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.
AB100-ASA1-AA8,453,13 13(25) "Small employer" has the meaning given in s. 635.02 (7).
AB100-ASA1-AA8,453,17 14(26) "Small group market" means the health insurance market under which
15individuals obtain health insurance coverage on behalf of themselves and their
16dependents, directly or through any arrangement, under a group health benefit plan
17maintained by, or obtained through, a small employer.
AB100-ASA1-AA8,453,22 18(27) "Waiting period" means, with respect to a group health plan or health
19insurance coverage and an individual who is a potential participant or beneficiary
20in the group health plan or who is potentially covered by the health insurance
21coverage, the period that must pass with respect to the individual before the
22individual is eligible for benefits under the terms of the plan or coverage.
AB100-ASA1-AA8, s. 4917m 23Section 4917m. 632.746 of the statutes is created to read:
AB100-ASA1-AA8,454,6 24632.746 Preexisting condition; portability; restrictions; and special
25enrollment periods.
(1) (a) Subject to subs. (2) and (3), an insurer that offers a

1group health benefit plan may, with respect to a participant or beneficiary under the
2plan, impose a preexisting condition exclusion only if the exclusion relates to a
3condition, whether physical or mental, regardless of the cause of the condition, for
4which medical advice, diagnosis, care or treatment was recommended or received
5within the 6-month period ending on the participant's or beneficiary's enrollment
6date under the plan.
AB100-ASA1-AA8,454,97 (b) A preexisting condition exclusion under par. (a) may not extend beyond 12
8months, or 18 months with respect to a late enrollee, after the participant's or
9beneficiary's enrollment date under the plan.
AB100-ASA1-AA8,454,12 10(2) (a) An insurer offering a group health benefit plan may not treat genetic
11information as a preexisting condition under sub. (1) without a diagnosis of a
12condition related to the information.
AB100-ASA1-AA8,454,1413 (b) An insurer offering a group health benefit plan may not impose a
14preexisting condition exclusion relating to pregnancy as a preexisting condition.
AB100-ASA1-AA8,454,1815 (c) Subject to par. (e), an insurer offering a group health benefit plan may not
16impose a preexisting condition exclusion with respect to an individual who is covered
17under creditable coverage on the last day of the 30-day period beginning with the
18day on which the individual is born.
AB100-ASA1-AA8,454,2519 (d) Subject to par. (e), an insurer offering a group health benefit plan may not
20impose a preexisting condition exclusion with respect to an individual who is adopted
21or placed for adoption before attaining the age of 18 years and who is covered under
22creditable coverage on the last day of the 30-day period beginning with the day on
23which the individual is adopted or placed for adoption. This paragraph does not
24apply to coverage before the day on which the individual is adopted or placed for
25adoption.
AB100-ASA1-AA8,455,6
1(e) Paragraphs (c) and (d) do not apply to an individual after the end of the first
2continuous period during which the individual was not covered under any creditable
3coverage for at least 63 days. For purposes of this paragraph, any waiting period or
4affiliation period for coverage under a group health plan or group health benefit plan
5shall not be taken into account in determining the period before enrollment in the
6group health plan or group health benefit plan.
AB100-ASA1-AA8,455,10 7(3) (a) The length of time during which any preexisting condition exclusion
8under sub. (1) may be imposed shall be reduced by the aggregate of the participant's
9or beneficiary's periods of creditable coverage on his or her enrollment date under the
10group health benefit plan.
AB100-ASA1-AA8,455,1811 (b) With respect to enrollment of an individual under a group health plan or a
12group health benefit plan, a period of creditable coverage after which the individual
13was not covered under any creditable coverage for a period of at least 63 days before
14enrollment in the group health plan or group health benefit plan may not be counted.
15For purposes of this paragraph, any waiting period or affiliation period for coverage
16under the group health plan or group health benefit plan shall not be taken into
17account in determining the period before enrollment in the group health plan or
18group health benefit plan.
AB100-ASA1-AA8,455,2419 (c) No period of creditable coverage before July 1, 1996, may be counted.
20Individuals who need to establish creditable coverage for periods before July 1, 1996,
21and who would have such coverage but for this paragraph may be given credit for
22creditable coverage for such periods through the presentation of documents or other
23means provided by the federal secretary of health and human services, consistent
24with section 104 of P.L. 104-191.
AB100-ASA1-AA8,456,3
1(d) 1. An insurer offering a group health benefit plan shall count a period of
2creditable coverage without regard to the specific benefits for which the individual
3had coverage during the period.
AB100-ASA1-AA8,456,104 2. Notwithstanding subd. 1., an insurer offering a group health benefit plan
5may elect to apply par. (a) on the basis of coverage of benefits within each of several
6classes or categories of benefits specified in regulations issued by the federal
7department of health and human services under P.L. 104-191. The election shall be
8made on a uniform basis for all participants and beneficiaries. Under the election,
9an insurer shall count a period of creditable coverage with respect to any class or
10category of benefits if any level of benefits is covered within the class or category.
