the supervision and approval of a board consisting of representatives of 2 participating insurers which are nonprofit corporations, 2 other participating insurers 3 insurers and 3 health care providers, and 3 public members, appointed by the commissioner for staggered 3-year terms. In addition, the commissioner or a designated representative from the office of the commissioner shall be a member of the board. The public members shall not be professionally affiliated with the practice of medicine, a hospital or an insurer. At least 2 of the public members shall be individuals reasonably expected to qualify for coverage under the plan or the parent or spouse of such an individual. The commissioner or the commissioner's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.

AB416-SSA1, s. 46 Section 46. 619.15 (3) (bc) of the statutes is created to read:

AB416-SSA1,19,13 619.15 (3) (bc) Specify all persons that are required to impose and collect the surcharge under s. 619.13 (1) (a). The board shall include every type of provider that may provide a covered service or article under s. 619.14 (3). This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 47 Section 47. 619.15 (3) (bc) of the statutes, as created by 1995 Wisconsin Act .... (this act), is repealed.

AB416-SSA1, s. 48 Section 48. 619.15 (3) (bm) of the statutes is created to read:

AB416-SSA1,19,23 619.15 (3) (bm) Set the amount of the surcharge under s. 619.13 (1) (a) at a level that is sufficient to cover claims paid under the plan, the operating and administrative expenses of the plan and the administrative expenses that may be retained by health care providers under s. 619.13 (1) (b) at a level sufficient to cover a health care provider's administrative expenses. The amount shall be a flat encounter fee, and the board may provide for different surcharge amounts for different services or articles. This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 49 Section 49. 619.15 (3) (bm) of the statutes, as created by 1995 Wisconsin Act .... (this act), is repealed.

AB416-SSA1, s. 50 Section 50. 619.15 (3) (c) of the statutes is amended to read:

AB416-SSA1,20,10 619.15 (3) (c) Collect assessments surcharges from all insurers health care providers to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board. Assessment of the insurers shall occur at the end of each calendar year or other fiscal year end established by the board. Assessments are due and payable within 30 days of receipt by the insurer of the assessment notice. The board shall ensure that all surcharges are deposited in the health insurance risk-sharing plan fund. This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 51 Section 51. 619.15 (3) (c) of the statutes, as affected by 1995 Wisconsin Act .... (this act), is repealed and recreated to read:

AB416-SSA1,20,20 619.15 (3) (c) Collect assessments from all insurers to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board. Assessment of the insurers shall occur at the end of each calendar year or other fiscal year end established by the board. Assessments are due and payable within 30 days of receipt by the insurer of the assessment notice. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 52 Section 52. 619.15 (3) (f) and (g) of the statutes are created to read:

AB416-SSA1,20,24 619.15 (3) (f) Determine the percentage, but not less than 60%, of the operating and administrative costs of the plan at which the commissioner must set premium rates under s. 619.14 (5) (a).

AB416-SSA1,21,3 (g) Establish a threshold amount for the household income, as defined in s. 71.52 (5) and as determined under s. 619.165 (1) (d), of an eligible person for purposes of determining premium rates under s. 619.14 (5) (a).

AB416-SSA1, s. 53 Section 53 . 619.15 (4) (c) of the statutes is repealed and recreated to read:

AB416-SSA1,21,8 619.15 (4) (c) Adjust the surcharge amount under sub. (3) (bm) to ensure adequate funding for the payment of claims, the operating and administrative expenses of the plan and the administrative expenses retained by health care providers. This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 54 Section 54 . 619.15 (4) (c) of the statutes, as affected by 1995 Wisconsin Act .... (this act), is repealed and recreated to read:

AB416-SSA1,21,18 619.15 (4) (c) In addition to assessments imposed under sub. (3) (c), levy interim assessments to ensure the financial ability of the plan to cover claims expense and administrative expenses incurred or estimated to be incurred in the operation of the plan prior to the end of the calendar year end or other fiscal year end established by the board. Interim assessments shall be due and payable within 30 days of receipt by an insurer of an interim assessment notice. Interim assessments shall be credited against each insurer's annual assessment. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 55 Section 55. 619.15 (4) (e) of the statutes is repealed.

AB416-SSA1, s. 56 Section 56. 619.15 (4) (e) of the statutes is created to read:

AB416-SSA1,21,24 619.15 (4) (e) By rule provide for a reduction in the assessment under s. 619.13 against an alternative plan that provides coverage to eligible persons. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 57 Section 57. 619.165 (1) (a) of the statutes is amended to read:

AB416-SSA1,22,4 619.165 (1) (a) The board shall reduce the premiums established by the commissioner under s. 619.11 in conformity with ss. 619.14 (5), 619.15 (3) (f) and (g) and 619.17 or established by the board under s. 619.145 (1m) (c), for the eligible persons and in the manner set forth in pars. (b) to (d).

AB416-SSA1, s. 58 Section 58. 619.165 (1) (d) of the statutes is amended to read:

AB416-SSA1,22,8 619.165 (1) (d) The board shall establish and implement the method for determining the household income of an eligible person under par. (b) and under ss. 619.14 (5) (a) and 619.15 (3) (g).

AB416-SSA1, s. 59 Section 59. 619.165 (2) of the statutes is amended to read:

AB416-SSA1,22,13 619.165 (2) The board shall direct the administering carrier to collect, under s. 619.16 (3) (b), from the eligible persons under sub. (1) the premiums as reduced under sub. (1) rather than the premiums established by the commissioner or by the board.

AB416-SSA1, s. 60 Section 60. 619.17 (1) of the statutes is amended to read:

AB416-SSA1,22,16 619.17 (1) Subject to s. ss. 619.14 (5) (a) and 619.15 (3) (f) and (g), a rating plan calculated in accordance with generally accepted actuarial principles.

