SB201,22,25 21(2) Individual health benefit plans. Except as provided in sub. (3) and
22notwithstanding s. 632.897 (4) (d), an insurer shall provide coverage under an
23individual health benefit plan subject to this subchapter to an individual who is a
24resident of this state, and to the individual's dependents, regardless of health
25condition or claims experience, if all of the following apply:
SB201,23,2
1(a) The insurer has in force a health benefit plan that is subject to this
2subchapter.
SB201,23,43 (b) The individual agrees to pay the premium required for coverage under the
4individual health benefit plan.
SB201,23,75 (c) The individual agrees to comply with all other provisions of the individual
6health benefit plan that apply generally to a policyholder or an insured without
7regard to health condition or claims experience.
SB201,23,12 8(3) Exceptions to guaranteed issue. (a) An insurer that is otherwise required
9to provide coverage under sub. (1) may refuse to issue a group health benefit plan to
10an employer if all of the individuals in the employer group that are to be covered
11under the group health benefit plan may be covered under an individual health
12benefit plan providing single or family coverage.
SB201,23,1613 (b) An insurer that is otherwise required to provide coverage under sub. (2) may
14refuse to provide coverage to an individual if the individual was excluded from
15coverage under an employer's health benefit plan or self-funded health care plan for
16reasons related to the individual's health condition.
SB201,23,2017 (c) An insurer that is otherwise required to provide coverage under sub. (2) may
18refuse to provide coverage to an individual if the individual waived coverage under
19an employer's health benefit plan or self-funded health care plan for reasons related
20to the individual's health condition.
SB201,23,2221 (d) 1. In this paragraph, "municipal" means county, city, village, town or school
22district.
SB201,24,223 2. Subsections (1) and (2) do not require an insurer to issue coverage that the
24insurer is not authorized to issue under its bylaws, charter or certificate of
25incorporation or authority if the insurer is authorized under its bylaws, charter or

1certificate of incorporation or authority to issue coverage only to state or municipal
2employes and former employes and their dependents.
SB201,24,63 (e) 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 subs. (1) and (2) to that single category or those limited categories
6of employers.
SB201,24,87 (f) The commissioner may exempt an insurer from the requirements of sub. (1)
8or (2) if the commissioner determines that any of the following applies:
SB201,24,109 1. It is inequitable to apply sub. (1) or (2) to the insurer due to its
10disproportionate share of groups or individuals with high claims experience.
SB201,24,1211 2. It is in the public interest to exempt the insurer from the requirements under
12sub. (1) or (2) because the insurer is in financially hazardous condition.
SB201,24,1413 (g) An insurer may limit its issuance of health benefit plans under subs. (1) and
14(2) to any of the following:
SB201,24,1615 1. Group health benefit plans, and related individual conversion policies, to
16small employer groups.
SB201,24,1817 2. Group health benefit plans, and related individual conversion policies, to
18employer groups that are not small employer groups.
SB201,24,1919 3. Individual health benefit plans.
SB201, s. 54 20Section 54. 635.17 (title) of the statutes is amended to read:
SB201,24,22 21635.17 (title) Coverage requirements for small employer health benefit
22plans.
SB201, s. 55 23Section 55. 635.17 (1) (a) (intro.) of the statutes is amended to read:
SB201,25,324 635.17 (1) (a) (intro.) A group or individual health benefit plan subject to this
25subchapter may not deny, exclude or limit benefits for a covered individual for losses

1incurred more than 12 months after the effective date of the individual's coverage
2due to a preexisting condition. Such a health benefit plan may not define a
3preexisting condition more restrictively than any of the following:
SB201, s. 56 4Section 56. 635.17 (1) (a) 1. of the statutes is renumbered 635.17 (1) (a) 1. a.
5and amended to read:
SB201,25,106 635.17 (1) (a) 1. a. A With respect to a group health benefit plan, a condition
7that would have caused an ordinarily prudent person to seek medical advice,
8diagnosis, care or treatment during the 6 months immediately preceding the
9effective date of coverage and for which the individual did not seek medical advice,
10diagnosis, care or treatment
.
SB201, s. 57 11Section 57. 635.17 (1) (a) 1. b. of the statutes is created to read:
SB201,25,1612 635.17 (1) (a) 1. b. With respect to an individual health benefit plan, a condition
13that would have caused an ordinarily prudent person to seek medical advice,
14diagnosis, care or treatment during the 12 months immediately preceding the
15effective date of coverage and for which the individual did not seek medical advice,
16diagnosis, care or treatment.
