Amendment SSA1-AB416

AB416-SSA1,46,5 (g) An insurer that is otherwise required to provide coverage under par. (a) shall be exempt from the requirement under par. (a) for the remainder of a calendar year after all of the following occur:

AB416-SSA1,46,10 1. The total number of individuals described under par. (a) and their dependents who are covered by the insurer equals at least 1% of the total number of individuals and their dependents covered under all individual health benefit plans issued by the insurer that were in effect on December 31 of the preceding year and that were qualifying coverage under sub. (1) (d) 1. b.

AB416-SSA1,46,12 2. The insurer applies for exemption from the requirement under par. (a) by submitting to the commissioner certification that includes all of the following:

AB416-SSA1,46,15 a. The total number of individuals and their dependents covered under all individual health benefit plans issued by the insurer that were in effect on December 31 of the preceding year and that were qualifying coverage under sub. (1) (d) 1. b.

AB416-SSA1,46,18 b. The total number of individuals described under par. (a) and their dependents who have been accepted by the insurer for coverage under par. (a) during the current year.

AB416-SSA1,46,22 (h) Whenever an insurer becomes exempt from the requirement under par. (a) by satisfying the criteria under par. (g), the commissioner shall provide notice of that exemption to all insurers to which this subsection applies and to all insurance agents listed under s. 628.11 by the insurers to which this subsection applies.

AB416-SSA1, s. 84 Section 84. 635.17 of the statutes is repealed and recreated to read:

AB416-SSA1,46,25 635.17 Contract termination and renewability for all group and individual health benefit plans. (1) Definitions. In this section and s. 635.18:

AB416-SSA1,47,1 (a) "Eligible employe" has the meaning given in s. 635.03 (1) (a).

AB416-SSA1,47,2 (b) "Employer" has the meaning given in s. 635.03 (1) (b).

AB416-SSA1,47,4 (c) "Established geographic service area" means a geographic area within which an insurer provides coverage and that has been approved by the commissioner.

AB416-SSA1,47,5 (d) "Group health benefit plan" has the meaning given in s. 635.03 (1) (c).

AB416-SSA1,47,13 (e) "Insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers group health benefit plans covering eligible employes of one or more employers in this state, or that sells individual health benefit plans to individuals who are residents of this state. The term includes a health maintenance organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), and an insurer operating as a cooperative association organized under ss. 185.981 to 185.985 and a limited service health organization, as defined in s. 609.01 (3).

AB416-SSA1,47,17 (f) "Restricted network provision" means a provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on obtaining services or articles from health care providers that have contracted with the insurer to provide health care services or articles to covered individuals.

AB416-SSA1,47,22 (1m) Midterm cancellation. Notwithstanding s. 631.36 (2) to (4m), a health benefit plan may not be canceled by an insurer before the expiration of the agreed term, and shall be renewable to the policyholder and all insureds and dependents eligible under the terms of the health benefit plan at the expiration of the agreed term at the option of the policyholder, except for any of the following reasons:

AB416-SSA1,47,23 (a) Failure to pay a premium when due.

AB416-SSA1,47,25 (b) Fraud or misrepresentation by the policyholder, or, with respect to coverage for an insured individual, fraud or misrepresentation by that insured individual.

AB416-SSA1,48,1 (c) Substantial breaches of contractual duties, conditions or warranties.

AB416-SSA1,48,4 (d) If a group health benefit plan, the number of individuals covered under the group health benefit plan is less than the number required by the group health benefit plan.

AB416-SSA1,48,6 (e) If a group health benefit plan, the employer to which the group health benefit plan is issued is no longer actively engaged in a business enterprise.

AB416-SSA1,48,9 (2) Nonrenewal. (a) Notwithstanding sub. (1m), an insurer that issues group health benefit plans may elect not to renew a group health benefit plan if the insurer complies with all of the following:

AB416-SSA1,48,11 1. The insurer ceases to renew all other group health benefit plans issued by the insurer.

AB416-SSA1,48,14 2. The insurer provides notice to all affected policyholders and to the commissioner in each state in which an affected insured individual resides at least one year before termination of coverage.

AB416-SSA1,48,16 3. The insurer does not issue a group health benefit plan before 5 years after the nonrenewal of the group health benefit plans.

AB416-SSA1,48,20 4. The insurer does not transfer or otherwise provide coverage to a policyholder from the nonrenewed business unless the insurer offers to transfer or provide coverage to all affected policyholders from the nonrenewed business without regard to claims experience, health condition or duration of coverage.

AB416-SSA1,48,23 (b) Notwithstanding sub. (1m), an insurer that issues individual health benefit plans may elect not to renew an individual health benefit plan if the insurer complies with all of the following:

AB416-SSA1,48,25 1. The insurer ceases to renew all other individual health benefit plans issued by the insurer.

AB416-SSA1,49,3 2. The insurer provides notice to all affected policyholders and to the commissioner in each state in which an affected insured individual resides at least one year before termination of coverage.

AB416-SSA1,49,5 3. The insurer does not issue an individual health benefit plan before 5 years after the nonrenewal of the individual health benefit plans.