AB416-SSA1, s. 61 Section 61 . 619.175 of the statutes is amended to read:

AB416-SSA1,22,22 619.175 Waiver or exemption from provisions prohibited. Except as provided in s. 619.13 (1) (a), the The commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.

AB416-SSA1, s. 62 Section 62 . 619.175 of the statutes, as affected by 1995 Wisconsin Act .... (this act), section 61, is repealed and recreated to read:

AB416-SSA1,23,5 619.175 Waiver or exemption from provisions prohibited. Except as provided in s. 619.13 (1) (a), the commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.

AB416-SSA1, s. 63 Section 63 . 619.175 of the statutes, as affected by 1995 Wisconsin Act .... (this act), sections 55 and 56, is repealed and recreated to read:

AB416-SSA1,23,11 619.175 Waiver or exemption from provisions prohibited. The commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.

AB416-SSA1, s. 64 Section 64. 625.12 (2) of the statutes is amended to read:

AB416-SSA1,23,21 625.12 (2) Classification. Risks Subject to s. 635.09, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to s. ss. 632.365 and 635.09, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB416-SSA1, s. 65 Section 65. 628.34 (3) (a) of the statutes is amended to read:

AB416-SSA1,24,4 628.34 (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 s. ss. 632.365, 635.03, 635.09 and 635.16. 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.

AB416-SSA1, s. 66 Section 66. 628.34 (3) (b) of the statutes is amended to read:

AB416-SSA1,24,11 628.34 (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. 635.03 to 635.09, 635.16 and 635.17.

AB416-SSA1, s. 67 Section 67. 632.727 of the statutes is created to read:

AB416-SSA1,24,14 632.727 Electronic claims capability. (1) Definition. In this section, "health care provider" has the meaning given in s. 146.81 (1) (a) to (m) and (p).

AB416-SSA1,24,16 (2) Insurers. Beginning on January 1, 1997, every insurer that offers disability insurance must have and use the capability to accept all claims electronically.

AB416-SSA1,24,19 (3) Health care providers. (a) Beginning on January 1, 1997, every health care provider that has annual gross revenues of more than $1,000,000 must have and use the capability to electronically transmit disability insurance claims information.

AB416-SSA1,24,22 (b) Beginning on January 1, 1998, every health care provider not specified in par. (a) must have and use the capability to electronically transmit disability insurance claims information.

AB416-SSA1, s. 68 Section 68. 632.76 (2) (a) of the statutes is amended to read:

AB416-SSA1,25,4 632.76 (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 health benefit plan, as defined in s. 635.02 (3), which is subject to s. 635.03 (2) or 635.16 (2).

AB416-SSA1, s. 69 Section 69. 632.896 (4) of the statutes is amended to read:

AB416-SSA1,25,11 632.896 (4) Preexisting conditions. Notwithstanding s. ss. 632.76 (2) (a), 635.03 (2) and 635.16 (2), 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).

AB416-SSA1, s. 70 Section 70. Chapter 635 (title) of the statutes is amended to read:

AB416-SSA1,25,13 CHAPTER 635

AB416-SSA1,25,15 SMALL EMPLOYER regulation of HEALTH INSURANCE

AB416-SSA1, s. 71 Section 71. 635.01 of the statutes is repealed.

AB416-SSA1, s. 72 Section 72. 635.02 of the statutes is repealed and recreated to read:

AB416-SSA1,25,18 635.02 Definitions. In this subchapter:

AB416-SSA1,25,20 (1) "Basic health benefit plan" means a small employer health insurance plan under subch. II.

AB416-SSA1,25,24 (2) "Dependent" means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.

AB416-SSA1,26,10 (3) "Health benefit plan" means any hospital or medical policy or certificate. "Health benefit plan" does not include accident-only, credit accident or health, dental, vision, medicare supplement, medicare replacement, long-term care, disability income or short-term insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, automobile medical payment insurance, student-only medical plans, policies issued to medicaid recipients, individual conversion policies, specified disease policies, hospital indemnity policies, as defined in s. 632.895 (1) (c), policies or certificates issued under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619 or other insurance exempted by rule of the commissioner.

AB416-SSA1,26,14 (4) "Short-term insurance" means a temporary individual major medical or accident insurance policy issued for a term of 6 months or less, except that such a policy may be renewed one time at the expiration of the initial term for a term of 6 months or less.

AB416-SSA1,26,19 (5) "Student-only medical plan" means a limited nonmedically underwritten individual or group health benefit plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate or graduate student at an accredited technical or trade school, college or university and to which any of the following applied at issuance:

AB416-SSA1,26,20 (a) The student was not insured under a health benefit plan.

AB416-SSA1,26,23 (b) The student was eligible for coverage under a health benefit plan of his or her parent, stepparent or guardian but was unable to access the full health benefits of the plan due to limitations in the plan's geographic service area.

AB416-SSA1, s. 73 Section 73. 635.03 of the statutes is created to read:

AB416-SSA1,27,2 635.03 Coverage requirements for all group health benefit plans. (1) Definitions. In this section and s. 635.04:

AB416-SSA1,27,9 (a) 1. Except as provided in subd. 2., "eligible employe" means an employe who works on a permanent basis and has a normal workweek 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.

AB416-SSA1,27,12 2. 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).

AB416-SSA1,27,13 (b) "Employer" means any of the following:

AB416-SSA1,27,16 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.

AB416-SSA1,27,17 2. A municipality, as defined in s. 16.70 (8).

AB416-SSA1,27,18 3. The state.

AB416-SSA1,27,22 (c) "Group health benefit plan" means a health benefit plan that is issued by an insurer to an employer on behalf of a group consisting of eligible employes of the employer. The term includes individual health benefit plans covering eligible employes when 3 or more are sold to an employer.