AB416-SSA1,30,1614 (d) An insurer may not increase a requirement for minimum employe
15participation or a requirement for minimum employer contribution that applies to
16an employer after the employer has been accepted for coverage.
AB416-SSA1,30,1817 (e) This subsection does not apply to a group health benefit plan offered by the
18state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).
AB416-SSA1,30,25 19(5) Prohibited coverage practices. (a) 1. Except as provided in rules
20promulgated under subd. 3., if an insurer offers a group health benefit plan to an
21employer, the insurer shall offer coverage to all of the eligible employes of the
22employer and their dependents. Except as provided in rules promulgated under
23subd. 3., an insurer may not offer coverage to only certain individuals in an employer
24group or to only part of the group, except for an eligible employe who has not yet
25satisfied an applicable waiting period, if any.
AB416-SSA1,31,7
12. Except as provided in rules promulgated under subd. 3., if the state or a
2county, city, village, town or school district offers coverage under a self-insured
3health plan, it shall offer coverage to all of its eligible employes and their dependents.
4Except as provided in rules promulgated under subd. 3., the state or a county, city,
5village, town or school district may not offer coverage to only certain individuals in
6the employer group or to only part of the group, except for an eligible employe who
7has not yet satisfied an applicable waiting period, if any.
AB416-SSA1,31,148 3. The secretary of employe trust funds, with the approval of the group
9insurance board, shall promulgate rules related to offering coverage to eligible
10employes under a group health benefit plan, or a self-insured health plan, offered
11by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7). The
12rules shall conform to the intent of subds. 1. and 2. and may not allow the state or
13the group insurance board to refuse to offer coverage to an eligible employe or
14dependent for reasons related to health condition.
AB416-SSA1,31,1815 (b) 1. An insurer may not modify a group health benefit plan with respect to
16an employer or an eligible employe or dependent, through riders, endorsements or
17otherwise, to restrict or exclude coverage for certain diseases or medical conditions
18otherwise covered by the group health benefit plan.
AB416-SSA1,31,2219 2. The state or a county, city, village, town or school district may not modify a
20self-insured health plan with respect to an eligible employe or dependent, through
21riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases
22or medical conditions otherwise covered by the self-insured health plan.
AB416-SSA1,32,223 3. Nothing in this paragraph limits the authority of the group insurance board
24to fulfill its obligations as trustee under s. 40.03 (6) (d) or to design or modify

1procedures or provisions pertaining to enrollment, premium transmitted or coverage
2of eligible employes for health care benefits under s. 40.51 (1).
AB416-SSA1, s. 74 3Section 74. 635.04 of the statutes is created to read:
AB416-SSA1,32,9 4635.04 Guaranteed acceptance. (1) Employe becomes eligible after
5commencement of coverage.
If an insurer provides coverage under a group health
6benefit plan, the insurer shall provide coverage under the group health benefit plan
7to an eligible employe who becomes eligible for coverage after the commencement of
8the employer's coverage, and to the eligible employe's dependents, regardless of
9health condition or claims experience, if all of the following apply:
AB416-SSA1,32,1010 (a) The employe has satisfied any applicable waiting period.
AB416-SSA1,32,1211 (b) The employer agrees to pay the premium required for coverage of the
12employe under the group health benefit plan.
AB416-SSA1,32,18 13(2) Employe waived coverage previously. If an insurer provides coverage
14under a group health benefit plan, the insurer shall provide coverage under the
15group health benefit plan to an eligible employe who waived coverage during an
16enrollment period during which the employe was entitled to enroll in the group
17health benefit plan, regardless of health condition or claims experience, if all of the
18following apply:
AB416-SSA1,32,2019 (a) The eligible employe was covered as a dependent under qualifying coverage
20when he or she waived coverage under the group health benefit plan.
AB416-SSA1,32,2521 (b) The eligible employe's coverage under the qualifying coverage has
22terminated or will terminate due to a divorce from the insured under the qualifying
23coverage, the death of the insured under the qualifying coverage, loss of employment
24by the insured under the qualifying coverage or involuntary loss of coverage under
25the qualifying coverage by the insured under the qualifying coverage.
