SB201: Bill Text

SB201,20,6 (d) The small employer insurer does not transfer or otherwise provide coverage to a small employer policyholder from the nonrenewed class of business unless the small employer insurer offers to transfer or provide coverage to all affected small employers policyholders from the nonrenewed class of business without regard to case characteristics, claim claims experience, health status condition or duration of coverage.

SB201, s. 47 Section 47. 635.07 (3) of the statutes is amended to read:

SB201,20,10 635.07 (3) This section does not apply to a health benefit plan or policy subject to this subchapter if the small employer insurer that issued the policy health benefit plan is in liquidation.

SB201, s. 48 Section 48. 635.09 of the statutes is repealed.

SB201, s. 49 Section 49. 635.11 (intro.), (1) and (4) of the statutes are amended to read:

SB201,20,16 635.11 Disclosure of rating factors and renewability provisions. (intro.) Before the sale of a health benefit plan or policy subject to this subchapter, a small employer an insurer shall disclose to a small employer an applicant all of the following:

SB201,20,18 (1) The small employer insurer's right to increase premium rates and the factors limiting the amount of increase.

SB201,20,19 (4) The small employer's A policyholder's renewability rights.

SB201, s. 50 Section 50. 635.13 (1) of the statutes is amended to read:

SB201,20,25 635.13 (1) Records. A small employer insurer shall maintain at its principal place of business complete and detailed records relating to its rating methods and practices and its renewal underwriting methods and practices, and shall make the records available to the commissioner and the small employer insurance or the board upon request.

SB201, s. 51 Section 51. 635.13 (1) of the statutes, as affected by 1995 Wisconsin Act .... (this act), is repealed and recreated to read:

SB201,21,6 635.13 (1) Records. An insurer shall maintain at its principal place of business complete and detailed records relating to its rating methods and practices and its renewal underwriting methods and practices, and shall make the records available to the commissioner or the board upon request.

SB201, s. 52 Section 52. 635.13 (2) of the statutes is amended to read:

SB201,21,10 635.13 (2) Certification. A small employer An insurer shall file with the commissioner on or before May 1 annually an actuarial opinion by a member of the American academy of actuaries certifying all of the following:

SB201,21,12 (a) That the small employer insurer is in compliance with the rate provisions of s. 635.05 and any rules promulgated under s. 635.06.

SB201,21,14 (b) That the small employer insurer's rating methods are based on generally accepted and sound actuarial principles, policies and procedures.

SB201,21,18 (c) That the opinion is based on the actuary's examination of the small employer insurer's records and a review of the small employer insurer's actuarial assumptions and statistical methods used in setting rates and procedures used in implementing rating plans.

SB201, s. 53 Section 53. 635.15 of the statutes is repealed and recreated to read:

SB201,21,24 635.15 Guaranteed issue. (1) Group health benefit plans. (a) Except as provided in sub. (3), an insurer shall provide coverage under a group health benefit plan that is subject to this subchapter to an employer and to all of the employer's eligible employes and their dependents, regardless of health condition or claims experience, if all of the following apply:

SB201,22,2 1. The insurer has in force a health benefit plan that is subject to this subchapter.

SB201,22,4 2. The employer agrees to pay the premium required for coverage under the group health benefit plan.

SB201,22,7 3. The employer agrees to comply with all other provisions of the group health benefit plan that apply generally to a policyholder or an insured without regard to health condition or claims experience.

SB201,22,10 (b) An insurer shall provide coverage under a group health benefit plan that is subject to this subchapter to all of the following, regardless of health condition or claims experience:

SB201,22,12 1. An eligible employe who becomes eligible for coverage after the commencement of the employer's coverage, and the eligible employe's dependents.

SB201,22,16 2. An eligible employe who was excluded from coverage, including an eligible employe with coverage under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619 on or before the effective date of this subdivision .... [revisor inserts date], and the eligible employe's dependents.

SB201,22,20 3. An eligible employe's dependent who was excluded from coverage, including an eligible employe's dependent with coverage under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619 on or before the effective date of this subdivision .... [revisor inserts date].

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: