SB201: Bill Text

SB201,22,25 (2) Individual health benefit plans. Except as provided in sub. (3) and notwithstanding s. 632.897 (4) (d), an insurer shall provide coverage under an individual health benefit plan subject to this subchapter to an individual who is a resident of this state, and to the individual's dependents, regardless of health condition or claims experience, if all of the following apply:

SB201,23,2 (a) The insurer has in force a health benefit plan that is subject to this subchapter.

SB201,23,4 (b) The individual agrees to pay the premium required for coverage under the individual health benefit plan.

SB201,23,7 (c) The individual agrees to comply with all other provisions of the individual health benefit plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

SB201,23,12 (3) Exceptions to guaranteed issue. (a) An insurer that is otherwise required to provide coverage under sub. (1) may refuse to issue a group health benefit plan to an employer if all of the individuals in the employer group that are to be covered under the group health benefit plan may be covered under an individual health benefit plan providing single or family coverage.

SB201,23,16 (b) An insurer that is otherwise required to provide coverage under sub. (2) may refuse to provide coverage to an individual if the individual was excluded from coverage under an employer's health benefit plan or self-funded health care plan for reasons related to the individual's health condition.

SB201,23,20 (c) An insurer that is otherwise required to provide coverage under sub. (2) may refuse to provide coverage to an individual if the individual waived coverage under an employer's health benefit plan or self-funded health care plan for reasons related to the individual's health condition.

SB201,23,22 (d) 1. In this paragraph, "municipal" means county, city, village, town or school district.

SB201,24,2 2. Subsections (1) and (2) do not require an insurer to issue coverage that the insurer is not authorized to issue under its bylaws, charter or certificate of incorporation or authority if the insurer is authorized under its bylaws, charter or certificate of incorporation or authority to issue coverage only to state or municipal employes and former employes and their dependents.

SB201,24,6 (e) An insurer that offers health care coverage exclusively to a single category or limited categories of employers may, with prior approval of the commissioner, limit its compliance with subs. (1) and (2) to that single category or those limited categories of employers.

SB201,24,8 (f) The commissioner may exempt an insurer from the requirements of sub. (1) or (2) if the commissioner determines that any of the following applies:

SB201,24,10 1. It is inequitable to apply sub. (1) or (2) to the insurer due to its disproportionate share of groups or individuals with high claims experience.

SB201,24,12 2. It is in the public interest to exempt the insurer from the requirements under sub. (1) or (2) because the insurer is in financially hazardous condition.

SB201,24,14 (g) An insurer may limit its issuance of health benefit plans under subs. (1) and (2) to any of the following:

SB201,24,16 1. Group health benefit plans, and related individual conversion policies, to small employer groups.

SB201,24,18 2. Group health benefit plans, and related individual conversion policies, to employer groups that are not small employer groups.

SB201,24,19 3. Individual health benefit plans.

SB201, s. 54 Section 54. 635.17 (title) of the statutes is amended to read:

SB201,24,22 635.17 (title) Coverage requirements for small employer health benefit plans.

SB201, s. 55 Section 55. 635.17 (1) (a) (intro.) of the statutes is amended to read:

SB201,25,3 635.17 (1) (a) (intro.) A group or individual health benefit plan subject to this subchapter may not deny, exclude or limit benefits for a covered individual for losses incurred more than 12 months after the effective date of the individual's coverage due to a preexisting condition. Such a health benefit plan may not define a preexisting condition more restrictively than any of the following:

SB201, s. 56 Section 56. 635.17 (1) (a) 1. of the statutes is renumbered 635.17 (1) (a) 1. a. and amended to read:

SB201,25,10 635.17 (1) (a) 1. a. A With respect to a group health benefit plan, a condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 6 months immediately preceding the effective date of coverage and for which the individual did not seek medical advice, diagnosis, care or treatment.

SB201, s. 57 Section 57. 635.17 (1) (a) 1. b. of the statutes is created to read:

SB201,25,16 635.17 (1) (a) 1. b. With respect to an individual health benefit plan, a condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 12 months immediately preceding the effective date of coverage and for which the individual did not seek medical advice, diagnosis, care or treatment.