AB416-SSA1,33,3
1(c) The eligible employe applies for coverage under the group health benefit
2plan not more than 30 days after termination of his or her coverage under the
3qualifying coverage.
AB416-SSA1,33,54 (d) The employer agrees to pay the premium required for coverage of the
5employe under the group health benefit plan.
AB416-SSA1,33,11 6(3) State or municipal self-insured plans. If the state or a county, city, village,
7town or school district provides coverage under a self-insured health plan, it shall
8provide coverage under the self-insured health plan to an eligible employe who
9waived coverage during an enrollment period during which the employe was entitled
10to enroll in the self-insured health plan, regardless of health condition or claims
11experience, if all of the following apply:
AB416-SSA1,33,1312 (a) The eligible employe was covered as a dependent under qualifying coverage
13when he or she waived coverage under the self-insured health plan.
AB416-SSA1,33,1814 (b) The eligible employe's coverage under the qualifying coverage has
15terminated or will terminate due to a divorce from the insured under the qualifying
16coverage, the death of the insured under the qualifying coverage, loss of employment
17by the insured under the qualifying coverage or involuntary loss of coverage under
18the qualifying coverage by the insured under the qualifying coverage.
AB416-SSA1,33,2119 (c) The eligible employe applies for coverage under the self-insured health plan
20not more than 30 days after termination of his or her coverage under the qualifying
21coverage.
AB416-SSA1, s. 75 22Section 75. 635.05 of the statutes is repealed.
AB416-SSA1, s. 76 23Section 76. 635.07 of the statutes is repealed and recreated to read:
AB416-SSA1,33,25 24635.07 Guaranteed issue for certain group health benefit plans. (1)
25Definitions. In this section and ss. 635.09 to 635.15:
AB416-SSA1,34,3
1(a) "Base premium rate" means the lowest premium rate chargeable under a
2rating system to employers or individuals with similar case characteristics and the
3same or similar benefit design characteristics.
AB416-SSA1,34,64 (b) "Benefit design characteristics" means covered services, cost sharing,
5utilization management, managed care networks and other features that
6differentiate plan or coverage designs.
AB416-SSA1,34,87 (c) "Case characteristics" means the age, gender, geographic location and
8tobacco use of the individuals covered under a health benefit plan.
AB416-SSA1,34,159 (d) "Eligible employe" means an employe who works on a permanent basis and
10has a normal workweek of 30 or more hours. The term includes a sole proprietor, a
11business owner, including the owner of a farm business, a partner of a partnership
12and a member of a limited liability company if the sole proprietor, business owner,
13partner or member is included as an employe under a health benefit plan of an
14employer, but the term does not include an employe who works on a temporary or
15substitute basis.
AB416-SSA1,34,1616 (e) "Employer" means any of the following:
AB416-SSA1,34,2217 1. An individual, firm, corporation, partnership, limited liability company or
18association that is actively engaged in a business enterprise in this state, including
19a farm business, and that employs in this state not fewer than 2 nor more than 100
20eligible employes. In determining the number of eligible employes, employers that
21are affiliated, or that are eligible to file a combined tax return for purposes of state
22taxation, shall be considered one employer.
AB416-SSA1,34,2423 2. A municipality, as defined in s. 16.70 (8), that employs not fewer than 2 nor
24more than 100 eligible employes.
AB416-SSA1,35,4
1(f) "Group health benefit plan" means a health benefit plan that is issued by
2an insurer to an employer on behalf of a group consisting of eligible employes of the
3employer. The term includes individual health benefit plans covering eligible
4employes when 3 or more are sold to an employer.
