Amendment AA8-ASA1-AB64

AB64-ASA1-AA8,12,2 253.07 (title) Women's health block grant; state family planning funds.

AB64-ASA1-AA8,1791dh Section 1791dh. 253.07 (6) of the statutes is created to read:

AB64-ASA1-AA8,12,4 253.07 (6) State-funded family planning program. (a) In this subsection:

AB64-ASA1-AA8,12,9 1. “Federal funding prohibition” means an enacted federal law, a regulation, or an executive order or action that prohibits federal moneys from being paid by the state to or directly to a provider under Title X of the federal Public Health Service Act, 42 USC 300 to 300a-6, because of the scope of services offered by the provider or the scope of services for which the provider offers referrals.

AB64-ASA1-AA8,12,13 2. “Nonpublic family planning provider” means an entity other than a public entity or governmental unit that is a provider of services for family planning and that is eligible to apply for grant funding under Title X of the federal Public Health Service Act, 42 USC 300 to 300a-6, on December 31, 2016.

AB64-ASA1-AA8,12,19 (b) Notwithstanding sub. (5), if a nonpublic family planning provider becomes subject to a federal funding prohibition, the department shall establish a state-funded family planning program to ensure continuity of family planning services in the state and distribute state funds to any nonpublic family planning providers that are subject to a federal funding prohibition to be used to provide family planning services.”.

AB64-ASA1-AA8,12,20 23. Page 925, line 14: after that line insert:

AB64-ASA1-AA8,12,21 “ Section 2218s. 625.02 (1) of the statutes is renumbered 625.02 (1m).

AB64-ASA1-AA8,2218t Section 2218t. 625.02 (1j) of the statutes is created to read:

AB64-ASA1-AA8,12,23 625.02 (1j) “Health insurance" has the meaning given in s. 632.745 (12).

AB64-ASA1-AA8,2218u Section 2218u. 625.03 (1m) (intro.) of the statutes is amended to read:

AB64-ASA1-AA8,13,4 625.03 (1m) (intro.) This Except as specifically provided otherwise in this chapter, this chapter applies to all kinds and lines of direct insurance written on risks or operations in this state by any insurer authorized to do business in this state, except:

AB64-ASA1-AA8,2218v Section 2218v. 625.13 (1) of the statutes is amended to read:

AB64-ASA1-AA8,13,11 625.13 (1) Filing procedure. Except as provided in sub. (2) and s. 625.25 (2) (a), 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.

AB64-ASA1-AA8,2218w Section 2218w. 625.15 (2) of the statutes is amended to read:

AB64-ASA1-AA8,13,20 625.15 (2) Rate filing. An insurer may discharge its obligation under s. 625.13 (1) or 625.25 (2) (a) by giving notice to the commissioner that it uses rates and supplementary rate information prepared by a designated rate service organization, with such information about modifications thereof as is necessary fully to inform the commissioner. The insurer's rates or proposed rates and supplementary rate information shall be those filed from time to time by the rate service organization, including any amendments or proposed amendments thereto as filed, subject, however, to the modifications filed by the insurer.

AB64-ASA1-AA8,2218x Section 2218x. 625.21 (1) of the statutes is amended to read:

AB64-ASA1-AA8,14,8 625.21 (1) Rule instituting delayed effect. If the commissioner finds that competition is not an effective regulator of the rates charged or that a substantial number of companies are competing irresponsibly through the rates charged, or that there are widespread violations of this chapter, in any kind or line of insurance or subdivision thereof or in any rating class or rating territory, he or she may promulgate a rule requiring that in the kind or line of insurance or subdivision thereof or rating class or rating territory comprehended by the finding any subsequent changes in the rates or supplementary rate information be filed with the commissioner at least 15 days before they become effective. The commissioner may extend the waiting period for not to exceed 15 additional days by written notice to the filer before the first 15-day period expires. This subsection does not apply to health insurance, which is subject to s. 625.25 (2) (a).

AB64-ASA1-AA8,2218y Section 2218y. 625.22 (1) of the statutes is amended to read:

AB64-ASA1-AA8,14,13 625.22 (1) Order in event of violation. If the commissioner finds after a hearing that a rate or proposed rate is not in compliance with s. 625.11, the commissioner shall order that its use be discontinued, or that it may not be used, for any policy issued or renewed after a date specified in the order.

AB64-ASA1-AA8,2218z Section 2218z. 625.22 (3) of the statutes is amended to read:

AB64-ASA1-AA8,14,19 625.22 (3) Approval of substituted rate. Within Except for rates for health insurance, which is subject to s. 625.25 (2) (a), within one year after the effective date of an order under sub. (1), no rate promulgated to replace a disapproved one may be used until it has been filed with the commissioner and not disapproved within 30 days thereafter.