SB201, s. 58 Section 58. 635.17 (1) (a) 2. of the statutes is renumbered 635.17 (1) (a) 2. a. and amended to read:

SB201,25,21 635.17 (1) (a) 2. a. A With respect to a group health benefit plan, a condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of coverage.

SB201, s. 59 Section 59. 635.17 (1) (a) 2. b. of the statutes is created to read:

SB201,25,25 635.17 (1) (a) 2. b. With respect to an individual health benefit plan, a condition for which medical advice, diagnosis, care or treatment was recommended or received during the 12 months immediately preceding the effective date of coverage.

SB201, s. 60 Section 60. 635.17 (1) (a) 3. of the statutes is amended to read:

SB201,26,7 635.17 (1) (a) 3. A With respect to a group or individual health benefit plan, a pregnancy existing on the effective date of coverage, except that coverage may not be excluded for any covered prenatal care expenses related to such a pregnancy or for other covered expenses related to such a pregnancy that exceed the deductible amount prescribed by the commissioner under par. (ac). Coverage not excluded may be subject to any deductibles or copayments that apply generally under the policy.

SB201, s. 61 Section 61. 635.17 (1) (ac) of the statutes is created to read:

SB201,26,15 635.17 (1) (ac) The commissioner shall by rule prescribe a separate deductible for covered expenses related to a pregnancy existing on the effective date of coverage, excluding covered prenatal care expenses. The rule shall provide for a sliding scale deductible that does not exceed $5,000 and that is determined on the basis of the stage of the pregnancy on the effective date of the coverage, so that the deductible is lower if coverage is obtained early in the pregnancy and higher if coverage is obtained late in the pregnancy.

SB201, s. 62 Section 62. 635.17 (1) (am) of the statutes is created to read:

SB201,26,22 635.17 (1) (am) Notwithstanding par. (a), an insurer shall provide coverage under an individual or group health benefit plan subject to this subchapter to an individual who has been a resident of this state for at least 6 months or to an eligible employe who has satisfied any waiting period imposed by his or her employer, and the dependents of the individual or eligible employe, without a preexisting condition exclusion or limitation if the individual or eligible employe applies for coverage:

SB201,26,24 1. During a 30-day enrollment period specified by the commissioner by rule under par. (ar).

SB201,26,25 2. Within 30 days after the later of the following:

SB201,27,1 a. The date on which the individual or employe becomes 18 years of age.

SB201,27,3 b. The date on which the individual's or employe's coverage as a dependent under a health benefit plan ceases.

SB201, s. 63 Section 63. 635.17 (1) (ar) of the statutes is created to read:

SB201,27,9 635.17 (1) (ar) The commissioner shall by rule specify a biennial 30-day enrollment period during which an individual or an eligible employe, and the dependents of the individual or eligible employe, may obtain coverage under par. (am) under a group or individual health benefit plan subject to this subchapter without any preexisting condition exclusion or limitation.

SB201, s. 64 Section 64. 635.17 (1) (b) 1. and 2. of the statutes are amended to read:

SB201,27,16 635.17 (1) (b) 1. A group or individual health benefit plan subject to this subchapter shall waive any period applicable to a preexisting condition exclusion or limitation period with respect to particular services for the period that an individual was previously covered by qualifying coverage that provided benefits with respect to such services, if the qualifying coverage was continuous to a date not less than 30 terminated not more than 60 days before the effective date of the new coverage.

SB201,27,23 2. Subdivision 1. does not prohibit the application of a waiting period to all new enrollees under the a health benefit plan issued to an employer; however, a waiting period may not be counted when determining whether the qualifying coverage was continuous to a date not less than 30 terminated not more than 60 days before the effective date of the new coverage. For the purpose of subd. 1., the new coverage shall be considered effective as of the date that it would be effective but for the waiting period.

