AB100-ASA1-AA8,441,14
13"
149.144 (title)
Insurer
Adjustments to insurer assessments and
14provider payment rates for".
AB100-ASA1-AA8,442,8
61364. Page 1813, line 25: after "state" insert "
and who is certified under s.
749.45 (2) (a) 11. and if the service or article is provided by a provider certified under
8s. 49.45 (2) (a) 11.".
AB100-ASA1-AA8,442,13
11"(a) Any charge for treatment for cosmetic purposes other than surgery for the
12repair or treatment of an injury or a congenital bodily defect.
Breast reconstruction
13incident to a mastectomy shall not be considered treatment for cosmetic purposes.".
AB100-ASA1-AA8,442,19
18"
Section 4869m. 619.15 (3) (f) of the statutes, as created by 1997 Wisconsin
19Act .... (this act), is repealed.".
AB100-ASA1-AA8,442,22
21"
Section 4891c. 619.165 (1) (d) of the statutes is renumbered 619.165 (1) (d)
221. and amended to read:
AB100-ASA1-AA8,443,3
1619.165
(1) (d) 1.
The Subject to subd. 2., the board shall establish and
2implement the method for determining the household income of an eligible person
3under par. (b).
AB100-ASA1-AA8, s. 4891r
4Section 4891r. 619.165 (1) (d) of the statutes, as affected by 1997 Wisconsin
5Act .... (this act), is renumbered 149.165 (3), and 149.165 (3) (a) and (b) (intro.), as
6renumbered, are amended to read:
AB100-ASA1-AA8,443,97
149.165
(3) (a) Subject to
subd. 2., the board par. (b), the department shall
8establish and implement the method for determining the household income of an
9eligible person under
par. (b) sub. (2).
AB100-ASA1-AA8,443,1310
(b) (intro.) In determining household income under
par. (b), the board sub. (2),
11the department shall consider information submitted by an eligible person on a
12completed federal profit or loss from farming form, schedule F, if all of the following
13apply:
AB100-ASA1-AA8,443,1715
619.165
(1) (d) 2. In determining household income under par. (b), the board
16shall consider information submitted by an eligible person on a completed federal
17profit or loss from farming form, schedule F, if all of the following apply:
AB100-ASA1-AA8,443,1818
a. The person is a farmer, as defined in s. 102.04 (3).
AB100-ASA1-AA8,443,2019
b. The person was not eligible to claim the homestead credit under subch. VIII
20of ch. 71 in the preceding taxable year.".
AB100-ASA1-AA8,444,7
1628.34
(3) (a) No insurer may unfairly discriminate among policyholders by
2charging different premiums or by offering different terms of coverage except on the
3basis of classifications related to the nature and the degree of the risk covered or the
4expenses involved, subject to ss. 632.365
and, 632.745
and 632.748. Rates are not
5unfairly discriminatory if they are averaged broadly among persons insured under
6a group, blanket or franchise policy, and terms are not unfairly discriminatory
7merely because they are more favorable than in a similar individual policy.
AB100-ASA1-AA8,444,1610
628.34
(3) (b) No insurer may refuse to insure or refuse to continue to insure,
11or limit the amount, extent or kind of coverage available to an individual, or charge
12an individual a different rate for the same coverage because of a mental or physical
13disability except when the refusal, limitation or rate differential is based on either
14sound actuarial principles supported by reliable data or actual or reasonably
15anticipated experience, subject to ss.
632.745, 632.747, 632.749, 635.09 and 635.26 16632.746 to 632.7495.
AB100-ASA1-AA8,444,2318
628.36
(2) (b) 1. Except for health maintenance organizations, preferred
19provider plans
, and limited service health organizations
and the small employer
20health insurance plan under subch. II of ch. 635, no health care plan may prevent
21any person covered under the plan from choosing freely among providers who have
22agreed to participate in the plan and abide by its terms, except by requiring the
23person covered to select primary providers to be used when reasonably possible.