AB416-SSA1,35,125 (g) "Insurer" means an insurer that is authorized to do business in this state,
6in one or more lines of insurance that includes health insurance, and that offers
7group health benefit plans covering eligible employes of one or more employers in
8this state, or that sells individual health benefit plans to individuals who are
9residents of this state. The term includes a health maintenance organization, as
10defined in s. 609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), an
11insurer operating as a cooperative association organized under ss. 185.981 to
12185.985 and a limited service health organization, as defined in s. 609.01 (3).
AB416-SSA1,35,1413 (h) "Midpoint rate" means the arithmetic average of the base premium rate and
14the corresponding highest premium rate.
AB416-SSA1,35,1715 (i) "New business premium rate" means the premium rate charged or offered
16to employers or individuals with similar case characteristics for newly issued health
17insurance with the same or similar benefit design characteristics.
AB416-SSA1,35,1918 (j) "Rating period" means the period, determined by an insurer, during which
19a premium rate established by the insurer remains in effect.
AB416-SSA1,35,23 20(2) Requirement. Except as provided in subs. (3) and (4), an insurer shall
21provide coverage under a group health benefit plan to an employer and to all of the
22employer's eligible employes and their dependents, regardless of health condition or
23claims experience, if all of the following apply:
AB416-SSA1,35,2424 (a) The insurer has in force a group health benefit plan.
AB416-SSA1,36,2
1(b) The employer agrees to pay the premium required for coverage under the
2group health benefit plan.
AB416-SSA1,36,53 (c) The employer agrees to comply with all other provisions of the group health
4benefit plan that apply generally to a policyholder or an insured without regard to
5health condition or claims experience.
AB416-SSA1,36,8 6(2m) Payment security provisions allowed. An insurer that provides coverage
7under sub. (2) may impose payment security provisions that are reasonably related
8to the risk covered.
AB416-SSA1,36,13 9(3) Exceptions to guaranteed issue. (a) An insurer that is otherwise required
10to provide coverage under sub. (2) may refuse to issue a group health benefit plan to
11an employer if all of the individuals in the employer group that are to be covered
12under the group health benefit plan may be covered under one individual health
13benefit plan providing family coverage.
AB416-SSA1,36,1614 (b) Subsection (2) does not require an insurer to issue coverage that the insurer
15is not authorized to issue under its bylaws, charter or certificate of incorporation or
16authority.
AB416-SSA1,36,2017 (c) Subsection (2) does not require an insurer that provides coverage to an
18employer under a group health benefit plan to issue a different group health benefit
19plan to the employer before the expiration of the agreed term of the group health
20benefit plan under which the employer has coverage.
AB416-SSA1,36,2421 (d) An insurer that offers health care coverage exclusively to a single category
22or limited categories of employers may, with prior approval of the commissioner, limit
23its compliance with sub. (2) to that single category or those limited categories of
24employers.
AB416-SSA1,37,4
1(e) The commissioner may exempt an insurer from the requirements of sub. (2)
2if the commissioner determines that it is in the public interest to exempt the insurer
3from the requirements under sub. (2) because the insurer is in financially hazardous
4condition.
AB416-SSA1,37,95 (f) If an employer loses coverage under a group health benefit plan for failure
6to pay a premium when due, an insurer that is otherwise required to provide
7coverage under sub. (2) may refuse to issue a group health benefit plan to that
8employer during the 12-month period after the date on which the employer lost
9coverage.
AB416-SSA1,37,1410 (g) 1. In this paragraph, "small employer" means an employer that employs in
11this state not fewer than 2 nor more than 25 eligible employes. In determining the
12number of eligible employes, employers that are affiliated, or that are eligible to file
13a combined tax return for purposes of state taxation, shall be considered one
14employer.
AB416-SSA1,37,2015 2. An insurer that previously issued group health benefit plans but, prior to the
16effective date of this subdivision .... [revisor inserts date], discontinued offering such
17plans to small employers, shall within 60 days after the effective date of this
18subdivision .... [revisor inserts date], again offer group health benefit plans to small
19employers or be subject to the requirements under s. 635.17 (2) (a) as if the insurer
20had elected to not renew a group health benefit plan.
AB416-SSA1,37,24 21(4) Group risk adjustment mechanism. (a) In this subsection, "high-risk
22individual" means an individual with a high-risk medical condition who has
23coverage under a group health benefit plan with a premium rate at the insurer's
24highest premium rate level.
AB416-SSA1,38,3
1(b) An insurer that is otherwise required to provide coverage under sub. (2)
2shall be exempt from the requirement under sub. (2) for the remainder of a calendar
3year after all of the following occur:
AB416-SSA1,38,54 1. The number of high-risk individuals covered by the insurer at least equals
5the threshold level determined under par. (e) 3.
AB416-SSA1,38,126 2. The insurer applies for exemption from the requirement under sub. (2) by
7certifying its qualification under subd. 1. to the commissioner and the commissioner,
8within 30 days after the insurer submits its certifying information, makes no
9objection and does not request additional information. If the commissioner does
10timely object or request additional information, the insurer shall be exempt from the
11requirements under sub. (2) 30 days after the commissioner objects or the insurer
12submits the additional information if the commissioner takes no further action.
AB416-SSA1,38,1613 (c) Whenever an insurer becomes exempt from the requirement under sub. (2)
14by satisfying the criteria under par. (b), the commissioner shall provide notice of that
15exemption to all insurers to which this section applies and to all insurance agents
16listed under s. 628.11 by the insurers to which this section applies.
AB416-SSA1,38,1917 (d) An insurer that satisfies the criterion under par. (b) 1. is not required to
18apply for exemption from the requirement under sub. (2). An insurer that does not
19apply for exemption shall remain subject to the requirement under sub. (2).
AB416-SSA1,38,2220 (e) In consultation with the committee on risk adjustment, the commissioner
21shall promulgate rules for the operation of the risk adjustment mechanism under
22this subsection, including rules that specify at least all of the following:
AB416-SSA1,38,2423 1. What diagnostic conditions constitute high risk medical conditions for
24purposes of the definition of a high-risk individual.
AB416-SSA1,39,2
12. How to determine an insurer's highest premium rate level for purposes of
2the definition of a high-risk individual.
AB416-SSA1,39,43 3. What percentage of an insurer's total enrollment under group health benefit
4plans issued by the insurer constitutes the threshold level for purposes of par. (b) 1.
AB416-SSA1, s. 77 5Section 77. 635.09 of the statutes is repealed and recreated to read:
AB416-SSA1,39,8 6635.09 Rate regulation for individual and certain group health benefit
7plans.
Notwithstanding ch. 625, the commissioner shall promulgate rules that do
8all of the following:
AB416-SSA1,39,13 9(1) Establish restrictions on premium rates that an insurer may charge an
10employer for coverage under a group health benefit plan such that the premium rates
11charged to employers with similar case characteristics for the same or similar benefit
12design characteristics do not vary from the midpoint rate for those employers by
13more than 30% of that midpoint rate.
AB416-SSA1,39,18 14(1m) Establish restrictions on premium rates that an insurer may charge an
15individual for coverage under an individual health benefit plan such that the
16premium rates charged to individuals with similar case characteristics for the same
17or similar benefit design characteristics do not vary from the midpoint rate for those
18individuals by more than 35% of that midpoint rate.
AB416-SSA1,39,20 19(2) Establish restrictions on increases in premium rates that an insurer may
20charge an employer for coverage under a group health benefit plan such that:
AB416-SSA1,39,2221 (a) The percentage increase in the premium rate for a new rating period does
22not exceed the sum of the following:
AB416-SSA1,39,2423 1. The percentage change in the new business premium rate measured from
24the first day of the prior rating period to the first day of the new rating period.
AB416-SSA1,40,5
12. An adjustment, not to exceed 15% per year for employers with 2 to 50 eligible
2employes or 25% per year for employers with 51 to 100 eligible employes, adjusted
3proportionally for rating periods of less than one year, for such rating factors as
4claims experience, health condition and duration of coverage, determined in
5accordance with the insurer's rate manual or rating procedures.