AB64-ASA1-AA8,2219b Section 2219b. 625.23 of the statutes is amended to read:

AB64-ASA1-AA8,15,7 625.23 Special restrictions on individual insurers. The commissioner may by order require that a particular insurer file any or all of its rates and supplementary rate information 15 days prior to their effective date, if and to the extent that he or she finds, after a hearing, that the protection of the interests of its insureds and the public in this state requires closer supervision of its rates because of the insurer's financial condition or rating practices. The commissioner may extend the waiting period for any filing for not to exceed 15 additional days by written notice to the insurer before the first 15-day period expires. A filing not disapproved before the expiration of the waiting period shall be deemed to meet the requirements of this chapter, subject to the possibility of subsequent disapproval under s. 625.22. This section does not apply to an insurer with respect to rates for health insurance, which is subject to s. 625.25 (2) (a).

AB64-ASA1-AA8,2219c Section 2219c. 625.25 of the statutes is created to read:

AB64-ASA1-AA8,15,9 625.25 Rates for health insurance. (1) Definitions. In this section:

AB64-ASA1-AA8,15,10 (a) “Group health benefit plan" has the meaning given in s. 632.745 (9).

AB64-ASA1-AA8,15,11 (b) “Health benefit plan" has the meaning given in s. 632.745 (11).

AB64-ASA1-AA8,15,12 (c) “Insurer" has the meaning given in s. 632.745 (15).

AB64-ASA1-AA8,15,13 (d) “Large group market" has the meaning given in s. 632.745 (17).

AB64-ASA1-AA8,15,14 (e) “Small group market" has the meaning given in s. 632.745 (26).

AB64-ASA1-AA8,16,6 (2) Filing of rates; hearing. (a) Every insurer, and every rate service organization licensed under s. 625.31 that has been designated by any insurer for the filing of rates under s. 625.15 (2), shall file with the commissioner all proposed rates and supplementary rate information, and all proposed changes and amendments to rates and supplementary rate information, for use in this state for any health benefit plan offered by the insurer before the proposed rates or changes to rates become effective. An insurer may not use a proposed rate or change to a rate until it has been filed with and approved by the commissioner. Unless the commissioner holds a hearing on the proposed rate or change to a rate, a proposed rate or change to a rate is approved if the commissioner does not disapprove the proposed rate or change within 30 days after filing, or within a 30-day extension of that period ordered by the commissioner prior to the expiration of the first 30 days. The requirement under this paragraph applies with respect to rates and changes to rates for all health benefit plans, including individual health benefit plans, group health benefit plans offered in the small group market, and group health benefit plans offered in the large group market, that have not gone into effect by the effective date of this paragraph .... [LRB inserts date].

AB64-ASA1-AA8,16,9 (b) If any proposed change to a rate filed under par. (a) increases the existing rate by more than 10 percent of that rate, the commissioner shall hold a public hearing before approving or disapproving the proposed change to the rate.

AB64-ASA1-AA8,16,12 (c) The commissioner may disapprove a proposed rate or change to a rate filed under par. (a) that the commissioner determines is not justified based on underlying medical costs.

AB64-ASA1-AA8,16,16 (3) Publication of increases, negotiated rates. (a) The commissioner shall publish on the office's Internet site, in a format that is readily understandable by members of the public, all rate changes filed under sub. (2) (a) that increase an existing rate by any amount and that are approved.

AB64-ASA1-AA8,16,21 (b) If the commissioner approves a rate increase after holding a hearing under sub. (2) (b) and the insurer justified the rate increase based on increased medical costs, the commissioner shall publish on the office's Internet site, in a format that is readily understandable by members of the public, the discounted payment rates the insurer has negotiated with each of the insurer's provider networks.

AB64-ASA1-AA8,16,25 (4) Notice of rate increase to insureds. If the commissioner approves a rate increase filed under sub. (2) (a), the insurer shall provide notice of the rate increase to each insured under the health benefit plan at least 60 days before the rate increase goes into effect.”.

AB64-ASA1-AA8,17,1 24. Page 925, line 14: after that line insert:

AB64-ASA1-AA8,17,2 “ Section 2218u. 609.713 of the statutes is created to read:

AB64-ASA1-AA8,17,4 609.713 Essential health benefits. Defined network plans and preferred provider plans are subject to s. 632.895 (14m).

AB64-ASA1-AA8,2218y Section 2218y. 632.895 (14m) of the statutes is created to read:

AB64-ASA1-AA8,17,7 632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB64-ASA1-AA8,17,10 (b) On a date specified by the commissioner, by rule, every disability insurance policy and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).

AB64-ASA1-AA8,17,12 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB64-ASA1-AA8,17,14 1. Include benefits, items, and services in, at least, all of the following categories:

AB64-ASA1-AA8,17,15 a. Ambulatory patient services.

AB64-ASA1-AA8,17,16 b. Emergency services.

AB64-ASA1-AA8,17,17 c. Hospitalization.

AB64-ASA1-AA8,17,18 d. Maternity and newborn care.

AB64-ASA1-AA8,17,20 e. Mental health and substance use disorder services, including behavioral health treatment.

AB64-ASA1-AA8,17,21 f. Prescription drugs.

AB64-ASA1-AA8,17,22 g. Rehabilitative and habilitative services and devices.

AB64-ASA1-AA8,17,23 h. Laboratory services.

AB64-ASA1-AA8,17,24 i. Preventive and wellness services and chronic disease management.

AB64-ASA1-AA8,18,1 j. Pediatric services, including oral and vision care.

AB64-ASA1-AA8,18,6 2. Conduct a survey of employer-sponsored coverage to determine benefits typically covered by employers and ensure that the scope of essential health benefits for which coverage is required under this subsection is equal to the scope of benefits covered under a typical disability insurance policy offered by an employer to its employees.

AB64-ASA1-AA8,18,8 3. Ensure that essential health benefits reflect a balance among the categories described in subd. 1. such that benefits are not unduly weighted toward one category.

AB64-ASA1-AA8,18,10 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB64-ASA1-AA8,18,14 5. Require that disability insurance policies and self-insured health plans do not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.

AB64-ASA1-AA8,18,17 6. Establish essential health benefits in a way that takes account of the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

AB64-ASA1-AA8,18,21 7. Ensure that essential health benefits established under this subsection not be subject to a coverage denial based on an insured's or plan participant's age, expected length of life, present or predicted disability, degree of dependency on medical care, or quality of life.

AB64-ASA1-AA8,19,3 8. Require that disability insurance policies and self-insured health plans cover emergency department services that are essential health benefits without imposing any requirement to obtain prior authorization for those services and without limiting coverage for services provided by an emergency services provider that is not in the provider network of a policy or plan in a way that is more restrictive than requirements or limitations that apply to emergency services provided by a provider that is in the provider network of the policy or plan.

AB64-ASA1-AA8,19,8 9. Require a disability insurance policy or self-insured health plan to apply to emergency department services that are essential health benefits provided by an emergency department provider that is not in the provider network of the policy or plan the same copayment amount or coinsurance rate that applies if those services are provided by a provider that is in the provider network of the policy or plan.

AB64-ASA1-AA8,19,10 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB64-ASA1-AA8,19,15 (e) If an essential health benefit is also subject to mandated coverage elsewhere under this section and the coverage requirements are not identical, the disability insurance policy or self-insured health plan shall provide coverage under whichever subsection provides the insured or plan participant with more comprehensive coverage of the medical condition, item, or service.

AB64-ASA1-AA8,19,19 (f) Nothing in this subsection or rules promulgated under this subsection prohibits a disability insurance policy or a self-insured health plan from providing benefits in excess of the essential health benefit coverage required under this subsection.”.

AB64-ASA1-AA8,19,20 25. Page 925, line 14: after that line insert:

AB64-ASA1-AA8,19,21 “ Section 2218t. 609.847 of the statutes is created to read:

AB64-ASA1-AA8,19,24 609.847 Preexisting condition discrimination prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.

AB64-ASA1-AA8,2218w Section 2218w. 625.12 (1) (a) of the statutes is amended to read:

AB64-ASA1-AA8,20,3 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB64-ASA1-AA8,2218y Section 2218y. 625.12 (1) (e) of the statutes is amended to read:

AB64-ASA1-AA8,20,6 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB64-ASA1-AA8,2219b Section 2219b. 625.12 (2) of the statutes is amended to read:

AB64-ASA1-AA8,20,16 625.12 (2) Classification. Risks Except as provided in s. 632.728, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to s. ss. 632.365 and 632.728, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB64-ASA1-AA8,2219d Section 2219d. 625.15 (1) of the statutes is amended to read:

AB64-ASA1-AA8,20,25 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB64-ASA1-AA8,2219f Section 2219f. 628.34 (3) (a) of the statutes is amended to read:

AB64-ASA1-AA8,21,8 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.746 and 632.748. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB64-ASA1-AA8,2219h Section 2219h. 632.728 of the statutes is created to read:

AB64-ASA1-AA8,21,11 632.728 Premiums and cost-sharing discrimination prohibited for preexisiting conditions. (1) Definition. In this section:

AB64-ASA1-AA8,21,12 (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB64-ASA1-AA8,21,13 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB64-ASA1-AA8,21,19 (2) Prohibition. For the purpose of setting rates or premiums for coverage under a group or individual disability insurance policy or a self-insured health plan and for the purpose of setting any deductibles, copayments, or coinsurance under a group or individual disability insurance policy or a self-insured health plan, the policy or plan may not consider whether an individual, including a dependent, who would be covered under the plan has a preexisting condition.

AB64-ASA1-AA8,2219j Section 2219j. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB64-ASA1-AA8,22,3 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not impose a preexisting condition exclusion only if the exclusion relates to 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 the 6-month period ending on the participant's or beneficiary's enrollment date under the plan on a participant or beneficiary under the plan.

AB64-ASA1-AA8,2219n Section 2219n. 632.746 (1) (b) of the statutes is repealed.

AB64-ASA1-AA8,2219p Section 2219p. 632.746 (2) (a) of the statutes is amended to read:

AB64-ASA1-AA8,22,8 632.746 (2) (a) An insurer offering a group health benefit plan may not treat genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.