Amendment ASA1-AB210

AB210-ASA1,10,24 632.76 (2) (ac) 1. Notwithstanding par. (a) and except as provided in subd. 4., no claim or loss incurred or disability commencing after 12 months from the date of issue of an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB210-ASA1, s. 36 Section 36. 632.76 (2) (ac) 2. of the statutes is amended to read:

AB210-ASA1,11,6 632.76 (2) (ac) 2. Except as provided in subd. subds. 3. and 4., an individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB210-ASA1, s. 37 Section 37. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB210-ASA1,11,11 632.76 (2) (ac) 3. (intro.) Except as provided in subd. 4. and except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy subject to s. 632.7495 (4) and (5):

AB210-ASA1, s. 38 Section 38. 632.76 (2) (ac) 4. of the statutes is created to read:

AB210-ASA1,11,17 632.76 (2) (ac) 4. Subdivisions 1., 2., and 3. do not apply to an individual disability insurance policy, as defined in s. 632.895 (1) (a), issued on or after September 23, 2010, and before January 1, 2014, that covers an individual who is under 19 years of age, with respect to coverage of that individual. Section 636.25 (1) (f) applies to such a policy with respect to coverage of that individual.

AB210-ASA1, s. 39 Section 39. 632.83 of the statutes is repealed.

AB210-ASA1, s. 40 Section 40. 632.835 of the statutes is repealed.

AB210-ASA1, s. 41 Section 41. 632.885 of the statutes, as affected by 2011 Wisconsin Act 32, is repealed.

AB210-ASA1, s. 42 Section 42. 632.895 (15) (c) (intro.) of the statutes is amended to read:

AB210-ASA1,11,25 632.895 (15) (c) (intro.) A Except as otherwise required under s. 636.25 (1) (c), (2) (a), or (3) (a), a policy or plan is required to continue coverage under par. (a) only until any of the following occurs:

AB210-ASA1, s. 43 Section 43. Chapter 636 of the statutes is created to read:

AB210-ASA1,12,2 Chapter 636

AB210-ASA1,12,3 Health insurance reform

AB210-ASA1,12,4 636.01 Definitions. In this chapter, unless the context requires otherwise:

AB210-ASA1,12,5 (1) "Defined network plan" has the meaning given in s. 609.01 (1b).

AB210-ASA1,12,7 (2) "Grandfathered health plan" has the meaning given in section 1251 (e) of the Patient Protection and Affordable Care Act.

AB210-ASA1,12,14 (3) "Health insurance coverage" has the meaning given in section 2791 (b) (1) of the Public Health Service Act (42 USC 300gg-91 (b) (1)). "Health insurance coverage" includes coverage issued by an insurer and insurance that is a group health plan, as defined in section 2791 (a) (1) of the Public Health Service Act (42 USC 300gg-91 (a) (1)). "Health insurance coverage" does not include excepted benefits that are excluded under section 2722 (b) or (c) of the Public Health Service Act (42 USC 300gg-21 (b) or (c)).

AB210-ASA1,12,17 (4) "Individual health insurance coverage" means health insurance coverage offered to individuals in the individual market. "Individual health insurance coverage" does not include short-term limited duration insurance.

AB210-ASA1,12,19 (5) "Individual market" has the meaning given in section 1304 (a) (2) of the Patient Protection and Affordable Care Act.

AB210-ASA1,12,23 (6) "Limited-scope dental or vision benefits" means limited-scope dental or vision benefits provided under a separate policy, certificate, or contract of insurance or plan, or otherwise not provided as an integral part of the policy, certificate, or contract of insurance or plan.

AB210-ASA1,13,3 (7) "Patient Protection and Affordable Care Act" means the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, P.L. 111-152.

AB210-ASA1,13,7 (8) "Preexisting condition exclusion denial determination" means a determination by or on behalf of an insurer that issues a health benefit plan denying or terminating treatment or payment for treatment on the basis of a preexisting condition exclusion, as defined in s. 632.745 (23).

AB210-ASA1,13,10 (9) "Public Health Service Act" means the federal Public Health Service Act of 1944, as amended, including by the Patient Protection and Affordable Care Act (42 USC 300gg et seq.).

AB210-ASA1,13,12 (10) "Secretary" means the secretary of the federal department of health and human services.

AB210-ASA1,13,14 (11) "Self-insured governmental health plan" means a self-insured health plan of the state or a county, city, village, town, or school district.

