SB218,25,1614 (b) The student was eligible for coverage under a health benefit plan of his or
15her parent, stepparent or guardian but was unable to access the full health benefits
16of the plan due to limitations in the plan's geographic service area.
SB218,25,22 17(35) "Waiting period" means, with respect to a group health plan, a
18self-insured health plan or health insurance coverage and an individual who is a
19potential participant or beneficiary in the group health plan or self-insured health
20plan or who is potentially covered by the health insurance coverage, the period that
21must pass with respect to the individual before the individual is eligible for benefits
22under the terms of the plan or coverage.
SB218, s. 43 23Section 43. 635.03 of the statutes is created to read:
SB218,26,6 24635.03 Preexisting conditions, portability, restrictions and special
25enrollment periods for group plans.
(1) (a) Subject to subs. (2) and (3), a

1self-insured health plan or an insurer that offers a group health benefit plan may,
2with respect to a participant or beneficiary under the plan, impose a preexisting
3condition exclusion only if the exclusion relates to a condition, whether physical or
4mental, regardless of the cause of the condition, for which medical advice, diagnosis,
5care or treatment was recommended or received within the 6-month period ending
6on the participant's or beneficiary's enrollment date under the plan.
SB218,26,97 (b) A preexisting condition exclusion under par. (a) may not extend beyond 12
8months, or 18 months with respect to a late enrollee, after the participant's or
9beneficiary's enrollment date under the plan.
SB218,26,12 10(2) (a) A self-insured health plan or an insurer offering a group health benefit
11plan may not treat genetic information as a preexisting condition under sub. (1)
12without a diagnosis of a condition related to the information.
SB218,26,1513 (b) A self-insured health plan or an insurer offering a group health benefit plan
14may not impose a preexisting condition exclusion relating to pregnancy as a
15preexisting condition.
SB218,26,1916 (c) Subject to par. (e), a self-insured health plan or an insurer offering a group
17health benefit plan may not impose a preexisting condition exclusion with respect to
18an individual who is covered under creditable coverage on the last day of the 30-day
19period beginning with the day on which the individual is born.
SB218,27,220 (d) Subject to par. (e), a self-insured health plan or an insurer offering a group
21health benefit plan may not impose a preexisting condition exclusion with respect to
22an individual who is adopted or placed for adoption before attaining the age of 18
23years and who is covered under creditable coverage on the last day of the 30-day
24period beginning with the day on which the individual is adopted or placed for

1adoption. This paragraph does not apply to coverage before the day on which the
2individual is adopted or placed for adoption.
SB218,27,93 (e) Paragraphs (c) and (d) do not apply to an individual after the end of the first
4continuous period during which the individual was not covered under any creditable
5coverage for at least 63 days. For purposes of this paragraph, any waiting period or
6affiliation period for coverage under a group health plan, group health benefit plan
7or self-insured health plan shall not be taken into account in determining the period
8before enrollment in the group health plan, group health benefit plan or self-insured
9health plan.
SB218,27,13 10(3) (a) The length of time during which any preexisting condition exclusion
11under sub. (1) may be imposed shall be reduced by the aggregate of the participant's
12or beneficiary's periods of creditable coverage on his or her enrollment date under the
13group health benefit plan or self-insured health plan.
SB218,27,2214 (b) With respect to enrollment of an individual under a group health plan,
15group health benefit plan or self-insured health plan, a period of creditable coverage
16after which the individual was not covered under any creditable coverage for a period
17of at least 63 days before enrollment in the group health plan, group health benefit
18plan or self-insured health plan may not be counted. For purposes of this paragraph,
19any waiting period or affiliation period for coverage under the group health plan,
20group health benefit plan or self-insured health plan shall not be taken into account
21in determining the period before enrollment in the group health plan, group health
22benefit plan or self-insured health plan.
SB218,28,323 (c) No period of creditable coverage before July 1, 1996, may be counted.
24Individuals who need to establish creditable coverage for periods before July 1, 1996,
25and who would have such coverage but for this paragraph may be given credit for