SB201, s. 58 17Section 58. 635.17 (1) (a) 2. of the statutes is renumbered 635.17 (1) (a) 2. a.
18and amended to read:
SB201,25,2119 635.17 (1) (a) 2. a. A With respect to a group health benefit plan, a condition
20for which medical advice, diagnosis, care or treatment was recommended or received
21during the 6 months immediately preceding the effective date of coverage.
SB201, s. 59 22Section 59. 635.17 (1) (a) 2. b. of the statutes is created to read:
SB201,25,2523 635.17 (1) (a) 2. b. With respect to an individual health benefit plan, a condition
24for which medical advice, diagnosis, care or treatment was recommended or received
25during the 12 months immediately preceding the effective date of coverage.
SB201, s. 60
1Section 60. 635.17 (1) (a) 3. of the statutes is amended to read:
SB201,26,72 635.17 (1) (a) 3. A With respect to a group or individual health benefit plan,
3a
pregnancy existing on the effective date of coverage, except that coverage may not
4be excluded for any covered prenatal care expenses related to such a pregnancy or
5for other covered expenses related to such a pregnancy that exceed the deductible
6amount prescribed by the commissioner under par. (ac). Coverage not excluded may
7be subject to any deductibles or copayments that apply generally under the policy
.
SB201, s. 61 8Section 61. 635.17 (1) (ac) of the statutes is created to read:
SB201,26,159 635.17 (1) (ac) The commissioner shall by rule prescribe a separate deductible
10for covered expenses related to a pregnancy existing on the effective date of coverage,
11excluding covered prenatal care expenses. The rule shall provide for a sliding scale
12deductible that does not exceed $5,000 and that is determined on the basis of the
13stage of the pregnancy on the effective date of the coverage, so that the deductible
14is lower if coverage is obtained early in the pregnancy and higher if coverage is
15obtained late in the pregnancy.
SB201, s. 62 16Section 62. 635.17 (1) (am) of the statutes is created to read:
SB201,26,2217 635.17 (1) (am) Notwithstanding par. (a), an insurer shall provide coverage
18under an individual or group health benefit plan subject to this subchapter to an
19individual who has been a resident of this state for at least 6 months or to an eligible
20employe who has satisfied any waiting period imposed by his or her employer, and
21the dependents of the individual or eligible employe, without a preexisting condition
22exclusion or limitation if the individual or eligible employe applies for coverage:
SB201,26,2423 1. During a 30-day enrollment period specified by the commissioner by rule
24under par. (ar).
SB201,26,2525 2. Within 30 days after the later of the following:
SB201,27,1
1a. The date on which the individual or employe becomes 18 years of age.
SB201,27,32 b. The date on which the individual's or employe's coverage as a dependent
3under a health benefit plan ceases.
SB201, s. 63 4Section 63. 635.17 (1) (ar) of the statutes is created to read:
SB201,27,95 635.17 (1) (ar) The commissioner shall by rule specify a biennial 30-day
6enrollment period during which an individual or an eligible employe, and the
7dependents of the individual or eligible employe, may obtain coverage under par.
8(am) under a group or individual health benefit plan subject to this subchapter
9without any preexisting condition exclusion or limitation.
SB201, s. 64 10Section 64. 635.17 (1) (b) 1. and 2. of the statutes are amended to read:
SB201,27,1611 635.17 (1) (b) 1. A group or individual health benefit plan subject to this
12subchapter shall waive any period applicable to a preexisting condition exclusion or
13limitation period with respect to particular services for the period that an individual
14was previously covered by qualifying coverage that provided benefits with respect to
15such services, if the qualifying coverage was continuous to a date not less than 30
16terminated not more than 60 days before the effective date of the new coverage.
SB201,27,2317 2. Subdivision 1. does not prohibit the application of a waiting period to all new
18enrollees under the a health benefit plan issued to an employer; however, a waiting
19period may not be counted when determining whether the qualifying coverage was
20continuous to a date not less than 30
terminated not more than 60 days before the
21effective date of the new coverage. For the purpose of subd. 1., the new coverage shall
22be considered effective as of the date that it would be effective but for the waiting
23period.
SB201, s. 65 24Section 65. 635.17 (1) (b) 3. of the statutes is repealed.
SB201, s. 66 25Section 66. 635.17 (1) (c) of the statutes is created to read:
SB201,28,2
1635.17 (1) (c) This subsection does not apply to a conversion health insurance
2policy, which is subject to s. 632.897 (4) (a).
SB201, s. 67 3Section 67. 635.17 (2) of the statutes is amended to read:
SB201,28,94 635.17 (2) Minimum participation of employes. (a) Except as provided in par.
5(d), requirements used by a small employer an insurer in determining whether to
6provide coverage to a small an employer, including requirements for minimum
7participation of eligible employes and minimum employer contributions, shall be
8applied uniformly among all small employers that apply for or receive coverage from
9the small employer insurer and that have the same number of eligible employes.
SB201,28,1210 (b) A small employer An insurer may vary its minimum participation
11requirements and minimum employer contribution requirements only by the size of
12the small employer group.
SB201,28,1713 (c) 1. Except as provided in subd. 2., in applying minimum participation
14requirements with respect to a small an employer, a small employer an insurer may
15not count eligible employes or their dependents who have other coverage that is
16qualifying coverage in determining whether the applicable percentage of
17participation is met.
SB201,28,2218 2. If a small an employer has 10 or fewer eligible employes, a small employer
19an insurer may count eligible employes or their dependents who have coverage under
20another health benefit plan sponsored by that small employer in applying minimum
21participation requirements to determine whether the applicable percentage of
22participation is met.
SB201,29,223 (d) A small employer An insurer may not increase a requirement for minimum
24employe participation or a requirement for minimum employer contribution that

1applies to a small an employer after the small employer has been accepted for
2coverage.
SB201, s. 68 3Section 68. 635.17 (3) of the statutes is amended to read:
SB201,29,94 635.17 (3) Prohibited coverage practices. (a) If a small employer an insurer
5offers coverage to a small an employer, the small employer insurer shall offer
6coverage to all of the eligible employes of the small employer and their dependents.
7A small employer An insurer may not offer coverage to only certain individuals in a
8small
an employer group or to only part of the group, except for an eligible employe
9who has not yet satisfied an applicable waiting period, if any.
SB201,29,1410 (b) A small employer An insurer may not modify a health benefit plan subject
11to this subchapter
with respect to a small an employer or an eligible employe or
12dependent, through riders, endorsements or otherwise, to restrict or exclude
13coverage for certain diseases or medical conditions otherwise covered by the health
14benefit plan.
SB201, s. 69 15Section 69. 635.18 (1) of the statutes is renumbered 635.18 (1) (intro.) and
16amended to read:
SB201,30,217 635.18 (1) (intro.) Every small employer insurer that provides coverage under
18a health benefit plan subject to this subchapter
shall actively market such health
19benefit plan coverage, including basic health benefit plans, to small employers in the
20state. If a small employer insurer denies coverage to a small employer under a health
21benefit plan that is not a basic health benefit plan on the basis of the health status
22or claims experience of the small employer or its eligible employes or their
23dependents, the small employer insurer shall offer the small employer the
24opportunity to purchase a basic health benefit plan
. In addition to other marketing

1limitations that the commissioner may authorize by rule, an insurer may limit its
2marketing under this subsection to any of the following:
SB201, s. 70 3Section 70. 635.18 (1) (a) to (c) of the statutes are created to read:
SB201,30,44 635.18 (1) (a) Health benefit plans for small employer groups of all sizes.
SB201,30,65 (b) Health benefit plans for employer groups of all sizes that are not small
6employer groups.
SB201,30,77 (c) Health benefit plans for individuals.
SB201, s. 71 8Section 71. 635.18 (2) of the statutes is amended to read:
SB201,30,109 635.18 (2) (a) Except as provided in par. (b), a small employer an insurer or an
10intermediary may not, directly or indirectly, do any of the following:
SB201,30,1411 1. Discourage a small an employer or an individual from applying, or direct a
12small
an employer or an individual not to apply, for coverage with the small employer
13insurer because of the health status condition, claims experience, industry,
14occupation or geographic location area of the small employer or individual.
SB201,30,1715 2. Encourage or direct a small an employer or an individual to seek coverage
16from another insurer because of the health status condition, claims experience,
17industry, occupation or geographic location area of the small employer or individual.
