SB218-SSA1,9,2321 (b) An A self-insured health plan or an insurer offering a group health benefit
22plan may not impose a preexisting condition exclusion relating to pregnancy as a
23preexisting condition.
SB218-SSA1,9,2524 (c) Subject to par. (e), a self-insured health plan or an insurer offering a group
25health benefit plan may not impose a preexisting condition exclusion with respect to

1an individual who is covered under creditable coverage on the last day of the 30-day
2period beginning with the day on which the individual is born.
SB218-SSA1,10,93 (d) Subject to par. (e), a self-insured health plan or an insurer offering a group
4health benefit plan may not impose a preexisting condition exclusion with respect to
5an individual who is adopted or placed for adoption before attaining the age of 18
6years and who is covered under creditable coverage on the last day of the 30-day
7period beginning with the day on which the individual is adopted or placed for
8adoption. This paragraph does not apply to coverage before the day on which the
9individual is adopted or placed for adoption.
SB218-SSA1,10,1610 (e) Paragraphs (c) and (d) do not apply to an individual after the end of the first
11continuous period during which the individual was not covered under any creditable
12coverage for at least 63 days. For purposes of this paragraph, any waiting period or
13affiliation period for coverage under a self-insured health plan, group health plan
14or group health benefit plan shall not be taken into account in determining the period
15before enrollment in the self-insured health plan, group health plan or group health
16benefit plan.
SB218-SSA1, s. 32 17Section 32. 632.746 (3) (a), (b) and (d) 1., of the statutes, as created by 1997
18Wisconsin Act 27
, are amended to read:
SB218-SSA1,10,2219 632.746 (3) (a) The length of time during which any preexisting condition
20exclusion under sub. (1) may be imposed shall be reduced by the aggregate of the
21participant's or beneficiary's periods of creditable coverage on his or her enrollment
22date under the self-insured health plan or group health benefit plan.
SB218-SSA1,11,623 (b) With respect to enrollment of an individual under a self-insured health
24plan, a
group health plan or a group health benefit plan, a period of creditable
25coverage after which the individual was not covered under any creditable coverage

1for a period of at least 63 days before enrollment in the self-insured health plan,
2group health plan or group health benefit plan may not be counted. For purposes of
3this paragraph, any waiting period or affiliation period for coverage under the
4self-insured health plan, group health plan or group health benefit plan shall not be
5taken into account in determining the period before enrollment in the self-insured
6health plan,
group health plan or group health benefit plan.
SB218-SSA1,11,97 (d) 1. An A self-insured health plan or an insurer offering a group health
8benefit plan shall count a period of creditable coverage without regard to the specific
9benefits for which the individual had coverage during the period.
SB218-SSA1, s. 33 10Section 33. 632.746 (6) of the statutes, as created by 1997 Wisconsin Act 27,
11is amended to read:
SB218-SSA1,11,1712 632.746 (6) An A self-insured health plan or an insurer offering a group health
13benefit plan shall permit an employe who is not enrolled but who is eligible for
14coverage under the terms of the self-insured health plan or group health benefit
15plan, or a participant's or employe's dependent who is not enrolled but who is eligible
16for coverage under the terms of the self-insured health plan or group health benefit
17plan, to enroll for coverage under the terms of the plan if all of the following apply:
SB218-SSA1,11,2018 (a) The employe or dependent was covered under a self-insured health plan or
19group health plan or had health insurance coverage at the time coverage was
20previously offered to the employe or dependent.
SB218-SSA1,12,321 (b) The employe or participant stated in writing at the time coverage was
22previously offered that coverage under a self-insured health plan or group health
23plan or health insurance coverage was the reason for declining enrollment under the
24self-insured health plan or insurer's group health benefit plan. This paragraph
25applies only if the self-insured health plan or insurer required such a statement at

1the time coverage was previously offered and provided the employe or participant,
2at the time coverage was previously offered, with notice of the requirement and the
3consequences of the requirement.
SB218-SSA1,12,84 (c) The employe or dependent is currently covered under the self-insured
5health plan,
group health plan or health insurance or, under the terms of the
6self-insured health plan or group health benefit plan, the employe or participant
7requests enrollment no later than 30 days after the date on which the coverage under
8par. (a) is exhausted or terminated.