AB100-ASA1-AA8,445,5
1628.36
(2) (b) 3. Except as provided in subd. 4., no provider may be denied the
2opportunity to participate in a health care plan, other than a health maintenance
3organization, a limited service health organization
,
or a preferred provider plan
or
4the small employer health insurance plan under subch. II of ch. 635, under the terms
5of the plan.
AB100-ASA1-AA8,445,117
628.36
(2) (b) 5.
Except for the small employer health insurance plan under
8subch. II of ch. 635 to the extent determined by the small employer insurance board
9under s. 635.23 (1) (b), all All health care plans, including health maintenance
10organizations, limited service health organizations and preferred provider plans are
11subject to s. 632.87 (3).
AB100-ASA1-AA8,445,2313
631.01
(4) Annuities and group policies for eleemosynary institutions. This
14chapter
, and ch. 632
and the health insurance mandates under ch. 632 that apply to
15the plan under subch. II of ch. 635 do not apply to annuities or group policies that
16are provided on a basis as uniform nationally as state statutes permit to educational,
17scientific research, religious or charitable institutions organized without profit to
18any person, for the benefit of employes of such institutions. The commissioner may
19by order subject such contracts issued by a particular insurer to this chapter
, or ch.
20632
or the health insurance mandates under ch. 632 that apply to the plan under
21subch. II of ch. 635 or any portion of those provisions upon a finding, after a hearing,
22that the interests of Wisconsin insureds or creditors or the public of this state so
23require.".
AB100-ASA1-AA8,446,5
4632.745 Coverage requirements for group and individual health
5benefit plans; definitions. In this section and ss. 632.746 to 632.7495:
AB100-ASA1-AA8,446,8
6(1) "Affiliation period" means the period which, under the terms of health
7insurance coverage offered by a health maintenance organization, must expire
8before the health insurance coverage becomes effective.
AB100-ASA1-AA8,446,10
9(2) "Beneficiary" has the meaning given in section 3 (8) of the federal Employee
10Retirement Income Security Act of 1974.
AB100-ASA1-AA8,446,12
11(3) "Bona fide association" means an association that satisfies all of the
12following:
AB100-ASA1-AA8,446,1313
(a) The association has been actively in existence for at least 5 years.
AB100-ASA1-AA8,446,1514
(b) The association has been formed and maintained in good faith for purposes
15other than obtaining insurance.
AB100-ASA1-AA8,446,1816
(c) The association does not condition membership in the association on any
17health status-related factor of an individual, including an employe of an employer
18or a dependent of an employe.
AB100-ASA1-AA8,446,2119
(d) The association makes health insurance coverage offered through the
20association available to all members, regardless of any health status-related factor
21of those members or individuals eligible for coverage through a member.
AB100-ASA1-AA8,446,2322
(e) The association does not make health insurance coverage offered through
23the association available other than in connection with a member of the association.
AB100-ASA1-AA8,447,3
1(f) The association meets any additional requirements that are imposed by a
2rule of the commissioner designed to prevent the use of an association for risk
3segmentation.
AB100-ASA1-AA8,447,5
4(4) (a) Except as provided in par. (b), "creditable coverage" means coverage
5under any of the following:
AB100-ASA1-AA8,447,66
1. A group health plan.
AB100-ASA1-AA8,447,77
2. Health insurance.
AB100-ASA1-AA8,447,88
3. Part A or part B of title XVIII of the federal Social Security Act.
AB100-ASA1-AA8,447,109
4. Title XIX of the federal Social Security Act, except for coverage consisting
10solely of benefits under section 1928 of that act.
AB100-ASA1-AA8,447,1111
5. Chapter 55 of title 10 of the United States Code.
AB100-ASA1-AA8,447,1312
6. A medical care program of the federal Indian health service or of an
13American Indian tribal organization.
AB100-ASA1-AA8,447,1414
7. A state health benefits risk pool.
AB100-ASA1-AA8,447,1515
8. A health plan offered under chapter 89 of title 5 of the United States Code.
AB100-ASA1-AA8,447,1716
9. A public health plan, as defined in regulations issued by the federal
17department of health and human services.
