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].
SB218-SSA1,21,1212 (e) Define the terms necessary for compliance with this section.
SB218-SSA1,21,1313 (f) Ensure that employers are classified using objective criteria.
SB218-SSA1,21,1514 (g) Ensure that rating factors are applied objectively and consistently to small
15employers.
SB218-SSA1, s. 45 16Section 45. 632.7498 of the statutes is created to read:
SB218-SSA1,21,19 17632.7498 Temporary suspension of rate regulation for individual and
18group health benefit plans.
(1) In this section, "employer" has the meaning given
19in s. 632.7497 (1).
SB218-SSA1,21,25 20(2) The commissioner may suspend the operation of all or any part of s.
21632.7497 with respect to one or more employers or one or more individuals for one
22or more rating periods upon the written request of an insurer and a finding by the
23commissioner that the suspension is necessary in light of the financial condition of
24the insurer or that the suspension would enhance the efficiency and fairness of the
25health insurance market.
SB218-SSA1, s. 46
1Section 46. 632.7499 of the statutes is created to read:
SB218-SSA1,22,6 2632.7499 Fair marketing standards for group and individual health
3benefit plans. (1)
Every insurer that provides coverage under a health benefit plan
4shall actively market such health benefit plan coverage. In addition to other
5marketing limitations that the commissioner may authorize by rule, an insurer may
6limit its marketing under this subsection to any of the following:
SB218-SSA1,22,77 (a) Health benefit plans for employer groups of all sizes.
SB218-SSA1,22,88 (b) Health benefit plans for individuals.
SB218-SSA1,22,10 9(2) (a) Except as provided in par. (b), an insurer or an intermediary may not,
10directly or indirectly, do any of the following:
SB218-SSA1,22,1411 1. Discourage an employer or an individual from applying, or direct an
12employer or an individual not to apply, for coverage with the insurer because of the
13health condition, claims experience, industry, occupation or geographic area of the
14employer or individual.
SB218-SSA1,22,1715 2. Encourage or direct an employer or an individual to seek coverage from
16another insurer because of the health condition, claims experience, industry,
17occupation or geographic area of the employer or individual.
SB218-SSA1,22,2018 (b) Paragraph (a) does not prohibit an insurer or an intermediary from
19providing an employer or an individual with information about an established
20geographic service area or a restricted network provision of the insurer.
SB218-SSA1,23,2 21(3) (a) Except as provided in par. (b), an insurer may not, directly or indirectly,
22enter into any contract, agreement or arrangement with an intermediary that
23provides for or results in compensation to the intermediary for the sale of a health
24benefit plan that varies according to the health condition, claims experience,

1industry, occupation or geographic area of the employer, eligible employes, insured
2individual or dependents.
SB218-SSA1,23,63 (b) Payment of compensation on the basis of percentage of premium is not a
4violation of par. (a) if the percentage does not vary based on the health condition,
5claims experience, industry, occupation or geographic area of the employer, eligible
6employes, insured individual or dependents.
SB218-SSA1,23,11 7(4) An insurer may not terminate, fail to renew or limit its contract or
8agreement of representation with an intermediary for any reason related to the
9health condition, claims experience, occupation or geographic area of the employers,
10eligible employes, insured individuals or dependents placed by the intermediary
11with the insurer.
SB218-SSA1,23,14 12(5) An insurer or an intermediary may not induce or otherwise encourage an
13employer to separate or otherwise exclude an employe from health coverage or
14benefits provided in connection with the employe's employment.
SB218-SSA1,23,16 15(6) Denial by an insurer of an application for coverage under a health benefit
16plan shall be in writing and shall state the reason or reasons for the denial.
SB218-SSA1,23,20 17(7) A 3rd-party administrator that enters into a contract, agreement or other
18arrangement with an insurer to provide administrative, marketing or other services
19related to the offering of health benefit plans to employers or individuals in this state
20is subject to this section and ss. 632.745 to 632.7498 as if it were an insurer.
SB218-SSA1,23,23 21(8) The commissioner may by rule establish additional standards to provide for
22the fair marketing and broad availability of health benefit plans to employers and
23individuals in this state.
SB218-SSA1, s. 47 24Section 47. 632.76 (2) (a) of the statutes, as affected by 1997 Wisconsin Act 27,
25is amended to read:
SB218-SSA1,24,6
1632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years
2from the date of issue of the policy may be reduced or denied on the ground that a
3disease or physical condition existed prior to the effective date of coverage, unless the
4condition was excluded from coverage by name or specific description by a provision
5effective on the date of loss. This paragraph does not apply to a group health benefit
6plan, as defined in s. 632.745 (9) (11), which is subject to s. 632.746 or 632.7494.
