AB100-ASA1-AA8,443,23 22" Section 4910c. 628.34 (3) (a) of the statutes, as affected by 1995 Wisconsin
23Act 289
, is amended to read:
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, s. 4910e 8Section 4910e. 628.34 (3) (b) of the statutes, as affected by 1995 Wisconsin Act
9289
, is amended to read:
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, s. 4910g 17Section 4910g. 628.36 (2) (b) 1. of the statutes is amended to read:
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, s. 4910i 24Section 4910i. 628.36 (2) (b) 3. of the statutes is amended to read:
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, s. 4910k 6Section 4910k. 628.36 (2) (b) 5. of the statutes is amended to read:
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, s. 4910m 12Section 4910m. 631.01 (4) of the statutes is amended to read:
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-AA8,445,24 241372. Page 1826, line 3: delete lines 3 to 22 and substitute:
AB100-ASA1-AA8,446,1
1" Section 4915m. 632.70 of the statutes is repealed.
AB100-ASA1-AA8, s. 4916m 2Section 4916m. 632.745 of the statutes, as affected by 1995 Wisconsin Acts
3289
and 453, is repealed and recreated to read:
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-AA8,448,1212 3. The state.
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-AA8,449,1
1(c) Title XXII of P.L. 104-191.
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.
AB100-ASA1-AA8,449,2424 2. Coverage issued as a supplement to liability insurance.
AB100-ASA1-AA8,450,2
13. Liability insurance, including general liability insurance and automobile
2liability insurance.
AB100-ASA1-AA8,450,33 4. Worker's compensation or similar insurance.
AB100-ASA1-AA8,450,44 5. Automobile medical payment insurance.
AB100-ASA1-AA8,450,55 6. Credit-only insurance.
AB100-ASA1-AA8,450,66 7. Coverage for on-site medical clinics.
AB100-ASA1-AA8,450,97 8. Other similar insurance coverage, as specified in regulations issued by the
8federal department of health and human services, under which benefits for medical
9care are secondary or incidental to other insurance benefits.
AB100-ASA1-AA8,450,1510 9. If provided under a separate policy, certificate or contract of insurance, or if
11otherwise not an integral part of the policy, certificate or contract of insurance:
12limited-scope dental or vision benefits; benefits for long-term care, nursing home
13care, home health care, community-based care, or any combination of those benefits;
14and such other similar, limited benefits as are specified in regulations issued by the
15federal department of health and human services under section 2791 of P.L. 104-191.
AB100-ASA1-AA8,450,1716 10. Hospital indemnity or other fixed indemnity insurance or coverage only for
17a specified disease or illness, if all of the following apply:
AB100-ASA1-AA8,450,1918 a. The benefits are provided under a separate policy, certificate or contract of
19insurance.
AB100-ASA1-AA8,450,2220 b. There is no coordination between the provision of such benefits and any
21exclusion of benefits under any group health plan maintained by the same plan
22sponsor.
AB100-ASA1-AA8,450,2523 c. Such benefits are paid with respect to an event without regard to whether
24benefits are provided with respect to such an event under any group health plan
25maintained by the same plan sponsor.
AB100-ASA1-AA8,451,6
111. Benefits that are provided under a separate policy, certificate or contract
2of insurance and that are medicare supplemental health insurance, as defined in
3section 1882 (g) (1) of the federal Social Security Act, coverage supplemental to the
4coverage provided under chapter 55 of title 10 of the United States Code or similar
5supplemental coverage provided as supplemental to coverage under a group health
6plan.
AB100-ASA1-AA8,451,77 12. Other insurance exempted by rule of the commissioner.
AB100-ASA1-AA8,451,9 8(12) "Health insurance" includes health benefit plans but does not include
9group health plans.
AB100-ASA1-AA8,451,10 10(13) "Health maintenance organization" has the meaning given in s. 609.01 (2).
AB100-ASA1-AA8,451,12 11(14) "Health status-related factor" means any of the factors listed in s. 632.748
12(1) (a).
AB100-ASA1-AA8,451,19 13(15) "Insurer" means an insurer that is authorized to do business in this state,
14in one or more lines of insurance that includes health insurance, and that offers
15health benefit plans covering individuals in this state or eligible employes of one or
16more employers in this state. The term includes a health maintenance organization,
17a preferred provider plan, as defined in s. 609.01 (4), an insurer operating as a
18cooperative association organized under ss. 185.981 to 185.985 and a limited service
19health organization, as defined in s. 609.01 (3).
AB100-ASA1-AA8,451,25 20(16) "Large employer" means, with respect to a calendar year and a plan year,
21an employer that employed an average of at least 51 employes on business days
22during the preceding calendar year, or that is reasonably expected to employ an
23average of at least 51 employes on business days during the current calendar year
24if the employer was not in existence during the preceding calendar year, and that
25employs at least 2 employes on the first day of the plan year.
AB100-ASA1-AA8,452,4
1(17) "Large group market" means the health insurance market under which
2individuals obtain health insurance coverage on behalf of themselves and their
3dependents, directly or through any arrangement, under a group health benefit plan
4maintained by a large employer.
AB100-ASA1-AA8,452,7 5(18) "Late enrollee" means, with respect to coverage under a group health plan
6or health insurance coverage, a participant, beneficiary or individual who enrolls
7under the plan or coverage at any time other than during any of the following:
AB100-ASA1-AA8,452,98 (a) The first period in which the individual is eligible to enroll under the plan
9or coverage.
AB100-ASA1-AA8,452,1010 (b) A special enrollment period under s. 632.746 (7).
AB100-ASA1-AA8,452,1411 (19) "Network plan" means health insurance coverage of an insurer under
12which the financing and delivery of medical care, including items and services paid
13for as medical care, are provided, in whole or in part, through a defined set of
14providers under contract with the insurer.
AB100-ASA1-AA8,452,19 15(20) "Participant" has the meaning given in section 3 (7) of the federal
16Employee Retirement Income Security Act of 1974. "Participant" includes an
17individual who is, or may become, eligible to receive a benefit, or whose beneficiaries
18may be eligible to receive any such benefit, in connection with a group health plan
19or group health benefit plan if the individual is any of the following:
AB100-ASA1-AA8,452,2120 (a) A partner in relation to a partnership and the group health plan or group
21health benefit plan is maintained by the partnership.
AB100-ASA1-AA8,452,2422 (b) A self-employed individual with one or more employes who are participants
23in the group health plan or group health benefit plan and the group health plan or
24group health benefit plan is maintained by the self-employed individual.
AB100-ASA1-AA8,453,5
1(21) "Placed for adoption" or "placement for adoption" means, with respect to
2the placement for adoption of a child with a person, the assumption and retention by
3the person of a legal obligation for the total or partial support of the child in
4anticipation of the adoption of the child. A child's placement for adoption with a
5person terminates upon the termination of the person's legal obligation for support.
AB100-ASA1-AA8,453,7 6(22) "Plan sponsor" has the meaning given in section 3 (16) (B) of the federal
7Employee Retirement Income Security Act of 1974.
AB100-ASA1-AA8,453,10 8(23) "Preexisting condition exclusion" means, with respect to coverage, a
9limitation or exclusion of benefits relating to a condition of an individual that existed
10before the individual's date of enrollment for coverage.
AB100-ASA1-AA8,453,12 11(24) "Self-insured health plan" means a self-insured health plan of the state
12or a county, city, village, town or school district.
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