AB416-SSA1,49,9 4. The insurer does not transfer or otherwise provide coverage to a policyholder from the nonrenewed business unless the insurer offers to transfer or provide coverage to all affected policyholders from the nonrenewed business without regard to claims experience, health condition or duration of coverage.

AB416-SSA1,49,11 (3) Insurer in liquidation. This section does not apply to a health benefit plan if the insurer that issued the health benefit plan is in liquidation.

AB416-SSA1,49,14 (4) Applicability to certain government plans. This section does not apply to a health benefit plan offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).

AB416-SSA1, s. 85 Section 85. 635.18 (title) of the statutes is amended to read:

AB416-SSA1,49,17 635.18 (title) Fair marketing standards for all group and individual health benefit plans.

AB416-SSA1, s. 86 Section 86. 635.18 (1) of the statutes is renumbered 635.18 (1) (intro.) and amended to read:

AB416-SSA1,50,4 635.18 (1) (intro.) Every small employer insurer that provides coverage under a health benefit plan shall actively market such 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. In addition to other marketing limitations that the commissioner may authorize by rule, an insurer may limit its marketing under this subsection to any of the following:

AB416-SSA1, s. 87 Section 87. 635.18 (1) (a) and (b) of the statutes are created to read:

AB416-SSA1,50,6 635.18 (1) (a) Health benefit plans for employer groups of all sizes.

AB416-SSA1,50,7 (b) Health benefit plans for individuals.

AB416-SSA1, s. 88 Section 88. 635.18 (2) of the statutes is amended to read:

AB416-SSA1,50,10 635.18 (2) (a) Except as provided in par. (b), a small employer an insurer or an intermediary may not, directly or indirectly, do any of the following:

AB416-SSA1,50,14 1. Discourage a small an employer or an individual from applying, or direct a small an employer or an individual not to apply, for coverage with the small employer insurer because of the health status condition, claims experience, industry, occupation or geographic location area of the small employer or individual.

AB416-SSA1,50,17 2. Encourage or direct a small an employer or an individual to seek coverage from another insurer because of the health status condition, claims experience, industry, occupation or geographic location area of the small employer or individual.

AB416-SSA1,50,21 (b) Paragraph (a) does not prohibit a small employer an insurer or an intermediary from providing a small an employer or an individual with information about an established geographic service area or a restricted network provision of the small employer insurer.

AB416-SSA1, s. 89 Section 89. 635.18 (3) of the statutes is amended to read:

AB416-SSA1,51,3 635.18 (3) (a) Except as provided in par. (b), a small employer an insurer may not, directly or indirectly, enter into any contract, agreement or arrangement with an intermediary that provides for or results in compensation to an the intermediary for the sale of a health benefit plan that varies according to the health status condition, claims experience, industry, occupation or geographic location area of the small employer or, eligible employes, insured individual or dependents.

AB416-SSA1,51,7 (b) Payment of compensation on the basis of percentage of premium is not a violation of par. (a) if the percentage does not vary based on the health status condition, claims experience, industry, occupation or geographic area of the small employer or, eligible employes, insured individual or dependents.

AB416-SSA1,51,9 (c) A small employer An insurer shall provide reasonable compensation to an intermediary, if any, for the sale of a basic health benefit plan.

AB416-SSA1, s. 90 Section 90. 635.18 (4) of the statutes is amended to read:

AB416-SSA1,51,15 635.18 (4) A small employer An insurer may not terminate, fail to renew or limit its contract or agreement of representation with an intermediary for any reason related to the health status condition, claims experience, occupation or geographic location area of the small employers or, eligible employes , insured individuals or their dependents placed by the intermediary with the small employer insurer.

AB416-SSA1, s. 91 Section 91. 635.18 (5) of the statutes is amended to read:

AB416-SSA1,51,20 635.18 (5) A small employer An insurer or an intermediary may not induce or otherwise encourage a small an employer to separate or otherwise exclude an employe from health coverage or benefits provided in connection with the employe's employment.

AB416-SSA1, s. 92 Section 92. 635.18 (6) of the statutes is amended to read:

AB416-SSA1,51,24 635.18 (6) Denial by a small employer an insurer of an application for coverage from a small employer under a health benefit plan shall be in writing and shall state the reason or reasons for the denial.

AB416-SSA1, s. 93 Section 93. 635.18 (7) of the statutes is amended to read:

AB416-SSA1,52,5 635.18 (7) A 3rd-party administrator that enters into a contract, agreement or other arrangement with a small employer an insurer to provide administrative, marketing or other services related to the offering of health benefit plans to small employers or individuals in this state is subject to this subchapter as if it were a small employer an insurer.

AB416-SSA1, s. 94 Section 94. 635.18 (8) of the statutes is amended to read:

AB416-SSA1,52,10 635.18 (8) The commissioner may by rule establish additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers and individuals in this state, including requirements designed to prevent evasion of the purposes of this chapter.

AB416-SSA1, s. 95 Section 95. 635.20 (1c) of the statutes is amended to read:

AB416-SSA1,52,12 635.20 (1c) "Dependent" has the meaning given in s. 635.02 (3c) (2).