SB201, s. 65 Section 65. 635.17 (1) (b) 3. of the statutes is repealed.

SB201, s. 66 Section 66. 635.17 (1) (c) of the statutes is created to read:

SB201,28,2 635.17 (1) (c) This subsection does not apply to a conversion health insurance policy, which is subject to s. 632.897 (4) (a).

SB201, s. 67 Section 67. 635.17 (2) of the statutes is amended to read:

SB201,28,9 635.17 (2) Minimum participation of employes. (a) Except as provided in par. (d), requirements used by a small employer an insurer in determining whether to provide coverage to a small an employer, including requirements for minimum participation of eligible employes and minimum employer contributions, shall be applied uniformly among all small employers that apply for or receive coverage from the small employer insurer and that have the same number of eligible employes.

SB201,28,12 (b) A small employer An insurer may vary its minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group.

SB201,28,17 (c) 1. Except as provided in subd. 2., in applying minimum participation requirements with respect to a small an employer, a small employer an insurer may not count eligible employes or their dependents who have other coverage that is qualifying coverage in determining whether the applicable percentage of participation is met.

SB201,28,22 2. If a small an employer has 10 or fewer eligible employes, a small employer an insurer may count eligible employes or their dependents who have coverage under another health benefit plan sponsored by that small employer in applying minimum participation requirements to determine whether the applicable percentage of participation is met.

SB201,29,2 (d) A small employer An insurer may not increase a requirement for minimum employe participation or a requirement for minimum employer contribution that applies to a small an employer after the small employer has been accepted for coverage.

SB201, s. 68 Section 68. 635.17 (3) of the statutes is amended to read:

SB201,29,9 635.17 (3) Prohibited coverage practices. (a) If a small employer an insurer offers coverage to a small an employer, the small employer insurer shall offer coverage to all of the eligible employes of the small employer and their dependents. A small employer An insurer may not offer coverage to only certain individuals in a small an employer group or to only part of the group, except for an eligible employe who has not yet satisfied an applicable waiting period, if any.

SB201,29,14 (b) A small employer An insurer may not modify a health benefit plan subject to this subchapter with respect to a small an employer or an eligible employe or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the health benefit plan.

SB201, s. 69 Section 69. 635.18 (1) of the statutes is renumbered 635.18 (1) (intro.) and amended to read:

SB201,30,2 635.18 (1) (intro.) Every small employer insurer that provides coverage under a health benefit plan subject to this subchapter shall actively market such health benefit plan coverage, including basic health benefit plans, to small employers in the state. If a small employer insurer denies coverage to a small employer under a health benefit plan that is not a basic health benefit plan on the basis of the health status or claims experience of the small employer or its eligible employes or their dependents, the small employer insurer shall offer the small employer the opportunity to purchase a basic health benefit plan. In addition to other marketing limitations that the commissioner may authorize by rule, an insurer may limit its marketing under this subsection to any of the following:

SB201, s. 70 Section 70. 635.18 (1) (a) to (c) of the statutes are created to read:

SB201,30,4 635.18 (1) (a) Health benefit plans for small employer groups of all sizes.

SB201,30,6 (b) Health benefit plans for employer groups of all sizes that are not small employer groups.

SB201,30,7 (c) Health benefit plans for individuals.

SB201, s. 71 Section 71. 635.18 (2) of the statutes is amended to read:

SB201,30,10 635.18 (2) (a) Except as provided in par. (b), a small employer an insurer or an intermediary may not, directly or indirectly, do any of the following:

SB201,30,14 1. Discourage a small an employer or an individual from applying, or direct a small an employer or an individual not to apply, for coverage with the small employer insurer because of the health status condition, claims experience, industry, occupation or geographic location area of the small employer or individual.

SB201,30,17 2. Encourage or direct a small an employer or an individual to seek coverage from another insurer because of the health status condition, claims experience, industry, occupation or geographic location area of the small employer or individual.

SB201,30,21 (b) Paragraph (a) does not prohibit a small employer an insurer or an intermediary from providing a small an employer or an individual with information about an established geographic service area or a restricted network provision of the small employer insurer.