AB210-ASA1,13,22 (12) "Small employer health insurance" means health insurance coverage offered in the small group market as defined in section 2791 (e) (5) of the Public Health Service Act (42 USC 300gg-91 (e) (5)) and section 1304 (a) (3) of the Patient Protection and Affordable Care Act, as applied by the secretary's regulation for the purposes of section 2718 of the Public Health Service Act (42 USC 300gg-18). For purposes of this definition, in section 1304 (a) (3) of the Patient Protection and Affordable Care Act, "small employer" has the meaning given in section 1304 (b) (2) of that act.

AB210-ASA1,14,3 636.10 General provisions. (1) Authority is additional. The commissioner's authority under this chapter is in addition to any authority otherwise provided under chs. 600 to 635 and chs. 644 to 646. The commissioner may by rule establish standards for compliance with this chapter. The commissioner may establish reporting requirements for the purpose of monitoring or enforcing compliance with this chapter and rules adopted under this chapter.

AB210-ASA1,14,8 (2) Emergency rule-making. Using the procedure under s. 227.24, the commissioner may promulgate any rule under this chapter or under s. 625.03 (1m) (e) 2. or 3. or 625.13 (3) as an emergency rule. Notwithstanding s. 227.24 (1) (c), any emergency rule promulgated under this subsection may remain in effect for up to one year and, in addition, may be extended under s. 227.24 (2).

AB210-ASA1,14,14 (3) Employer size election. Notwithstanding s. 636.01 (12), this state reserves the right to elect through legislation, as permitted under section 1304 (b) (3) of the Patient Protection and Affordable Care Act, to substitute "51 employees" for "101 employees" and "50 employees" for "100 employees," after the effective date of this subsection .... [LRB inserts date], for any purpose permitted under the Public Health Service Act.

AB210-ASA1,14,17 636.12 Internal and external appeals. (1) Establishing standards. Notwithstanding any inconsistent provision of chs. 600 to 635 or chs. 644 to 646, the commissioner shall by rule do all of the following:

AB210-ASA1,14,22 (a) Establish standards for internal appeals that, at a minimum, include consumer protections consistent with section 2719 (a) of the Public Health Service Act (42 USC 300gg-19 (a)), and require an insurer to comply with the standards. The commissioner shall apply the standards established under this paragraph to all of the following:

AB210-ASA1,14,24 1. Group and individual health insurance coverage subject to section 2719 (a) of the Public Health Service Act (42 USC 300gg-19 (a)).

AB210-ASA1,15,2 2. Grandfathered health plans that otherwise would be subject to section 2719 (a) of the Public Health Service Act (42 USC 300gg-19 (a)).

AB210-ASA1,15,4 3. A policy, certificate, or contract that provides only limited-scope dental or vision benefits.

AB210-ASA1,15,5 4. Coverage specified in s. 632.745 (11) (b) 10.

AB210-ASA1,15,13 (b) Establish standards for external appeals, including standards for appealing a preexisting condition exclusion denial determination or the rescission of a policy or certificate, and require an insurer to comply with the standards. The commissioner shall adopt standards under this paragraph that comply either with section 2719 (b) (1) of the Public Health Service Act (42 USC 300gg-19 (b) (1)) or with the standards established by the secretary under section 2719 (b) (2) of the Public Health Service Act (42 USC 300gg-19 (b) (2)). The commissioner shall apply the external appeal standards established under this paragraph to all of the following:

AB210-ASA1,15,15 1. Group and individual health insurance coverage subject to section 2719 (b) of the Public Health Service Act (42 USC 300gg-19 (b)).

AB210-ASA1,15,16 2. Grandfathered health plans.

AB210-ASA1,15,17 3. Coverage specified in s. 632.745 (11) (b) 10.

AB210-ASA1,15,19 4. Coverage specified in s. 632.745 (11) (b) 11., including Medicare supplement or replacement policies, but excluding Medicare advantage plans.

AB210-ASA1,15,20 (c) Establish standards for independent review organizations.

AB210-ASA1,15,22 (2) Compliance required. An insurer and an independent review organization shall comply with the rules promulgated under this chapter.

AB210-ASA1,16,8 636.15 Independent review organizations. (1) Certification. (a) An independent review organization may not perform a review for purposes of the external appeals process established in accordance with standards promulgated under s. 636.12 (1) (b) unless the organization is certified by the commissioner. Unless the commissioner provides otherwise by rule, only an independent review organization that is accredited by a nationally recognized private accreditation organization may be certified under this paragraph. An independent review organization must demonstrate to the satisfaction of the commissioner that it is unbiased and does not have a conflict of interest, as defined by the commissioner by rule. An organization certified under this paragraph must be recertified on a biennial basis.

AB210-ASA1,16,13 (b) An organization applying for certification or recertification as an independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp) or (Lr). Every organization certified or recertified as an independent review organization shall file a report with the commissioner in accordance with rules promulgated under s. 636.12 (1) (c).

AB210-ASA1,16,18 (c) An independent review organization that was certified or recertified by the commissioner under s. 632.835, 2009 stats., and whose certification is in effect on the effective date of this paragraph .... [LRB inserts date], shall be considered to have been certified under par. (a), and its certification shall remain in effect until the certification expires or it is revoked or suspended under sub. (5) or s. 227.51 (3).

AB210-ASA1,16,23 (2) Quality assurance mechanism. An independent review organization shall have in operation a quality assurance mechanism to ensure the timeliness and quality of the independent reviews, the qualifications and independence of the clinical peer reviewers, and the confidentiality of the medical records and review materials.

AB210-ASA1,17,4 (3) Reasonable fees. An independent review organization shall establish reasonable fees that it will charge for independent reviews and shall submit its fee schedule to the commissioner for a determination of reasonableness and for prior approval. An independent review organization may not change any fees approved by the commissioner more than once per year and shall submit any proposed fee changes to the commissioner for prior approval.

AB210-ASA1,17,9 (4) Examinations and audits. The commissioner may examine, audit, or accept an audit of, the books and records of an independent review organization as provided for examination of licensees and permittees under s. 601.43 (1), (3), (4), and (5), to be conducted as provided in s. 601.44, and with costs to be paid as provided in s. 601.45.

AB210-ASA1,17,19 (5) Revocation, suspension, refusal to recertify. The commissioner may revoke, suspend, or limit in whole or in part the certification of an independent review organization, or may refuse to recertify an independent review organization, if the commissioner finds that the independent review organization is unqualified or has violated a statute, or a rule promulgated, under chs. 600 to 646 or a valid order of the commissioner under s. 601.41 (4), or if the independent review organization's methods or practices in the conduct of its business endanger, or its financial resources are inadequate to safeguard, the legitimate interests of consumers and the public. The commissioner may summarily suspend an independent review organization's certification under s. 227.51 (3).

AB210-ASA1,17,22 (6) Decision is binding. Unless otherwise required by the standards under section 2719 (b) of the Public Health Service Act (42 USC 300gg-19 (b)), a decision of an independent review organization is binding on the insured and the insurer.

AB210-ASA1,18,4 (7) Immunity from liability. (a) An independent review organization that is certified under this section is immune from any civil or criminal liability that may result because of an independent review determination made under the rules promulgated under this chapter. An employee, agent, or contractor of a certified independent review organization is immune from any civil or criminal liability for any act or omission done in good faith within the scope of his or her powers and duties under the rules promulgated under this chapter.

AB210-ASA1,18,7 (b) An insurer is not liable to any person for damages attributable to the insurer's actions taken in compliance with any decision regarding a determination rendered by a certified independent review organization.

AB210-ASA1,18,10 (8) Insured's right to commence civil proceeding. Nothing in this section affects an insured's right to commence a civil proceeding relating to a matter that may be appealed under the standards established under s. 636.12 (1).

AB210-ASA1,18,16 636.18 Rebate and report requirement. Subject to s. 636.35, an insurer offering small employer health insurance or individual health insurance coverage shall comply with section 2718 of the Public Health Service Act (42 USC 300gg-18) and shall file the report required under section 2718 (a) of that act (42 USC 300gg-18 (a)) with the commissioner no later than the date required for filing with the secretary.

AB210-ASA1,18,20 636.25 Implementing health insurance coverage provisions. Subject to s. 636.35, notwithstanding any inconsistent provision in chs. 600 to 635 or chs. 644 to 646, and unless the commissioner provides otherwise by rule under s. 636.10, all of the following apply:

AB210-ASA1,18,22 (1) Insurers. An insurer shall comply with all of the following provisions of the Public Health Service Act:

AB210-ASA1,18,24 (a) Standards relating to benefits for mothers and newborns. Section 2725 (42 USC 300gg-25).

AB210-ASA1,19,2 (b) Required coverage for reconstructive surgery following mastectomies. Section 2727 (42 USC 300gg-27).

AB210-ASA1,19,4 (c) Coverage of dependent students on medically necessary leave of absence. Section 2728 (42 USC 300gg-28).

AB210-ASA1,19,5 (d) No lifetime limit or annual limits. Section 2711 (42 USC 300gg-11).

AB210-ASA1,19,6 (e) Prohibition on rescissions. Section 2712 (42 USC 300gg-12).

AB210-ASA1,19,8 (f) Prohibition on preexisting condition exclusions for under age 19. Section 2704 (42 USC 300gg-04), but only for enrollees who are under 19 years of age.

