Amendment ASA1-AB210

2011 - 2012 LEGISLATURE

ASSEMBLY SUBSTITUTE AMENDMENT 1, TO 2011 ASSEMBLY BILL 210

October 11, 2011 - Offered by Committee on Insurance.

AB210-ASA1,2,2 An Act to repeal 609.755, 632.83, 632.835 and 632.885; to renumber 625.02 (1); to renumber and amend 625.03 (1m) (e); to amend 40.51 (8), 40.51 (8), 40.51 (8m), 40.51 (8m), 49.67 (3) (am) 2. b., 66.0137 (4), 66.0137 (4), 111.91 (2) (n), 111.91 (2) (nm), 111.91 (2) (s), 111.998 (2) (n), 111.998 (2) (s), 120.13 (2) (g), 120.13 (2) (g), 185.983 (1) (intro.), 185.983 (1) (intro.), 600.01 (2) (b), 601.31 (1) (Lp), 601.31 (1) (Lr), 601.42 (4), 609.655 (4) (b), 625.13 (1), 625.14, 632.76 (2) (ac) 1., 632.76 (2) (ac) 2., 632.76 (2) (ac) 3. (intro.) and 632.895 (15) (c) (intro.); and to create 601.465 (1m) (d), 625.02 (1h), 625.02 (1p), 625.02 (2f), 625.02 (2s), 625.03 (1m) (e) 2., 625.03 (1m) (e) 3., 625.13 (3), 632.76 (2) (ac) 4. and chapter 636 of the statutes; relating to: implementing health insurance reform, extending the time limit for emergency rule procedures, specifying that any health benefit exchange must be established by legislation, and granting rule-making authority.

Analysis by the Legislative Reference Bureau

This substitute amendment differs from 2011 Assembly Bill 210 (the bill) in the following respects:

1. In the bill, the Office of the Commissioner of Insurance (OCI) may promulgate any rule related to the provisions created in the bill as an emergency rule and is not required to provide evidence that promulgating the rule as an emergency rule is necessary for the preservation of public peace, health, safety, or welfare and is not required to provide a finding of emergency. The substitute amendment removes this exception so that OCI, in promulgating an emergency rule, would be required to provide evidence that the emergency rule is necessary for the preservation of public peace, health, safety, or welfare and required to provide a finding of emergency.

2. Under the bill, grandfathered plans are required to comply with the federal Patient Protection and Affordable Care Act (PPACA) relating to requirements for coverage of preventive health services. The substitute amendment removes this requirement for grandfathered plans.

3. PPACA defines a small employer as one that employs not more than 100 employees, but allows states to elect to define a small employer, for plan years beginning before January 1, 2016, as an employer with not more than 50 employees. The bill defines a small employer for purposes of the PPACA requirements as an employer with not more than 100 employees but specifically reserves the right to elect to substitute 50 for 100 for the definition of small employer. The substitute amendment provides that this election must be done through legislation.

4. The bill provides that if PPACA is found unconstitutional in its entirety and all appeals are exhausted or the time for appeal expires, insurers and self-insured governmental health plans are exempt from a number of provisions in the bill. The substitute amendment adds that, if PPACA is found unconstitutional in its entirety, the powers of OCI with respect to promulgating rules for, and enforcing, the PPACA requirements, as well as any rules or requirements already established related to those requirements, do not apply. The substitute amendment also provides that if any of PPACA's provisions are repealed, insurers and self-insured governmental health plans are exempt from those provisions, or if PPACA is found unconstitutional in part, insurers and self-insured governmental health plans are exempt from any rebate and report and coverage requirements that are found unconstitutional, and the powers of OCI with respect to promulgating rules for, and enforcing, provisions from which insurers and self-insured governmental health plans are exempt, as well as any rules or requirements already established related to those provisions, do not apply.

5. The substitute amendment specifies that any health benefit exchange established in this state under PPACA must be done so by legislation. The bill does not address the establishment of a health benefit exchange.

For further information, see the analysis for the bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB210-ASA1, s. 1 Section 1 . 40.51 (8) of the statutes is amended to read:

AB210-ASA1,3,6 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896 and, so far as applicable, ch. 636.

AB210-ASA1, s. 2 Section 2 . 40.51 (8) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB210-ASA1,3,13 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.85, 632.853, 632.855, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896 and, so far as applicable, ch. 636.

AB210-ASA1, s. 3 Section 3 . 40.51 (8m) of the statutes is amended to read:

AB210-ASA1,3,18 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.885, 632.89, and 632.895 (11) to (17) and, so far as applicable, ch. 636.

AB210-ASA1, s. 4 Section 4 . 40.51 (8m) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB210-ASA1,4,4 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.85, 632.853, 632.855, 632.885, 632.89, and 632.895 (11) to (17) and, so far as applicable, ch. 636.