SB218-SSA1, s. 34 9Section 34. 632.746 (7) (a) (intro.), (b) (intro.) and 1. and (c) 1., of the statutes,
10as created by 1997 Wisconsin Act 27, are amended to read:
SB218-SSA1,12,1311 632.746 (7) (a) (intro.) If par. (b) applies, a self-insured health plan or an
12insurer offering a group health benefit plan shall provide for a special enrollment
13period during which any of the following may occur:
SB218-SSA1,12,1514 (b) (intro.) An A self-insured health plan or an insurer under par. (a) is required
15to provide for a special enrollment period if all of the following apply:
SB218-SSA1,12,1716 1. The self-insured health plan or group health benefit plan makes coverage
17available for dependents of participants under the plan.
SB218-SSA1,12,1918 (c) 1. The date dependent coverage is made available under the self-insured
19health plan or
group health benefit plan.
SB218-SSA1, s. 35 20Section 35. 632.7465 of the statutes is created to read:
SB218-SSA1,13,3 21632.7465 Guaranteed issue for group health benefit plans. (1) In this
22section, "employer" means, with respect to a calendar year and a plan year, an
23employer that employed an average of at least 2 but not more than 100 employes on
24business days during the preceding calendar year, or that is reasonably expected to
25employ an average of at least 2 but not more than 100 employes on business days

1during the current calendar year if the employer was not in existence during the
2preceding calendar year, and that employs at least 2 employes on the first day of the
3plan year.
SB218-SSA1,13,7 4(2) Except as provided in subs. (4) and (5), an insurer shall provide coverage
5under a group health benefit plan to an employer and to all of the employer's eligible
6employes and their dependents, regardless of health condition or claims experience,
7if all of the following apply:
SB218-SSA1,13,88 (a) The insurer has in force a group health benefit plan.
SB218-SSA1,13,109 (b) The employer agrees to pay the premium required for coverage under the
10group health benefit plan.
SB218-SSA1,13,1311 (c) The employer agrees to comply with all other provisions of the group health
12benefit plan that apply generally to a policyholder or an insured without regard to
13health condition or claims experience.
SB218-SSA1,13,15 14(3) An insurer that provides coverage under sub. (2) may impose payment
15security provisions that are reasonably related to the risk covered.
SB218-SSA1,13,19 16(4) (a) An insurer that is otherwise required to provide coverage under sub. (2)
17may refuse to issue a group health benefit plan to an employer if all of the individuals
18in the employer group that are to be covered under the group health benefit plan may
19be covered under one individual health benefit plan providing family coverage.
SB218-SSA1,13,2220 (b) Subsection (2) does not require an insurer to issue coverage that the insurer
21is not authorized to issue under its bylaws, charter or certificate of incorporation or
22authority.
SB218-SSA1,14,223 (c) Subsection (2) does not require an insurer that provides coverage to an
24employer under a group health benefit plan to issue a different group health benefit

1plan to the employer before the expiration of the agreed term of the group health
2benefit plan under which the employer has coverage.
SB218-SSA1,14,63 (d) An insurer that offers health care coverage exclusively to a single category
4or limited categories of employers may, with prior approval of the commissioner, limit
5its compliance with sub. (2) to that single category or those limited categories of
6employers.
SB218-SSA1,14,107 (e) The commissioner may exempt an insurer from the requirements of sub. (2)
8if the commissioner determines that it is in the public interest to exempt the insurer
9from the requirements under sub. (2) because the insurer is in financially hazardous
10condition.
SB218-SSA1,14,1511 (f) If an employer loses coverage under a group health benefit plan for failure
12to pay a premium when due, an insurer that is otherwise required to provide
13coverage under sub. (2) may refuse to issue a group health benefit plan to that
14employer during the 12-month period beginning on the day on which the employer
15lost coverage.
SB218-SSA1,14,2116 (g) An insurer that previously issued group health benefit plans but, prior to
17the effective date of this paragraph .... [revisor inserts date], discontinued offering
18such plans to small employers shall within 60 days after the effective date of this
19paragraph .... [revisor inserts date], again offer group health benefit plans to small
20employers or be subject to the requirements under s. 632.749 as if the insurer had
21elected to discontinue offering a group health benefit plan.
SB218-SSA1,14,24 22(5) (a) In this subsection, "high-risk individual" means an individual with a
23high-risk medical condition who has coverage under a group health benefit plan
24with a premium rate at the insurer's highest premium rate level.
SB218-SSA1,15,3
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:
SB218-SSA1,15,54 1. The number of high-risk individuals covered by the insurer at least equals
5the threshold level determined under par. (e) 3.
SB218-SSA1,15,126 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.
SB218-SSA1,15,1613 (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 offering group health benefit plans to employers in this
16state and to all insurance agents listed under s. 628.11 by those insurers.
SB218-SSA1,15,1917 (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).