AB100-ASA1-AA8,447,1918
10. A health coverage plan under section 5 (e) of the federal Peace Corps Act,
1922 USC 2504 (e).
AB100-ASA1-AA8,447,2120
(b) "Creditable coverage" does not include coverage consisting solely of
21coverage of excepted benefits, as defined in section 2791 (c) of P.L.
104-191.
AB100-ASA1-AA8,448,3
22(5) (a) Except as provided in par. (b), "eligible employe" means an employe who
23works on a permanent basis and has a normal work week of 30 or more hours. The
24term includes a sole proprietor, a business owner, including the owner of a farm
25business, a partner of a partnership and a member of a limited liability company if
1the sole proprietor, business owner, partner or member is included as an employe
2under a health benefit plan of an employer, but the term does not include an employe
3who works on a temporary or substitute basis.
AB100-ASA1-AA8,448,64
(b) For purposes of a group health benefit plan, or a self-insured health plan,
5that is offered by the state under s. 40.51 (6) or by the group insurance board under
6s. 40.51 (7), "eligible employe" has the meaning given in s. 40.02 (25).
AB100-ASA1-AA8,448,7
7(6) (a) "Employer" means any of the following:
AB100-ASA1-AA8,448,108
1. An individual, firm, corporation, partnership, limited liability company or
9association that is actively engaged in a business enterprise in this state, including
10a farm business.
AB100-ASA1-AA8,448,1111
2. A municipality, as defined in s. 16.70 (8).
AB100-ASA1-AA8,448,1313
(b) For purposes of this definition, all of the following apply:
AB100-ASA1-AA8,448,1514
1. All persons treated as a single employer under subsection (b), (c), (m) or (o)
15of section
414 of the Internal Revenue Code of 1986 shall be treated as one employer.
AB100-ASA1-AA8,448,1616
2. "Employer" includes any predecessor of an employer.
AB100-ASA1-AA8,448,20
17(7) "Enrollment date" means, with respect to an individual covered under a
18group health plan or health insurance, the date of enrollment of the individual under
19the plan or insurance or, if earlier, the first day of the waiting period for such
20enrollment.
AB100-ASA1-AA8,448,21
21(8) "Federal continuation provision" means any of the following:
AB100-ASA1-AA8,448,2322(a) Section
4980B of the Internal Revenue Code of 1986, except for section
234980B (f) (1) of that code insofar as it relates to pediatric vaccines.
AB100-ASA1-AA8,448,2524
(b) Part 6 of subtitle B of title I of the federal Employee Retirement Income
25Security Act of 1974, except for section 609 of that act.
AB100-ASA1-AA8,449,6
2(9) "Group health benefit plan" means a health benefit plan that is issued by
3an insurer to or through an employer on behalf of a group consisting of at least 2
4employes or a group including at least 2 eligible employes. The term includes
5individual health benefit plans covering eligible employes when 3 or more are sold
6to or through an employer.
AB100-ASA1-AA8,449,7
7(10) "Group health plan" means any of the following:
AB100-ASA1-AA8,449,128
(a) An employe welfare plan, as defined in section 3 (1) of the federal Employee
9Retirement Security Act of 1974, to the extent that the employe welfare plan provides
10medical care, including items and services paid for as medical care, to employes or
11to their dependents, as defined under the terms of the employe welfare plan, directly
12or through insurance, reimbursement or otherwise.
AB100-ASA1-AA8,449,1813
(b) Any program that would not otherwise be an employe welfare benefit plan
14and that is established or maintained by a partnership, to the extent that the
15program provides medical care, including items and services paid for as medical care,
16to present or former partners of the partnership or to their dependents, as defined
17under the terms of the program, directly or through insurance, reimbursement or
18otherwise.
AB100-ASA1-AA8,449,20
19(11) (a) Except as provided in par. (b), "health benefit plan" means any hospital
20or medical policy or certificate.
AB100-ASA1-AA8,449,2121
(b) "Health benefit plan" does not include any of the following:
AB100-ASA1-AA8,449,2322
1. Coverage that is only accident or disability income insurance, or any
23combination of the 2 types.