AB210-ASA1, s. 5 Section 5. 49.67 (3) (am) 2. b. of the statutes, as affected by 2011 Wisconsin Act 32, is amended to read:

AB210-ASA1,4,11 49.67 (3) (am) 2. b. If the applicant is under 26 years of age, notice that he or she may be eligible for coverage as a dependent under his or her parent's health care plan in accordance with s. 632.885 636.25 (1) (h) or (3) (b), and that his or her parent's plan must include coverage for services that are not covered under the plan under this section.

AB210-ASA1, s. 6 Section 6 . 66.0137 (4) of the statutes is amended to read:

AB210-ASA1,4,19 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4) and, so far as applicable, ch. 636.

AB210-ASA1, s. 7 Section 7 . 66.0137 (4) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB210-ASA1,5,3 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4) and, so far as applicable, ch. 636.

AB210-ASA1, s. 8 Section 8. 111.91 (2) (n) of the statutes is amended to read:

AB210-ASA1,5,7 111.91 (2) (n) The provision to employees of the health insurance coverage required under s. 632.895 (11) to (14), (16), and (16m), and (17) and, so far as applicable, s. 636.25.

AB210-ASA1, s. 9 Section 9. 111.91 (2) (nm) of the statutes is amended to read:

AB210-ASA1,5,11 111.91 (2) (nm) The requirements related to providing coverage for a dependent under s. 632.885 and to continuing coverage for a dependent student on a medical leave of absence under s. 632.895 (15).

AB210-ASA1, s. 10 Section 10. 111.91 (2) (s) of the statutes is amended to read:

AB210-ASA1,5,15 111.91 (2) (s) The requirements related to internal grievance procedures under s. 632.83 and independent review and external appeals of certain health benefit plan determinations established under s. 632.835 636.12.

AB210-ASA1, s. 11 Section 11. 111.998 (2) (n) of the statutes is amended to read:

AB210-ASA1,5,18 111.998 (2) (n) The provision to employees of the health insurance coverage required under s. 632.895 (11) to (14) and, so far as applicable, s. 636.25.

AB210-ASA1, s. 12 Section 12. 111.998 (2) (s) of the statutes is amended to read:

AB210-ASA1,5,22 111.998 (2) (s) The requirements related to internal grievance procedures under s. 632.83 and independent review and external appeals of certain health benefit plan determinations established under s. 632.835 636.12.

AB210-ASA1, s. 13 Section 13 . 120.13 (2) (g) of the statutes is amended to read:

AB210-ASA1,6,2 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4) and, so far as applicable, ch. 636.

AB210-ASA1, s. 14 Section 14 . 120.13 (2) (g) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB210-ASA1,6,8 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4) and, so far as applicable, ch. 636.

AB210-ASA1, s. 15 Section 15 . 185.983 (1) (intro.) of the statutes is amended to read:

AB210-ASA1,6,17 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.87 (2), (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 625, 630, 635, 636, 645, and 646, but the sponsoring association shall:

AB210-ASA1, s. 16 Section 16 . 185.983 (1) (intro.) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB210-ASA1,7,2 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.87 (2), (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 625, 630, 635, 636, 645, and 646, but the sponsoring association shall:

AB210-ASA1, s. 17 Section 17. 600.01 (2) (b) of the statutes is amended to read:

AB210-ASA1,7,5 600.01 (2) (b) Group or blanket insurance described in sub. (1) (b) 3. and 4. is not exempt from ss. 632.745 to 632.749, 632.83 or 632.835 or 636.12 or ch. 633 or 635.

AB210-ASA1, s. 18 Section 18. 601.31 (1) (Lp) of the statutes is amended to read:

AB210-ASA1,7,8 601.31 (1) (Lp) For certifying as an independent review organization under s. 632.835 636.15 (1) (a), $400.

AB210-ASA1, s. 19 Section 19. 601.31 (1) (Lr) of the statutes is amended to read:

AB210-ASA1,7,11 601.31 (1) (Lr) For each biennial recertification as an independent review organization under s. 632.835 636.15 (1) (a), $100.

AB210-ASA1, s. 20 Section 20. 601.42 (4) of the statutes is amended to read:

AB210-ASA1,7,24 601.42 (4) Replies. Any officer, manager or general agent of any insurer authorized to do or doing an insurance business in this state, any person controlling or having a contract under which the person has a right to control such an insurer, whether exclusively or otherwise, any person with executive authority over or in charge of any segment of such an insurer's affairs, any individual practice association or officer, director or manager of an individual practice association, any insurance agent or other person licensed under chs. 600 to 646, any provider of services under a continuing care contract, as defined in s. 647.01 (2), any independent review organization certified or recertified under s. 632.835 (4) 636.15 (1) (a) or any health care provider, as defined in s. 655.001 (8), shall reply promptly in writing or in other designated form, to any written inquiry from the commissioner requesting a reply.