SB218-SSA1,15,2220 (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:
SB218-SSA1,15,2423 1. What diagnostic conditions constitute high-risk medical conditions for
24purposes of the definition of a high-risk individual.
SB218-SSA1,16,2
12. How to determine an insurer's highest premium rate level for purposes of
2the definition of a high-risk individual.
SB218-SSA1,16,43 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.
SB218-SSA1, s. 36 5Section 36. 632.747 (title) of the statutes is amended to read:
SB218-SSA1,16,7 6632.747 (title) Guaranteed acceptance under group health benefit
7plans
.
SB218-SSA1, s. 37 8Section 37. 632.748 (title) of the statutes, as created by 1997 Wisconsin Act
927
, is amended to read:
SB218-SSA1,16,10 10632.748 Prohibiting discrimination under group health benefit plans.
SB218-SSA1, s. 38 11Section 38. 632.748 (4) (c) of the statutes, as created by 1997 Wisconsin Act
1227
, is amended to read:
SB218-SSA1,16,1413 632.748 (4) (c) Provide an exception from, or limit, the rate regulation under
14s. 635.05 632.7497.
SB218-SSA1, s. 39 15Section 39. 632.749 (title) of the statutes, as affected by 1997 Wisconsin Act
1627
, is amended to read:
SB218-SSA1,16,18 17632.749 (title) Contract termination and renewability for group health
18benefit plans
.
SB218-SSA1, s. 40 19Section 40. 632.749 (2) (e) of the statutes, as affected by 1997 Wisconsin Act
2027
, is amended to read:
SB218-SSA1,16,2521 632.749 (2) (e) In the case of a group health benefit plan that the insurer offers
22through a network plan, there is no longer an enrollee under the plan who resides,
23lives or works in the service area of the insurer or in an area in which the insurer is
24authorized to do business and, in the case of the small group market, the insurer
25would deny enrollment under the plan under s. 635.19 (2) (a) 1
.
SB218-SSA1, s. 41
1Section 41. 632.7491 of the statutes is created to read:
SB218-SSA1,17,4 2632.7491 Disclosure of rating factors and renewability provisions for
3group health benefit plans.
(1) Before the sale of a group health benefit plan, an
4insurer shall disclose to an employer all of the following:
SB218-SSA1,17,65 (a) The insurer's right to increase premium rates and any factors limiting the
6amount of increase.
SB218-SSA1,17,87 (b) The extent to which benefit design characteristics and case characteristics
8affect premium rates.
SB218-SSA1,17,109 (c) The extent to which rating factors and changes in benefit design benefit
10design characteristics and case characteristics affect changes in premium rates.
SB218-SSA1,17,1111 (d) The employer's renewability rights.
SB218-SSA1,17,1312 (e) As part of the insurer's solicitation and sales materials, the availability of
13the information under par. (f).
SB218-SSA1,17,1414 (f) Upon the request of the employer, the following information:
SB218-SSA1,17,1615 1. The provisions, if any, of the plan or policy relating to preexisting condition
16exclusions.
SB218-SSA1,17,1817 2. The benefits and premiums available under all health insurance coverage
18offered by the insurer for which the employer is qualified.
SB218-SSA1,17,22 19(2) Information required to be disclosed under this section shall be provided
20in a manner that is understandable to an employer and shall be sufficient to
21reasonably inform an employer of the employer's rights and obligations under the
22health insurance coverage.
SB218-SSA1,17,24 23(3) An insurer is not required under this section to disclose information that
24is proprietary or trade secret information under applicable law.
SB218-SSA1, s. 42 25Section 42. 632.7492 of the statutes is created to read:
SB218-SSA1,18,7
1632.7492 Annual certification of compliance for group health benefit
2plans. (1)
Records. An insurer that issues group health benefit plans to employers,
3as defined in s. 632.7497 (1), shall maintain at its principal place of business
4complete and detailed records with respect to those group health benefit plans
5relating to its rating methods and practices and its renewal underwriting methods
6and practices, and shall make the records available to the commissioner upon
7request.
SB218-SSA1,18,12 8(2) Certification. An insurer that issues group health benefit plans to
9employers, as defined in s. 632.7497 (1), shall file with the commissioner on or before
10May 1 annually an actuarial opinion by a member of the American Academy of
11Actuaries certifying all of the following with respect to those group health benefit
12plans:
SB218-SSA1,18,1313 (a) That the insurer is in compliance with the rate provisions of s. 632.7497.
SB218-SSA1,18,1514 (b) That the insurer's rating methods are based on generally accepted and
15sound actuarial principles, policies and procedures.