AB416-SSA1,40,86 3. An adjustment for a change in case characteristics or in benefit design
7characteristics, determined in accordance with the insurer's rate manual or rating
8procedures.
AB416-SSA1,40,129 (b) The percentage increase in the premium rate for a new rating period for a
10group health benefit plan issued before the effective date of this paragraph ....
11[revisor inserts date], does not exceed the sum of par. (a) 1. and 3., unless premium
12rates are in compliance with the rules promulgated under sub. (1).
AB416-SSA1,40,16 13(3) Require the premium rate of a health benefit plan issued before the effective
14date of this subsection .... [revisor inserts date], to comply with the rules promulgated
15under sub. (1) or (1m) no later than 2 years after the effective date of this subsection
16.... [revisor inserts date].
AB416-SSA1,40,17 17(4) Define the terms necessary for compliance with this section.
AB416-SSA1,40,18 18(5) Ensure that employers are classified using objective criteria.
AB416-SSA1,40,20 19(6) Ensure that rating factors are applied objectively and consistently to
20employers with 2 to 50 eligible employes.
AB416-SSA1, s. 78 21Section 78. 635.11 (intro.) of the statutes is amended to read:
AB416-SSA1,40,25 22635.11 (title) Disclosure of rating factors and renewability provisions
23for certain group health benefit plans. (intro.) Before the sale of a group health
24benefit
plan or policy subject to this subchapter, a small employer, an insurer shall
25disclose to a small an employer all of the following:
AB416-SSA1, s. 79
1Section 79. 635.11 (1) of the statutes is amended to read:
AB416-SSA1,41,32 635.11 (1) The small employer insurer's right to increase premium rates and
3the factors limiting the amount of increase.
AB416-SSA1, s. 80 4Section 80. 635.11 (4) of the statutes is amended to read:
AB416-SSA1,41,55 635.11 (4) The small employer's renewability rights.
AB416-SSA1, s. 81 6Section 81. 635.13 of the statutes is amended to read:
AB416-SSA1,41,13 7635.13 (title) Annual certification of  compliance for certain group
8health benefit plans
. (1) Records. A small employer An insurer that issues group
9health benefit plans
shall maintain at its principal place of business complete and
10detailed records with respect to those group health benefit plans relating to its rating
11methods and practices and its renewal underwriting methods and practices, and
12shall make the records available to the commissioner and the small employer
13insurance board
upon request.
AB416-SSA1,41,17 14(2) Certification. A small employer An insurer that issues group health
15benefit plans
shall file with the commissioner on or before May 1 annually an
16actuarial opinion by a member of the American academy of actuaries certifying all
17of the following with respect to those group health benefit plans:
AB416-SSA1,41,1918 (a) That the small employer insurer is in compliance with the rate provisions
19of s. 635.05 635.09.
AB416-SSA1,41,2120 (b) That the small employer insurer's rating methods are based on generally
21accepted and sound actuarial principles, policies and procedures.
AB416-SSA1,41,2522 (c) That the opinion is based on the actuary's examination of the small employer
23insurer's records and a review of the small employer insurer's actuarial assumptions
24and statistical methods used in setting rates and procedures used in implementing
25rating plans.
AB416-SSA1, s. 82
1Section 82. 635.15 of the statutes is amended to read:
AB416-SSA1,42,9 2635.15 (title) Temporary suspension of rate regulation for individual
3and certain group health benefit plans
. The commissioner may suspend the
4operation of all or any part of s. 635.05 635.09 with respect to one or more small
5employers or one or more individuals for one or more rating periods upon the written
6request of a small employer an insurer and a finding by the commissioner that the
7suspension is necessary in light of the financial condition of the small employer
8insurer or that the suspension would enhance the efficiency and fairness of the small
9employer
health insurance market.
AB416-SSA1, s. 83 10Section 83. 635.16 of the statutes is created to read:
AB416-SSA1,42,12 11635.16 Coverage requirements for individual health benefit plans. (1)
12Definitions. In this section:
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