AB210-ASA1, s. 21 Section 21. 601.465 (1m) (d) of the statutes is created to read:

AB210-ASA1,8,3 601.465 (1m) (d) Information contained in individual or small group health insurance rate and supplementary rate information filed under ch. 625 that the office determines is proprietary.

AB210-ASA1, s. 22 Section 22. 609.655 (4) (b) of the statutes is amended to read:

AB210-ASA1,8,12 609.655 (4) (b) Upon completion of the review under par. (a), the medical director of the defined network plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the defined network plan's internal grievance procedure established under s. 632.83 636.12.

AB210-ASA1, s. 23 Section 23. 609.755 of the statutes is repealed.

AB210-ASA1, s. 24 Section 24. 625.02 (1) of the statutes is renumbered 625.02 (1m).

AB210-ASA1, s. 25 Section 25. 625.02 (1h) of the statutes is created to read:

AB210-ASA1,8,17 625.02 (1h) "Individual health insurance coverage" has the meaning given in s. 636.01 (4).

AB210-ASA1, s. 26 Section 26. 625.02 (1p) of the statutes is created to read:

AB210-ASA1,8,19 625.02 (1p) "Public Health Service Act" has the meaning given in s. 636.01 (9).

AB210-ASA1, s. 27 Section 27. 625.02 (2f) of the statutes is created to read:

AB210-ASA1,8,22 625.02 (2f) "Secretary" means the secretary of the federal department of health and human services.

AB210-ASA1, s. 28 Section 28. 625.02 (2s) of the statutes is created to read:

AB210-ASA1,9,5 625.02 (2s) "Small employer health insurance" means health insurance coverage as defined in s. 636.01 (3) that is 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)). For purposes of this subsection, a small employer is an employer that employed an average of at least one but not more than 50 employees on business days during the preceding calendar year and that employs at least one employee on the first day of the plan year.

AB210-ASA1, s. 29 Section 29. 625.03 (1m) (e) of the statutes is renumbered 625.03 (1m) (e) (intro.) and amended to read:

AB210-ASA1,9,9 625.03 (1m) (e) (intro.) Group and blanket accident and sickness insurance other than credit, except for the following:

AB210-ASA1,9,10 1. Credit accident and sickness insurance.

AB210-ASA1, s. 30 Section 30. 625.03 (1m) (e) 2. of the statutes is created to read:

AB210-ASA1,9,14 625.03 (1m) (e) 2. Subject to s. 636.35, on and after September 1, 2011, small employer health insurance, unless the commissioner provides otherwise by rule, including emergency rule as provided in s. 636.10 (2).

AB210-ASA1, s. 31 Section 31. 625.03 (1m) (e) 3. of the statutes is created to read:

AB210-ASA1,9,19 625.03 (1m) (e) 3. Subject to s. 636.35, on and after September 1, 2011, group and blanket accident and sickness insurance offered in the individual market, as defined in s. 636.01 (5), unless the commissioner provides otherwise by rule, including emergency rule as provided in s. 636.10 (2).

AB210-ASA1, s. 32 Section 32. 625.13 (1) of the statutes is amended to read:

AB210-ASA1,9,24 625.13 (1) Filing procedure. Except as provided in sub. subs. (2) and (3), every authorized insurer and every rate service organization licensed under s. 625.31 which has been designated by any insurer for the filing of rates under s. 625.15 (2) shall file with the commissioner all rates and supplementary rate information and all changes and amendments thereof made by it for use in this state within 30 days after they become effective.

AB210-ASA1, s. 33 Section 33. 625.13 (3) of the statutes is created to read:

AB210-ASA1,10,12 625.13 (3) Individual and small employer health insurance. Subject to s. 636.35, on and after September 1, 2011, unless the commissioner provides otherwise by rule, including emergency rule as provided in s. 636.10 (2), for individual health insurance coverage, group and blanket accident and sickness insurance offered in the individual market, or small employer health insurance an insurer, or a rate service organization licensed under s. 625.31 that has been designated by the insurer for the filing of rates under s. 625.15 (2), shall file with the commissioner all rates and supplementary rate information, and all changes and amendments to the information, before they become effective.

AB210-ASA1, s. 34 Section 34. 625.14 of the statutes is amended to read:

AB210-ASA1,10,17 625.14 Filings open to inspection. Each Subject to s. 601.465 (1m) (d), each filing and any supporting information filed under this chapter shall, as soon as filed, be open to public inspection at any reasonable time. Copies may be obtained by any person on request and upon payment of a reasonable charge therefor.

AB210-ASA1, s. 35 Section 35. 632.76 (2) (ac) 1. of the statutes is amended to read:

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.