AB210-ASA1,19,9 (g) Coverage of preventive health services. Section 2713 (42 USC 300gg-13).

AB210-ASA1,19,10 (h) Extension of dependent coverage. Section 2714 (42 USC 300gg-14).

AB210-ASA1,19,11 (i) Provision of additional information. Section 2715A (42 USC 300gg-15a).

AB210-ASA1,19,13 (j) Patient protections; choice of health care professional. Section 2719A (a) (42 USC 300gg-19a (a)).

AB210-ASA1,19,17 (k) Patient protections; coverage of emergency services. Section 2719A (b) (42 USC 300gg-19a (b)). In addition, an insurer also shall comply with s. 632.85 and an insurer that provides coverage under a defined network plan also shall comply with s. 609.22 (6).

AB210-ASA1,19,19 (2) Grandfathered health plans. A grandfathered health plan shall comply with all of the following provisions of the Public Health Service Act:

AB210-ASA1,19,21 (a) Coverage of dependent students on medically necessary leave of absence. Section 2728 (42 USC 300gg-28).

AB210-ASA1,19,23 (b) Patient protections; coverage of emergency services. Section 2719A (b) (42 USC 300gg-19a (b)).

AB210-ASA1,20,3 (3) Self-insured governmental health plans. A self-insured governmental health plan shall comply with all of the following provisions of the Public Health Service Act:

AB210-ASA1,20,5 (a) Coverage of dependent students on medically necessary leave of absence. Section 2728 (42 USC 300gg-28).

AB210-ASA1,20,6 (b) Extension of dependent coverage. Section 2714 (42 USC 300gg-14).

AB210-ASA1,20,9 (c) Patient protections; coverage of emergency services. Section 2719A (b) (42 USC 300gg-19a (b)). In addition, a self-insured governmental health plan also shall comply with s. 632.85.

AB210-ASA1,20,12 (4) Additional requirements for insurers. With respect to health insurance coverage that is issued or renewed on or after March 23, 2012, all of the following apply:

AB210-ASA1,20,14 (a) Insurers. An insurer shall comply with all of the following provisions of the Public Health Service Act:

AB210-ASA1,20,16 1. `Uniform explanation of coverage documents and standardization of definitions.' Section 2715 (42 USC 300gg-15).

AB210-ASA1,20,17 2. `Ensuring the quality of care.' Section 2717 (42 USC 300gg-17).

AB210-ASA1,20,20 (b) Grandfathered health plans. A grandfathered health plan shall comply with section 2717 of the Public Health Service Act (42 USC 300gg-17), relating to ensuring the quality of care.

AB210-ASA1,20,25 (5) Application of section to grandfathered health plans. In addition to subs. (2) and (4) (b), this section applies to a grandfathered health plan, but only with respect to those provisions of the Public Health Service Act referred to in this section that apply to a grandfathered health plan under section 1251 of the Patient Protection and Affordable Care Act.

AB210-ASA1,21,9 636.35 Applicability if federal law found unconstitutional or repealed. (1) Unconstitutional. (a) If the Patient Protection and Affordable Care Act is found by a final decision of a federal court of competent jurisdiction to be unconstitutional in its entirety and unenforceable in this state, and if all appeals are exhausted or the time for appeal expires, on and after the first day of the 3rd month beginning after the date on which all appeals are exhausted or the time for appeal expires s. 636.10 does not apply, any rules promulgated or requirements established under s. 636.10 are void and may not be enforced, and insurers and self-insured governmental health plans are exempt from all of the following provisions:

AB210-ASA1,21,10 1. Section 625.13 (3).

AB210-ASA1,21,11 2. Section 636.18.

AB210-ASA1,21,13 3. Section 636.25, except for the extension of dependent coverage requirements described in s. 636.25 (1) (h) and (3) (b).

AB210-ASA1,21,15 4. Chapter 625 with respect to small employer health insurance and group and blanket accident and sickness insurance offered in the individual market.

AB210-ASA1,21,21 (b) If the Patient Protection and Affordable Care Act is found by a final decision of a federal court of competent jurisdiction to be unconstitutional in part and unenforceable in part in this state, and if all appeals are exhausted or the time for appeal expires, on and after the first day of the 3rd month beginning after the date on which all appeals are exhausted or the time for appeal expires all of the following apply:

AB210-ASA1,22,2 1. Insurers and self-insured governmental health plans are exempt from any provisions of the Public Health Service Act referred to in ss. 636.18 and 636.25 that correspond to the provisions of the Patient Protection and Affordable Care Act that are found to be unconstitutional, except for the extension of dependent coverage requirements described in s. 636.25 (1) (h) and (3) (b).