1creditable coverage for such periods through the presentation of documents or other
2means provided by the federal secretary of health and human services, consistent
3with section 104 of P.L. 104-191.
SB218,28,64 (d) 1. A self-insured health plan or an insurer offering a group health benefit
5plan shall count a period of creditable coverage without regard to the specific benefits
6for which the individual had coverage during the period.
SB218,28,137 2. Notwithstanding subd. 1., an insurer offering a group health benefit plan
8may elect to apply par. (a) on the basis of coverage of benefits within each of several
9classes or categories of benefits specified in regulations issued by the federal
10department of health and human services under P.L. 104-191. The election shall be
11made on a uniform basis for all participants and beneficiaries. Under the election,
12an insurer shall count a period of creditable coverage with respect to any class or
13category of benefits if any level of benefits is covered within the class or category.
SB218,28,1714 3. An insurer that makes an election under subd. 2. shall prominently state in
15any disclosure statements concerning the coverage offered, and to each employer at
16the time of the offer or sale of coverage, that the insurer has made the election and
17what the effect of the election is.
SB218,28,2018 (e) Periods of creditable coverage shall be established through the presentation
19of certifications described in sub. (4) or in any other manner specified in regulations
20issued by the federal department of health and human services under P.L. 104-191.
SB218,28,23 21(4) (a) On and after October 1, 1996, an insurer that provides health benefit
22plan coverage shall provide the certification described in par. (b) upon the happening
23of any of the following events:
SB218,29,324 1. An individual ceases to be covered under the health benefit plan or otherwise
25becomes covered under a federal continuation provision. The certification required

1under this subdivision may be provided, to the extent practicable, at a time
2consistent with notices required under any applicable federal continuation provision
3or s. 632.897.
SB218,29,44 2. An individual ceases to be covered under a federal continuation provision.
SB218,29,75 3. Upon the request of an individual that is made not later than 24 months after
6the date of the cessation of the individual's coverage under subd. 1. or 2., whichever
7is later.
SB218,29,98 (b) The certification required under this subsection shall be a written
9certification that includes all of the following information:
SB218,29,1110 1. The period of creditable coverage of the individual under the health benefit
11plan and the coverage, if any, under the federal continuation provision.
SB218,29,1312 2. The waiting period, if any, or affiliation period, if any, imposed with respect
13to the individual for coverage under the health benefit plan.
SB218,29,1714 (c) Upon the happening after June 30, 1996, and before October 1, 1996, of an
15event described in par. (a) 1. to 3., an insurer providing health benefit plan coverage
16shall provide a certification described in par. (b) if the individual with respect to
17whom the certification is provided requests the certification in writing.
SB218,29,2018 (d) If an individual seeks to establish creditable coverage with respect to a
19period for which a certification is not required because of the happening of an event
20described in par. (a) 1. to 3. before July 1, 1996, all of the following apply:
SB218,29,2221 1. The individual may present other credible evidence of the coverage in order
22to establish the period of creditable coverage.
SB218,30,223 2. An insurer may not be subject to any penalty or enforcement action with
24respect to the crediting or not crediting of the individual's coverage under subd. 1.

1if the insurer has sought to comply in good faith with any applicable requirements
2under this subsection.
SB218,30,9 3(5) (a) If an insurer that made an election under sub. (3) (d) 2. enrolls an
4individual for coverage under a group health benefit plan and the individual provides
5a certification under sub. (4), upon the request of that insurer or the group health
6benefit plan the insurer that issued the certification shall promptly disclose to the
7requesting insurer or group health benefit plan information on coverage of classes
8or categories of health benefits available under the coverage on which the
9certification was based.
SB218,30,1110 (b) The insurer providing the information may charge the requesting insurer
11or plan for the reasonable cost of disclosing the information.
SB218,30,1412 (c) An insurer providing information under this subsection shall comply with
13regulations issued by the federal department of health and human services under
14section 2701 (e) (3) of P.L. 104-191.
SB218,30,20 15(6) A self-insured health plan or an insurer offering a group health benefit plan
16shall permit an employe who is not enrolled but who is eligible for coverage under
17the terms of the self-insured health plan or group health benefit plan, or a
18participant's or employe's dependent who is not enrolled but who is eligible for
19coverage under the terms of the self-insured health plan or group health benefit
20plan, to enroll for coverage under the terms of the plan if all of the following apply:
SB218,30,2321 (a) The employe or dependent was covered under a group health plan or
22self-insured health plan or had health insurance coverage at the time coverage was
23previously offered to the employe or dependent.
SB218,31,624 (b) The employe or participant stated in writing at the time coverage was
25previously offered that coverage under a group health plan, self-insured health plan