SB218-SSA1, s. 48 7Section 48. 632.896 (4) of the statutes, as affected by 1997 Wisconsin Act 27,
8is amended to read:
SB218-SSA1,24,149 632.896 (4) Preexisting conditions. Notwithstanding ss. 632.746, 632.7494 and
10632.76 (2) (a), a disability insurance policy that is subject to sub. (2) and that is in
11effect when a court makes a final order granting adoption or when the child is placed
12for adoption may not exclude or limit coverage of a disease or physical condition of
13the child on the ground that the disease or physical condition existed before coverage
14is required to begin under sub. (3).
SB218-SSA1, s. 49 15Section 49. Chapter 635 of the statutes, as affected by 1997 Wisconsin Act 27,
16is repealed.
SB218-SSA1, s. 50 17Section 50 . Nonstatutory provisions.
SB218-SSA1,24,2318 (1) Risk adjustment committee. The commissioner of insurance shall appoint
19a committee on risk adjustment under section 15.04 (1) (c) of the statutes, consisting
20of 5 to 8 members, to advise the commissioner on, and to assist the commissioner in
21developing rules for, the group risk adjustment mechanism under section 633.7465
22(4) of the statutes, as created by this act. The commissioner shall appoint at least
235 representatives of insurers to be members of the committee.
SB218-SSA1,25,624 (2) Risk adjustment mechanism emergency rule-making authority. Using the
25procedure under section 227.24 of the statutes, the commissioner of insurance may

1promulgate rules under section 632.7465 (5) (e) of the statutes, as created by this act,
2for the period before the effective date of the permanent rules promulgated under
3section 632.7465 (5) (e) of the statutes, as created by this act, but not to exceed the
4period authorized under section 227.24 (1) (c) and (2) of the statutes.
5Notwithstanding section 227.24 (1) and (3) of the statutes, the commissioner is not
6required to make a finding of emergency.
SB218-SSA1,25,77 (3) Evaluation of market reforms.
SB218-SSA1,25,128 (a) The commissioner of insurance shall evaluate the effectiveness of the health
9insurance market reforms under sections 632.745 to 632.7499 of the statutes, as
10affected by this act, and under the federal Health Insurance Portability and
11Accountability Act of 1996, P.L. 104-191, including the effectiveness of the reforms
12with respect to all of the following:
SB218-SSA1,25,14 131. Accessibility of health insurance coverage, including such accessibility for
14persons who reside in rural areas of the state.
SB218-SSA1,25,15 152. Availability of health insurance coverage for uninsured persons.
SB218-SSA1,25,16 163. Affordability of health insurance coverage.
SB218-SSA1,25,2017 (b) The commissioner shall submit a report of the results of the evaluation and
18any recommendations to the legislature in the manner provided under section
1913.172 (2) of the statutes no later than the first day of the 24th month beginning after
20publication.
SB218-SSA1, s. 51 21Section 51 . Initial applicability.
SB218-SSA1,25,2222 (1) Unless otherwise specified, this act first applies to all of the following:
SB218-SSA1,25,2523 (a) Except as provided in paragraphs (b) and (c ), health benefit plans that are
24issued or renewed, and self-insured health plans that are established, extended,
25modified or renewed, on the effective date of this paragraph.
SB218-SSA1,26,3
1(b) Health benefit plans covering employes who are affected by a collective
2bargaining agreement containing provisions inconsistent with this act that are
3issued or renewed on the earlier of the following:
SB218-SSA1,26,4 41. The day on which the collective bargaining agreement expires.
SB218-SSA1,26,6 52. The day on which the collective bargaining agreement is extended, modified
6or renewed.
SB218-SSA1,26,97 (c) Self-insured health plans covering employes who are affected by a collective
8bargaining agreement containing provisions inconsistent with this act that are
9established, extended, modified or renewed on the earlier of the following:
SB218-SSA1,26,10 101. The day on which the collective bargaining agreement expires.
SB218-SSA1,26,12 112. The day on which the collective bargaining agreement is extended, modified
12or renewed.
SB218-SSA1, s. 52 13Section 52. Effective dates. This act takes effect on the first day of the 7th
14month beginning after publication, except as follows:
SB218-SSA1,26,1515 (1) Section 50 (1 ) and (2) of this act takes effect on the day after publication.
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