AB100-ASA1-AA8,456,1411 3. An insurer that makes an election under subd. 2. shall prominently state in
12any disclosure statements concerning the coverage offered, and to each employer at
13the time of the offer or sale of coverage, that the insurer has made the election and
14what the effect of the election is.
AB100-ASA1-AA8,456,1715 (e) Periods of creditable coverage shall be established through the presentation
16of certifications described in sub. (4) or in any other manner specified in regulations
17issued by the federal department of health and human services under P.L. 104-191.
AB100-ASA1-AA8,456,20 18(4) (a) On and after October 1, 1996, an insurer that provides health benefit
19plan coverage shall provide the certification described in par. (b) upon the happening
20of any of the following events:
AB100-ASA1-AA8,456,2521 1. An individual ceases to be covered under the health benefit plan or otherwise
22becomes covered under a federal continuation provision. The certification required
23under this subdivision may be provided, to the extent practicable, at a time
24consistent with notices required under any applicable federal continuation provision
25or s. 632.897.
AB100-ASA1-AA8,457,1
12. An individual ceases to be covered under a federal continuation provision.
AB100-ASA1-AA8,457,42 3. Upon the request of an individual that is made not later than 24 months after
3the date of the cessation of the individual's coverage under subd. 1. or 2., whichever
4is later.
AB100-ASA1-AA8,457,65 (b) The certification required under this subsection shall be a written
6certification that includes all of the following information:
AB100-ASA1-AA8,457,87 1. The period of creditable coverage of the individual under the health benefit
8plan and the coverage, if any, under the federal continuation provision.
AB100-ASA1-AA8,457,109 2. The waiting period, if any, or affiliation period, if any, imposed with respect
10to the individual for coverage under the health benefit plan.
AB100-ASA1-AA8,457,1411 (c) Upon the happening after June 30, 1996, and before October 1, 1996, of an
12event described in par. (a) 1. to 3., an insurer providing health benefit plan coverage
13shall provide a certification described in par. (b) if the individual with respect to
14whom the certification is provided requests the certification in writing.
AB100-ASA1-AA8,457,1715 (d) If an individual seeks to establish creditable coverage with respect to a
16period for which a certification is not required because of the happening of an event
17described in par. (a) 1. to 3. before July 1, 1996, all of the following apply:
AB100-ASA1-AA8,457,1918 1. The individual may present other credible evidence of the coverage in order
19to establish the period of creditable coverage.
AB100-ASA1-AA8,457,2320 2. An insurer may not be subject to any penalty or enforcement action with
21respect to the crediting or not crediting of the individual's coverage under subd. 1.
22if the insurer has sought to comply in good faith with any applicable requirements
23under this subsection.
AB100-ASA1-AA8,458,5 24(5) (a) If an insurer that made an election under sub. (3) (d) 2. enrolls an
25individual for coverage under a group health benefit plan and the individual provides

1a certification under sub. (4), upon the request of that insurer or the group health
2benefit plan the insurer that issued the certification shall promptly disclose to the
3requesting insurer or group health benefit plan information on coverage of classes
4or categories of health benefits available under the coverage on which the
5certification was based.
AB100-ASA1-AA8,458,76 (b) The insurer providing the information may charge the requesting insurer
7or plan for the reasonable cost of disclosing the information.
AB100-ASA1-AA8,458,108 (c) An insurer providing information under this subsection shall comply with
9regulations issued by the federal department of health and human services under
10section 2701 (e) (3) of P.L. 104-191.
AB100-ASA1-AA8,458,15 11(6) An insurer offering a group health benefit plan shall permit an employe who
12is not enrolled but who is eligible for coverage under the terms of the group health
13benefit plan, or a participant's or employe's dependent who is not enrolled but who
14is eligible for coverage under the terms of the group health benefit plan, to enroll for
15coverage under the terms of the plan if all of the following apply:
AB100-ASA1-AA8,458,1816 (a) The employe or dependent was covered under a group health plan or had
17health insurance coverage at the time coverage was previously offered to the employe
18or dependent.
AB100-ASA1-AA8,458,2519 (b) The employe or participant stated in writing at the time coverage was
20previously offered that coverage under a group health plan or health insurance
21coverage was the reason for declining enrollment under the insurer's group health
22benefit plan. This paragraph applies only if the insurer required such a statement
23at the time coverage was previously offered and provided the employe or participant,
24at the time coverage was previously offered, with notice of the requirement and the
25consequences of the requirement.
AB100-ASA1-AA8,459,4
1(c) The employe or dependent is currently covered under the group health plan
2or health insurance or, under the terms of the group health benefit plan, the employe
3or participant requests enrollment no later than 30 days after the date on which the
4coverage under par. (a) is exhausted or terminated.
Loading...
Loading...