SB218-SSA1,18,1816 (c) That the opinion is based on the actuary's examination of the insurer's
17records and a review of the insurer's actuarial assumptions and statistical methods
18used in setting rates and procedures used in implementing rating plans.
SB218-SSA1, s. 43 19Section 43. 632.7494 of the statutes is created to read:
SB218-SSA1,18,23 20632.7494 Preexisting conditions and portability for individual health
21benefit plans. (1)
(a) An individual health benefit plan may not impose a
22preexisting condition exclusion with respect to a covered individual for losses
23incurred more than 12 months after the individual's enrollment date under the plan.
SB218-SSA1,18,2524 (b) An individual health benefit plan may not define a preexisting condition
25more restrictively than any of the following:
SB218-SSA1,19,4
11. A condition that would have caused an ordinarily prudent person to seek
2medical advice, diagnosis, care or treatment during the 18 months immediately
3preceding the individual's enrollment date under the plan and for which the
4individual did not seek medical advice, diagnosis, care or treatment.
SB218-SSA1,19,75 2. A condition for which medical advice, diagnosis, care or treatment was
6recommended or received during the 18 months immediately preceding the
7individual's enrollment date under the plan.
SB218-SSA1,19,108 (c) Notwithstanding pars. (a) and (b), an individual health benefit plan may not
9impose a preexisting condition exclusion relating to pregnancy as a preexisting
10condition.
SB218-SSA1,19,15 11(2) An individual health benefit plan shall waive any period applicable to a
12preexisting condition exclusion period with respect to particular services for the
13period that the individual was covered with respect to those services under creditable
14coverage, if the creditable coverage terminated not more than 31 days before the
15individual applied for coverage under the individual health benefit plan.
SB218-SSA1, s. 44 16Section 44. 632.7497 of the statutes is created to read:
SB218-SSA1,19,24 17632.7497 Rate regulation for individual and group health benefit
18plans.
(1) In this section, "employer" means, with respect to a calendar year and
19a plan year, an employer that employed an average of at least 2 but not more than
20100 employes on business days during the preceding calendar year, or that is
21reasonably expected to employ an average of at least 2 but not more than 100
22employes on business days during the current calendar year if the employer was not
23in existence during the preceding calendar year, and that employs at least 2 employes
24on the first day of the plan year.
SB218-SSA1,20,2
1(2) Notwithstanding ch. 625, the commissioner shall promulgate rules that do
2all of the following:
SB218-SSA1,20,73 (a) Establish restrictions on premium rates that an insurer may charge an
4employer for coverage under a group health benefit plan such that the premium rates
5charged to employers with similar case characteristics for the same or similar benefit
6design characteristics do not vary from the midpoint rate for those employers by
7more than 30% of that midpoint rate.
SB218-SSA1,20,128 (b) Establish restrictions on premium rates that an insurer may charge an
9individual for coverage under an individual health benefit plan such that the
10premium rates charged to individuals with similar case characteristics for the same
11or similar benefit design characteristics do not vary from the midpoint rate for those
12individuals by more than 35% of that midpoint rate.
SB218-SSA1,20,1413 (c) Establish restrictions on increases in premium rates that an insurer may
14charge an employer for coverage under a group health benefit plan such that:
SB218-SSA1,20,1615 1. The percentage increase in the premium rate for a new rating period does
16not exceed the sum of the following:
SB218-SSA1,20,1817 a. The percentage change in the new business premium rate measured from
18the first day of the prior rating period to the first day of the new rating period.
SB218-SSA1,20,2319 b. An adjustment, not to exceed 15% per year for small employers or 25% per
20year for large employers, adjusted proportionally for rating periods of less than one
21year, for such rating factors as claims experience, health condition and duration of
22coverage, determined in accordance with the insurer's rate manual or rating
23procedures.
SB218-SSA1,21,3
1c. An adjustment for a change in case characteristics or in benefit design
2characteristics, determined in accordance with the insurer's rate manual or rating
3procedures.
SB218-SSA1,21,74 2. The percentage increase in the premium rate for a new rating period for a
5group health benefit plan issued before the effective date of this subdivision ....
6[revisor inserts date], does not exceed the sum of subd. 1. a. and c., unless premium
7rates are in compliance with the rules promulgated under par. (a).
SB218-SSA1,21,118 (d) Require the premium rate of a health benefit plan issued before the effective
9date of this paragraph .... [revisor inserts date], to comply with the rules promulgated
10under par. (a) or (b) no later than 2 years after the effective date of this paragraph
11.... [revisor inserts date].
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