1or health insurance coverage was the reason for declining enrollment under the
2self-insured health plan or insurer's group health benefit plan. This paragraph
3applies only if the self-insured health plan or insurer required such a statement at
4the time coverage was previously offered and provided the employe or participant,
5at the time coverage was previously offered, with notice of the requirement and the
6consequences of the requirement.
SB218,31,117 (c) The employe or dependent is currently covered under the group health plan,
8self-insured health plan or health insurance or, under the terms of the self-insured
9health plan or group health benefit plan, the employe or participant requests
10enrollment no later than 30 days after the date on which the coverage under par. (a)
11is exhausted or terminated.
SB218,31,14 12(7) (a) If par. (b) applies, a self-insured health plan or an insurer offering a
13group health benefit plan shall provide for a special enrollment period during which
14any of the following may occur:
SB218,31,1615 1. A person who marries an individual and who is otherwise eligible for
16coverage may be enrolled under the plan as a dependent of the individual.
SB218,31,1817 2. A person who is born to, adopted by or placed for adoption with, an individual
18may be enrolled under the plan as a dependent of the individual.
SB218,31,2219 3. An individual who has met any waiting period applicable to becoming a
20participant under the plan, who is eligible to be enrolled under the plan and who
21failed to enroll during a previous enrollment period or such an individual's spouse,
22or both, may be enrolled under the plan.
SB218,31,2423 (b) A self-insured health plan or an insurer under par. (a) is required to provide
24for a special enrollment period if all of the following apply:
SB218,32,2
11. The self-insured health plan or group health benefit plan makes coverage
2available for dependents of participants under the plan.
SB218,32,53 2. The individual is a participant under the plan, or the individual has met any
4waiting period applicable to becoming a participant under the plan and is eligible to
5be enrolled under the plan but failed to enroll during a previous enrollment period.
SB218,32,76 3. A person becomes a dependent of the individual through marriage, birth,
7adoption or placement for adoption.
SB218,32,98 (c) A special enrollment period provided for under this subsection shall be for
9a period of not less than 30 days and shall begin on the later of either of the following:
SB218,32,1110 1. The date dependent coverage is made available under the self-insured
11health plan or group health benefit plan.
SB218,32,1312 2. The date of the marriage, birth, adoption or placement for adoption described
13in par. (a), whichever is applicable.
SB218,32,1614 (d) If an individual seeks to enroll a dependent during the first 30 days of a
15special enrollment period, the coverage of the dependent shall become effective on
16the following date:
SB218,32,1917 1. If the person becomes a dependent through marriage, not later than the first
18day of the first month beginning after the date on which the completed request for
19enrollment is received.
SB218,32,2020 2. If the person becomes a dependent through birth, as of the date of birth.
SB218,32,2221 3. If the person becomes a dependent through adoption or placement for
22adoption, the date of the adoption or placement for adoption.
SB218,33,2 23(8) (a) A health maintenance organization that offers a group health benefit
24plan and that does not impose any preexisting condition exclusion under sub. (1) with

1respect to a particular coverage option may impose an affiliation period for that
2coverage option, but only if all of the following apply:
SB218,33,43 1. The affiliation period is applied uniformly without regard to any health
4status-related factors.
SB218,33,65 2. The affiliation period does not exceed 2 months, or 3 months with respect to
6a late enrollee.
SB218,33,127 (b) A health maintenance organization that imposes an affiliation period under
8this subsection is not required to provide health care services or benefits during the
9affiliation period. A health maintenance organization may not charge a premium
10to a participant or beneficiary for any coverage that is provided during an affiliation
11period. An affiliation period shall begin on the enrollment date and run concurrently
12with any waiting period under the group health benefit plan.
SB218,33,1513 (c) A health maintenance organization under par. (a) may use methods other
14than those described in par. (a) to address adverse selection, if the methods are
15approved by the commissioner.
SB218,33,20 16(9) (a) Except as provided in pars. (b) and (c), requirements used by an insurer
17in determining whether to provide coverage under a group health benefit plan to an
18employer, including requirements for minimum participation of eligible employes
19and minimum employer contributions, shall be applied uniformly among all
20employers that apply for or receive coverage from the insurer.
SB218,33,2321 (b) An insurer may vary its minimum participation requirements and
22minimum employer contribution requirements only by the size of the employer group
23based on the number of eligible employes.
SB218,34,224 (c) An insurer may vary requirements used by the insurer in determining
25whether to provide coverage under a group health benefit plan to a large employer,

1but only if the requirements are applied uniformly among all large employers that
2have the same number of eligible employes.
SB218,34,83 (d) In applying minimum participation requirements with respect to an
4employer, an insurer may not count eligible employes who have other coverage that
5is creditable coverage in determining whether the applicable percentage of
6participation is met, except that an insurer may count eligible employes who have
7coverage under another health benefit plan that is sponsored by that employer and
8that is creditable coverage.
SB218,34,119 (e) An insurer may not increase a requirement for minimum employe
10participation or a requirement for minimum employer contribution that applies to
11an employer after the employer has been accepted for coverage.
SB218,34,1312 (f) This subsection does not apply to a group health benefit plan offered by the
13state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).
SB218,34,19 14(10) (a) 1. Except as provided in rules promulgated under subd. 3., if an insurer
15offers a group health benefit plan to an employer, the insurer shall offer coverage to
16all of the eligible employes of the employer and their dependents. Except as provided
17in rules promulgated under subd. 3., an insurer may not offer coverage to only certain
18individuals in an employer group or to only part of the group, except for an eligible
19employe who has not yet satisfied an applicable waiting period, if any.
SB218,35,220 2. Except as provided in rules promulgated under subd. 3., if the state or a
21county, city, village, town or school district offers coverage under a self-insured
22health plan, it shall offer coverage to all of its eligible employes and their dependents.
23Except as provided in rules promulgated under subd. 3., the state or a county, city,
24village, town or school district may not offer coverage to only certain individuals in

1the employer group or to only part of the group, except for an eligible employe who
2has not yet satisfied an applicable waiting period, if any.
SB218,35,93 3. The secretary of employe trust funds, with the approval of the group
4insurance board, shall promulgate rules related to offering coverage to eligible
5employes under a group health benefit plan, or a self-insured health plan, offered
6by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7). The
7rules shall conform to the intent of subds. 1. and 2. and may not allow the state or
8the group insurance board to refuse to offer coverage to an eligible employe or
9dependent for reasons related to health condition.
SB218,35,1310 (b) 1. An insurer may not modify a group health benefit plan with respect to
11an employer or an eligible employe or dependent, through riders, endorsements or
12otherwise, to restrict or exclude coverage for certain diseases or medical conditions
13otherwise covered by the group health benefit plan.
SB218,35,1714 2. The state or a county, city, village, town or school district may not modify a
15self-insured health plan with respect to an eligible employe or dependent, through
16riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases
17or medical conditions otherwise covered by the self-insured health plan.
SB218,35,2118 3. Nothing in this paragraph limits the authority of the group insurance board
19to fulfill its obligations as trustee under s. 40.03 (6) (d) or to design or modify
20procedures or provisions pertaining to enrollment, premium transmitted or coverage
21of eligible employes for health care benefits under s. 40.51 (1).
SB218, s. 44 22Section 44. 635.05 of the statutes is repealed and recreated to read:
SB218,36,2 23635.05 Prohibiting discrimination under group health benefit plans.
24(1) (a) Subject to sub. (2), an insurer may not establish rules for the eligibility of any
25individual to enroll, or for the continued eligibility of any individual to remain

1enrolled, under a group health benefit plan based on any of the following factors with
2respect to the individual or a dependent of the individual:
SB218,36,33 1. Health status.
SB218,36,44 2. Medical condition, including both physical and mental illnesses.
SB218,36,55 3. Claims experience.
SB218,36,66 4. Receipt of health care.
SB218,36,77 5. Medical history.
SB218,36,88 6. Genetic information.
SB218,36,109 7. Evidence of insurability, including conditions arising out of acts of domestic
10violence.
SB218,36,1111 8. Disability.
SB218,36,1312 (b) For purposes of par. (a), rules for eligibility to enroll under a group health
13benefit plan include rules defining any applicable waiting periods for enrollment.
SB218,36,18 14(2) An insurer offering a group health benefit plan may not require any
15individual, as a condition of enrollment or continued enrollment under the plan, to
16pay, on the basis of any health status-related factor with respect to the individual
17or a dependent of the individual, a premium or contribution that is greater than the
18premium or contribution for a similarly situated individual enrolled under the plan.
SB218,36,20 19(3) To the extent consistent with s. 635.03, sub. (1) shall not be construed to do
20any of the following:
SB218,36,2221 (a) Require a group health benefit plan to provide particular benefits other
22than those provided under the terms of the plan.
SB218,36,2523 (b) Prevent a group health benefit plan from establishing limitations or
24restrictions on the amount, level, extent or nature of benefits or coverage for
25similarly situated individuals enrolled under the plan.
SB218,37,1
1(4) Nothing in sub. (1) shall be construed to do any of the following:
SB218,37,32 (a) Restrict the amount that an insurer may charge an employer for coverage
3under a group health benefit plan.
SB218,37,74 (b) Prevent an insurer offering a group health benefit plan from establishing
5premium discounts or rebates, or from modifying otherwise applicable copayments
6or deductibles, in return for adherence to programs of health promotion and disease
7prevention.
SB218,37,88 (c) Provide an exception from, or limit, the rate regulation under s. 635.09.
SB218, s. 45 9Section 45. 635.06 of the statutes is created to read:
SB218,37,14 10635.06 Guaranteed issue for group health benefit plans. (1) Except as
11provided in subs. (3) and (4), an insurer shall provide coverage under a group health
12benefit plan to an employer and to all of the employer's eligible employes and their
13dependents, regardless of health condition or claims experience, if all of the following
14apply:
SB218,37,1515 (a) The insurer has in force a group health benefit plan.
Loading...
Loading...