AB416-SSA1, s. 96 Section 96. 635.20 (1m) of the statutes is repealed and recreated to read:

AB416-SSA1,52,20 635.20 (1m) "Eligible employe" means an employe of a small employer 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 a small employer, but the term does not include an employe who works on a temporary or substitute basis.

AB416-SSA1, s. 97 Section 97. 635.20 (2) of the statutes is amended to read:

AB416-SSA1,52,23 635.20 (2) "Eligible small employer" means an employer that satisfies the requirements of s. 635.25 (1).

AB416-SSA1, s. 98 Section 98. 635.20 (13) of the statutes is repealed and recreated to read:

AB416-SSA1,53,9 635.20 (13) "Small employer insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers group health benefit plans covering eligible employes of one or more small employers in this state, or that sells 3 or more individual health benefit plans to a small employer, covering eligible employes of the small employer. The term includes a health maintenance organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), and an insurer operating as a cooperative association organized under ss. 185.981 to 185.985, but does not include a limited service health organization, as defined in s. 609.01 (3).

AB416-SSA1, s. 99 Section 99. 635.23 (1) (a), (d), (dp), (dr) and (e) (intro.), 1., 2. and 3. of the statutes are amended to read:

AB416-SSA1,53,14 635.23 (1) (a) By rule determine the basic benefits that small employer insurers may offer to eligible small employers for providing coverage to eligible employes and their dependents.

AB416-SSA1,53,16 (d) By rule establish small employer eligibility requirements for participation in the plan the purchase of a policy providing the basic benefits.

AB416-SSA1,53,21 (dp) By rule determine whether small employers participating in the plan that purchase a policy providing the basic benefits may impose a probationary or waiting period on employes who become eligible for coverage after the commencement of the small employer's coverage. The plan board may not allow for a probationary or waiting period that exceeds 90 days.

AB416-SSA1,53,23 (dr) By rule determine enrollment periods, if any, for small employer or employe coverage under the plan.

AB416-SSA1,54,3 (e) (intro.) Annually submit a report to the chief clerk of each house of the legislature, for distribution under s. 13.172 (3) to the appropriate standing committees, under s. 13.172 (3) summarizing the activities of the plan board and the operation of the plan in the preceding year, and including but not limited to all of the following:

AB416-SSA1,54,5 1. The number of small employers participating in the plan purchasing a policy providing the basic benefits.

AB416-SSA1,54,7 2. The number of employes and dependents participating in the plan covered under a policy providing the basic benefits.

AB416-SSA1,54,8 3. An evaluation of the plan's operation and, effectiveness and availability.

AB416-SSA1, s. 100 Section 100. 635.23 (4) and (5) of the statutes are amended to read:

AB416-SSA1,54,16 635.23 (4) In the formulation of the plan, for the purpose of cost containment the plan board shall encourage the use, to the extent possible, of the services of health care providers other than physicians. The plan board shall report any recommendations on ways to encourage the use of the services of health care providers other than physicians to the chief clerk of each house of the legislature for distribution under s. 13.172 (3) to the standing committees with jurisdiction over health insurance under s. 13.172 (3).

AB416-SSA1,54,20 (5) The plan board may submit any recommendations for legislation to improve the plan to the chief clerk of each house of the legislature for distribution under s. 13.172 (3) to the standing committees with jurisdiction over health insurance under s. 13.172 (3).

AB416-SSA1, s. 101 Section 101. 635.25 (title) of the statutes is amended to read:

AB416-SSA1,54,22 635.25 (title) Eligibility for participation in plan.

AB416-SSA1, s. 102 Section 102. 635.25 (1) (a) (intro.) of the statutes is amended to read:

AB416-SSA1,54,25 635.25 (1) (a) (intro.) To be eligible to participate in the plan by purchasing purchase a policy under this subchapter containing the basic benefits, an employer:

AB416-SSA1, s. 103 Section 103. 635.25 (1) (b) of the statutes is amended to read:

AB416-SSA1,55,5 635.25 (1) (b) Except as provided in ss. 645.43 and 646.35, an a small employer that purchases a policy under this subchapter containing the basic benefits and that ceases to be eligible to participate in the plan during a policy period shall retain coverage under the plan policy to the end of the policy period.

AB416-SSA1, s. 104 Section 104. 635.25 (1m) of the statutes is amended to read:

AB416-SSA1,55,10 635.25 (1m) Notwithstanding sub. (1), an a small employer is not eligible to participate in the plan purchase a policy under this subchapter containing the basic benefits if all of the individuals to be covered under the plan policy may be covered by a single under an individual policy providing individual single or family coverage.

AB416-SSA1, s. 105 Section 105. 635.25 (2) of the statutes is amended to read:

AB416-SSA1,55,14 635.25 (2) Employes and dependents. (a) All eligible employes of an eligible small employer that participates in the plan purchases a policy under this subchapter are eligible for coverage under the plan policy, subject to the policy terms.

AB416-SSA1,55,16 (b) Any dependent of an eligible employe who is covered under the plan policy is also eligible for coverage under the plan policy, subject to the policy terms.