SB218: Bill Text

SB218,22,5 (15) "Health insurance" includes health benefit plans but does not include group health plans.

SB218,22,6 (16) "Health maintenance organization" has the meaning given in s. 609.01 (2).

SB218,22,8 (17) "Health status-related factor" means any of the factors listed in s. 635.05 (1) (a).

SB218,22,15 (18) "Insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers health benefit plans covering individuals in this state or eligible employes of one or more employers in this state. The term includes a health maintenance organization, a preferred provider plan, as defined in s. 609.01 (4), an insurer operating as a cooperative association organized under ss. 185.981 to 185.985 and a limited service health organization, as defined in s. 609.01 (3).

SB218,22,21 (19) "Large employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 51 employes on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 51 employes on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 employes on the first day of the plan year.

SB218,22,25 (20) "Large group market" means the health insurance market under which individuals obtain health insurance coverage on behalf of themselves and their dependents, directly or through any arrangement, under a group health benefit plan maintained by a large employer.

SB218,23,4 (21) "Late enrollee" means, with respect to coverage under a group health plan, a self-insured health plan or health insurance coverage, a participant, beneficiary or individual who enrolls under the plan or coverage at any time other than during any of the following:

SB218,23,6 (a) The first period in which the individual is eligible to enroll under the plan or coverage.

SB218,23,7 (b) A special enrollment period under s. 635.03 (7).

SB218,23,9 (22) "Midpoint rate" means the arithmetic average of the base premium rate and the corresponding highest premium rate.

SB218,23,13 (23) "Network plan" means health insurance coverage of an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer.

SB218,23,16 (24) "New business premium rate" means the premium rate charged or offered to employers or individuals with similar case characteristics for newly issued health insurance with the same or similar benefit design characteristics.

SB218,23,21 (25) "Participant" has the meaning given in section 3 (7) of the federal Employee Retirement Income Security Act of 1974. "Participant" includes an individual who is, or may become, eligible to receive a benefit, or whose beneficiaries may be eligible to receive any such benefit, in connection with a group health plan or group health benefit plan if the individual is any of the following:

SB218,23,23 (a) A partner in relation to a partnership and the group health plan or group health benefit plan is maintained by the partnership.

SB218,24,3 (b) A self-employed individual with one or more employes who are participants in the group health plan or group health benefit plan and the group health plan or group health benefit plan is maintained by the self-employed individual.

SB218,24,8 (26) "Placed for adoption" or "placement for adoption" means, with respect to the placement for adoption of a child with a person, the assumption and retention by the person of a legal obligation for the total or partial support of the child in anticipation of the adoption of the child. A child's placement for adoption with a person terminates upon the termination of the person's legal obligation for support.

SB218,24,10 (27) "Plan sponsor" has the meaning given in section 3 (16) (B) of the federal Employee Retirement Income Security Act of 1974.

SB218,24,13 (28) "Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage.

SB218,24,15 (29) "Rating period" means the period, determined by an insurer, during which a premium rate established by the insurer remains in effect.

SB218,24,17 (30) "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.

SB218,24,21 (31) "Short-term insurance" means a temporary individual major medical or accident insurance policy issued for a term of 6 months or less, except that such a policy may be renewed one time at the expiration of the initial term for a term of 6 months or less.

SB218,25,3 (32) "Small employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 2 but not more than 50 employes on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 2 but not more than 50 employes on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 employes on the first day of the plan year.

SB218,25,7 (33) "Small group market" means the health insurance market under which individuals obtain health insurance coverage on behalf of themselves and their dependents, directly or through any arrangement, under a group health benefit plan maintained by, or obtained through, a small employer.

SB218,25,12 (34) "Student-only medical plan" means a limited nonmedically underwritten individual or group health benefit plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate or graduate student at an accredited technical or trade school, college or university and to which any of the following applied at issuance:

SB218,25,13 (a) The student was not insured under a health benefit plan.

SB218,25,16 (b) The student was eligible for coverage under a health benefit plan of his or her parent, stepparent or guardian but was unable to access the full health benefits of the plan due to limitations in the plan's geographic service area.

SB218,25,22 (35) "Waiting period" means, with respect to a group health plan, a self-insured health plan or health insurance coverage and an individual who is a potential participant or beneficiary in the group health plan or self-insured health plan or who is potentially covered by the health insurance coverage, the period that must pass with respect to the individual before the individual is eligible for benefits under the terms of the plan or coverage.

SB218, s. 43 Section 43. 635.03 of the statutes is created to read:

SB218,26,6 635.03 Preexisting conditions, portability, restrictions and special enrollment periods for group plans. (1) (a) Subject to subs. (2) and (3), a self-insured health plan or an insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, 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.

SB218,26,9 (b) A preexisting condition exclusion under par. (a) may not extend beyond 12 months, or 18 months with respect to a late enrollee, after the participant's or beneficiary's enrollment date under the plan.

SB218,26,12 (2) (a) A self-insured health plan or 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.

SB218,26,15 (b) A self-insured health plan or an insurer offering a group health benefit plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition.

SB218,26,19 (c) Subject to par. (e), a self-insured health plan or an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is born.

SB218,27,2 (d) Subject to par. (e), a self-insured health plan or an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is adopted or placed for adoption before attaining the age of 18 years and who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is adopted or placed for adoption. This paragraph does not apply to coverage before the day on which the individual is adopted or placed for adoption.

SB218,27,9 (e) Paragraphs (c) and (d) do not apply to an individual after the end of the first continuous period during which the individual was not covered under any creditable coverage for at least 63 days. For purposes of this paragraph, any waiting period or affiliation period for coverage under a group health plan, group health benefit plan or self-insured health plan shall not be taken into account in determining the period before enrollment in the group health plan, group health benefit plan or self-insured health plan.

SB218,27,13 (3) (a) The length of time during which any preexisting condition exclusion under sub. (1) may be imposed shall be reduced by the aggregate of the participant's or beneficiary's periods of creditable coverage on his or her enrollment date under the group health benefit plan or self-insured health plan.

SB218,27,22 (b) With respect to enrollment of an individual under a group health plan, group health benefit plan or self-insured health plan, a period of creditable coverage after which the individual was not covered under any creditable coverage for a period of at least 63 days before enrollment in the group health plan, group health benefit plan or self-insured health plan may not be counted. For purposes of this paragraph, any waiting period or affiliation period for coverage under the group health plan, group health benefit plan or self-insured health plan shall not be taken into account in determining the period before enrollment in the group health plan, group health benefit plan or self-insured health plan.

SB218,28,3 (c) No period of creditable coverage before July 1, 1996, may be counted. Individuals who need to establish creditable coverage for periods before July 1, 1996, and who would have such coverage but for this paragraph may be given credit for creditable coverage for such periods through the presentation of documents or other means provided by the federal secretary of health and human services, consistent with section 104 of P.L. 104-191.

SB218,28,6 (d) 1. A self-insured health plan or an insurer offering a group health benefit plan shall count a period of creditable coverage without regard to the specific benefits for which the individual had coverage during the period.

SB218,28,13 2. Notwithstanding subd. 1., an insurer offering a group health benefit plan may elect to apply par. (a) on the basis of coverage of benefits within each of several classes or categories of benefits specified in regulations issued by the federal department of health and human services under P.L. 104-191. The election shall be made on a uniform basis for all participants and beneficiaries. Under the election, an insurer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within the class or category.

SB218,28,17 3. An insurer that makes an election under subd. 2. shall prominently state in any disclosure statements concerning the coverage offered, and to each employer at the time of the offer or sale of coverage, that the insurer has made the election and what the effect of the election is.

SB218,28,20 (e) Periods of creditable coverage shall be established through the presentation of certifications described in sub. (4) or in any other manner specified in regulations issued by the federal department of health and human services under P.L. 104-191.

SB218,28,23 (4) (a) On and after October 1, 1996, an insurer that provides health benefit plan coverage shall provide the certification described in par. (b) upon the happening of any of the following events:

SB218,29,3 1. An individual ceases to be covered under the health benefit plan or otherwise becomes covered under a federal continuation provision. The certification required under this subdivision may be provided, to the extent practicable, at a time consistent with notices required under any applicable federal continuation provision or s. 632.897.

SB218,29,4 2. An individual ceases to be covered under a federal continuation provision.

SB218,29,7 3. Upon the request of an individual that is made not later than 24 months after the date of the cessation of the individual's coverage under subd. 1. or 2., whichever is later.

SB218,29,9 (b) The certification required under this subsection shall be a written certification that includes all of the following information:

SB218,29,11 1. The period of creditable coverage of the individual under the health benefit plan and the coverage, if any, under the federal continuation provision.

SB218,29,13 2. The waiting period, if any, or affiliation period, if any, imposed with respect to the individual for coverage under the health benefit plan.

SB218,29,17 (c) Upon the happening after June 30, 1996, and before October 1, 1996, of an event described in par. (a) 1. to 3., an insurer providing health benefit plan coverage shall provide a certification described in par. (b) if the individual with respect to whom the certification is provided requests the certification in writing.

SB218,29,20 (d) If an individual seeks to establish creditable coverage with respect to a period for which a certification is not required because of the happening of an event described in par. (a) 1. to 3. before July 1, 1996, all of the following apply:

SB218,29,22 1. The individual may present other credible evidence of the coverage in order to establish the period of creditable coverage.

SB218,30,2 2. An insurer may not be subject to any penalty or enforcement action with respect to the crediting or not crediting of the individual's coverage under subd. 1. if the insurer has sought to comply in good faith with any applicable requirements under this subsection.

SB218,30,9 (5) (a) If an insurer that made an election under sub. (3) (d) 2. enrolls an individual for coverage under a group health benefit plan and the individual provides a certification under sub. (4), upon the request of that insurer or the group health benefit plan the insurer that issued the certification shall promptly disclose to the requesting insurer or group health benefit plan information on coverage of classes or categories of health benefits available under the coverage on which the certification was based.

SB218,30,11 (b) The insurer providing the information may charge the requesting insurer or plan for the reasonable cost of disclosing the information.

SB218,30,14 (c) An insurer providing information under this subsection shall comply with regulations issued by the federal department of health and human services under section 2701 (e) (3) of P.L. 104-191.

SB218,30,20 (6) A self-insured health plan or an insurer offering a group health benefit plan shall permit an employe who is not enrolled but who is eligible for coverage under the terms of the self-insured health plan or group health benefit plan, or a participant's or employe's dependent who is not enrolled but who is eligible for coverage under the terms of the self-insured health plan or group health benefit plan, to enroll for coverage under the terms of the plan if all of the following apply:

SB218,30,23 (a) The employe or dependent was covered under a group health plan or self-insured health plan or had health insurance coverage at the time coverage was previously offered to the employe or dependent.

SB218,31,6 (b) The employe or participant stated in writing at the time coverage was previously offered that coverage under a group health plan, self-insured health plan or health insurance coverage was the reason for declining enrollment under the self-insured health plan or insurer's group health benefit plan. This paragraph applies only if the self-insured health plan or insurer required such a statement at the time coverage was previously offered and provided the employe or participant, at the time coverage was previously offered, with notice of the requirement and the consequences of the requirement.

SB218,31,11 (c) The employe or dependent is currently covered under the group health plan, self-insured health plan or health insurance or, under the terms of the self-insured health plan or group health benefit plan, the employe or participant requests enrollment no later than 30 days after the date on which the coverage under par. (a) is exhausted or terminated.

SB218,31,14 (7) (a) If par. (b) applies, a self-insured health plan or an insurer offering a group health benefit plan shall provide for a special enrollment period during which any of the following may occur:

SB218,31,16 1. A person who marries an individual and who is otherwise eligible for coverage may be enrolled under the plan as a dependent of the individual.

SB218,31,18 2. A person who is born to, adopted by or placed for adoption with, an individual may be enrolled under the plan as a dependent of the individual.

SB218,31,22 3. An individual who has met any waiting period applicable to becoming a participant under the plan, who is eligible to be enrolled under the plan and who failed to enroll during a previous enrollment period or such an individual's spouse, or both, may be enrolled under the plan.

SB218,31,24 (b) A self-insured health plan or an insurer under par. (a) is required to provide for a special enrollment period if all of the following apply:

SB218,32,2 1. The self-insured health plan or group health benefit plan makes coverage available for dependents of participants under the plan.

SB218,32,5 2. The individual is a participant under the plan, or the individual has met any waiting period applicable to becoming a participant under the plan and is eligible to be enrolled under the plan but failed to enroll during a previous enrollment period.

SB218,32,7 3. A person becomes a dependent of the individual through marriage, birth, adoption or placement for adoption.

SB218,32,9 (c) A special enrollment period provided for under this subsection shall be for a period of not less than 30 days and shall begin on the later of either of the following:

SB218,32,11 1. The date dependent coverage is made available under the self-insured health plan or group health benefit plan.

SB218,32,13 2. The date of the marriage, birth, adoption or placement for adoption described in par. (a), whichever is applicable.

SB218,32,16 (d) If an individual seeks to enroll a dependent during the first 30 days of a special enrollment period, the coverage of the dependent shall become effective on the following date:

SB218,32,19 1. If the person becomes a dependent through marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received.

SB218,32,20 2. If the person becomes a dependent through birth, as of the date of birth.

SB218,32,22 3. If the person becomes a dependent through adoption or placement for adoption, the date of the adoption or placement for adoption.

SB218,33,2 (8) (a) A health maintenance organization that offers a group health benefit plan and that does not impose any preexisting condition exclusion under sub. (1) with respect to a particular coverage option may impose an affiliation period for that coverage option, but only if all of the following apply:

SB218,33,4 1. The affiliation period is applied uniformly without regard to any health status-related factors.

SB218,33,6 2. The affiliation period does not exceed 2 months, or 3 months with respect to a late enrollee.

SB218,33,12 (b) A health maintenance organization that imposes an affiliation period under this subsection is not required to provide health care services or benefits during the affiliation period. A health maintenance organization may not charge a premium to a participant or beneficiary for any coverage that is provided during an affiliation period. An affiliation period shall begin on the enrollment date and run concurrently with any waiting period under the group health benefit plan.

SB218,33,15 (c) A health maintenance organization under par. (a) may use methods other than those described in par. (a) to address adverse selection, if the methods are approved by the commissioner.

SB218,33,20 (9) (a) Except as provided in pars. (b) and (c), requirements used by an insurer in determining whether to provide coverage under a group health benefit plan to an employer, including requirements for minimum participation of eligible employes and minimum employer contributions, shall be applied uniformly among all employers that apply for or receive coverage from the insurer.

SB218,33,23 (b) An insurer may vary its minimum participation requirements and minimum employer contribution requirements only by the size of the employer group based on the number of eligible employes.

SB218,34,2 (c) An insurer may vary requirements used by the insurer in determining whether to provide coverage under a group health benefit plan to a large employer, but only if the requirements are applied uniformly among all large employers that have the same number of eligible employes.

SB218,34,8 (d) In applying minimum participation requirements with respect to an employer, an insurer may not count eligible employes who have other coverage that is creditable coverage in determining whether the applicable percentage of participation is met, except that an insurer may count eligible employes who have coverage under another health benefit plan that is sponsored by that employer and that is creditable coverage.

SB218,34,11 (e) An insurer may not increase a requirement for minimum employe participation or a requirement for minimum employer contribution that applies to an employer after the employer has been accepted for coverage.

SB218,34,13 (f) This subsection does not apply to a group health benefit plan offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).

SB218,34,19 (10) (a) 1. Except as provided in rules promulgated under subd. 3., if an insurer offers a group health benefit plan to an employer, the insurer shall offer coverage to all of the eligible employes of the employer and their dependents. Except as provided in rules promulgated under subd. 3., an insurer may not offer coverage to only certain individuals in 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.

SB218,35,2 2. Except as provided in rules promulgated under subd. 3., if the state or a county, city, village, town or school district offers coverage under a self-insured health plan, it shall offer coverage to all of its eligible employes and their dependents. Except as provided in rules promulgated under subd. 3., the state or a county, city, village, town or school district may not offer coverage to only certain individuals in the 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.

SB218,35,9 3. The secretary of employe trust funds, with the approval of the group insurance board, shall promulgate rules related to offering coverage to eligible employes under a group health benefit plan, or a self-insured health plan, offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7). The rules shall conform to the intent of subds. 1. and 2. and may not allow the state or the group insurance board to refuse to offer coverage to an eligible employe or dependent for reasons related to health condition.