SB201,30,2118 (b) Paragraph (a) does not prohibit a small employer an insurer or an
19intermediary from providing a small an employer or an individual with information
20about an established geographic service area or a restricted network provision of the
21small employer insurer.
SB201, s. 72 22Section 72. 635.18 (3) of the statutes is amended to read:
SB201,31,423 635.18 (3) (a) Except as provided in par. (b), a small employer an insurer may
24not, directly or indirectly, enter into any contract, agreement or arrangement with
25an intermediary that provides for or results in compensation to an the intermediary

1for the sale of a health benefit plan subject to this subchapter that varies according
2to the health status condition, claims experience, industry, occupation or geographic
3location area of the small employer or, eligible employes, insured individual or
4dependents.
SB201,31,85 (b) Payment of compensation on the basis of percentage of premium is not a
6violation of par. (a) if the percentage does not vary based on the health status
7condition, claims experience, industry, occupation or geographic area of the small
8employer or, eligible employes, insured individual or dependents.
SB201,31,109 (c) A small employer An insurer shall provide reasonable compensation to an
10intermediary, if any, for the sale of a basic health benefit plan.
SB201, s. 73 11Section 73. 635.18 (4) of the statutes is amended to read:
SB201,31,1612 635.18 (4) A small employer An insurer may not terminate, fail to renew or
13limit its contract or agreement of representation with an intermediary for any reason
14related to the health status condition, claims experience, occupation or geographic
15location area of the small employers or, eligible employes , insured individuals or
16their dependents placed by the intermediary with the small employer insurer.
SB201, s. 74 17Section 74. 635.18 (5) of the statutes is amended to read:
SB201,31,2118 635.18 (5) A small employer An insurer or an intermediary may not induce or
19otherwise encourage a small an employer to separate or otherwise exclude an
20employe from health coverage or benefits provided in connection with the employe's
21employment.
SB201, s. 75 22Section 75. 635.18 (6) of the statutes is amended to read:
SB201,31,2523 635.18 (6) Denial by a small employer an insurer of an application for coverage
24from a small employer under a health benefit plan subject to this subchapter shall
25be in writing and shall state the reason or reasons for the denial.
SB201, s. 76
1Section 76. 635.18 (7) of the statutes is amended to read:
SB201,32,62 635.18 (7) A 3rd-party administrator that enters into a contract, agreement
3or other arrangement with a small employer an insurer to provide administrative,
4marketing or other services related to the offering of health benefit plans subject to
5this subchapter
to small employers or individuals in this state is subject to this
6subchapter as if it were a small employer an insurer.
SB201, s. 77 7Section 77. 635.18 (8) of the statutes is amended to read:
SB201,32,118 635.18 (8) The commissioner may by rule establish additional standards to
9provide for the fair marketing and broad availability of health benefit plans subject
10to this subchapter
to small employers and individuals in this state, including
11requirements designed to prevent evasion of the purposes of this chapter
.
SB201, s. 78 12Section 78. 635.18 (9), (9m) and (10) of the statutes are created to read:
SB201,32,1613 635.18 (9) An insurer that has in force one or more health benefit plans that
14are included in a category under sub. (1) (a) to (c) and that are subject to this
15subchapter shall actively market and issue health benefit plans in that category, as
16provided in s. 635.15, unless the insurer complies with all of the following:
SB201,32,1817 (a) Files notice with the commissioner that the insurer is ceasing to issue health
18benefit plans in that category.
SB201,32,2019 (b) Except as provided in sub. (9m), ceases to issue health benefit plans in that
20category for not less than 5 years.
SB201,32,2321 (c) Except as provided in sub. (9m), does not commence marketing or issuing
22health benefit plans in that category until the insurer files notice with the
23commissioner that the insurer intends to market and issue such health benefit plans.
SB201,33,2 24(9m) If an insurer ceases to issue health benefit plans in the category under
25sub. (1) (c) but continues to issue health benefit plans in a category under sub. (1) (a)

1or (b), the insurer shall continue to issue individual conversion policies, as provided
2in s. 635.15, and sub. (9) (b) and (c) does not apply to those policies.
SB201,33,5 3(10) An insurer may not cease to actively market or issue health benefit plans
4in all categories under sub. (1) (a) to (c) unless the insurer complies with s. 635.07
5(2).
SB201, s. 79 6Section 79. 635.20 (1) of the statutes is amended to read:
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