SB201, s. 72 Section 72. 635.18 (3) of the statutes is amended to read:

SB201,31,4 635.18 (3) (a) Except as provided in par. (b), a small employer an insurer may not, directly or indirectly, enter into any contract, agreement or arrangement with an intermediary that provides for or results in compensation to an the intermediary for the sale of a health benefit plan subject to this subchapter that varies according to the health status condition, claims experience, industry, occupation or geographic location area of the small employer or, eligible employes, insured individual or dependents.

SB201,31,8 (b) Payment of compensation on the basis of percentage of premium is not a violation of par. (a) if the percentage does not vary based on the health status condition, claims experience, industry, occupation or geographic area of the small employer or, eligible employes, insured individual or dependents.

SB201,31,10 (c) A small employer An insurer shall provide reasonable compensation to an intermediary, if any, for the sale of a basic health benefit plan.

SB201, s. 73 Section 73. 635.18 (4) of the statutes is amended to read:

SB201,31,16 635.18 (4) A small employer An insurer may not terminate, fail to renew or limit its contract or agreement of representation with an intermediary for any reason related to the health status condition, claims experience, occupation or geographic location area of the small employers or, eligible employes , insured individuals or their dependents placed by the intermediary with the small employer insurer.

SB201, s. 74 Section 74. 635.18 (5) of the statutes is amended to read:

SB201,31,21 635.18 (5) A small employer An insurer or an intermediary may not induce or otherwise encourage a small an employer to separate or otherwise exclude an employe from health coverage or benefits provided in connection with the employe's employment.

SB201, s. 75 Section 75. 635.18 (6) of the statutes is amended to read:

SB201,31,25 635.18 (6) Denial by a small employer an insurer of an application for coverage from a small employer under a health benefit plan subject to this subchapter shall be in writing and shall state the reason or reasons for the denial.

SB201, s. 76 Section 76. 635.18 (7) of the statutes is amended to read:

SB201,32,6 635.18 (7) A 3rd-party administrator that enters into a contract, agreement or other arrangement with a small employer an insurer to provide administrative, marketing or other services related to the offering of health benefit plans subject to this subchapter to small employers or individuals in this state is subject to this subchapter as if it were a small employer an insurer.

SB201, s. 77 Section 77. 635.18 (8) of the statutes is amended to read:

SB201,32,11 635.18 (8) The commissioner may by rule establish additional standards to provide for the fair marketing and broad availability of health benefit plans subject to this subchapter to small employers and individuals in this state, including requirements designed to prevent evasion of the purposes of this chapter.

SB201, s. 78 Section 78. 635.18 (9), (9m) and (10) of the statutes are created to read:

SB201,32,16 635.18 (9) An insurer that has in force one or more health benefit plans that are included in a category under sub. (1) (a) to (c) and that are subject to this subchapter shall actively market and issue health benefit plans in that category, as provided in s. 635.15, unless the insurer complies with all of the following:

SB201,32,18 (a) Files notice with the commissioner that the insurer is ceasing to issue health benefit plans in that category.

SB201,32,20 (b) Except as provided in sub. (9m), ceases to issue health benefit plans in that category for not less than 5 years.

SB201,32,23 (c) Except as provided in sub. (9m), does not commence marketing or issuing health benefit plans in that category until the insurer files notice with the commissioner that the insurer intends to market and issue such health benefit plans.

SB201,33,2 (9m) If an insurer ceases to issue health benefit plans in the category under sub. (1) (c) but continues to issue health benefit plans in a category under sub. (1) (a) or (b), the insurer shall continue to issue individual conversion policies, as provided in s. 635.15, and sub. (9) (b) and (c) does not apply to those policies.

SB201,33,5 (10) An insurer may not cease to actively market or issue health benefit plans in all categories under sub. (1) (a) to (c) unless the insurer complies with s. 635.07 (2).

SB201, s. 79 Section 79. 635.20 (1) of the statutes is amended to read: