SB218: Bill Text

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.

SB218,35,13 (b) 1. An insurer may not modify a group health benefit plan with respect to 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 group health benefit plan.

SB218,35,17 2. The state or a county, city, village, town or school district may not modify a self-insured health plan with respect to 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 self-insured health plan.

SB218,35,21 3. Nothing in this paragraph limits the authority of the group insurance board to fulfill its obligations as trustee under s. 40.03 (6) (d) or to design or modify procedures or provisions pertaining to enrollment, premium transmitted or coverage of eligible employes for health care benefits under s. 40.51 (1).

SB218, s. 44 Section 44. 635.05 of the statutes is repealed and recreated to read:

SB218,36,2 635.05 Prohibiting discrimination under group health benefit plans. (1) (a) Subject to sub. (2), an insurer may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under a group health benefit plan based on any of the following factors with respect to the individual or a dependent of the individual:

SB218,36,3 1. Health status.

SB218,36,4 2. Medical condition, including both physical and mental illnesses.

SB218,36,5 3. Claims experience.

SB218,36,6 4. Receipt of health care.

SB218,36,7 5. Medical history.

SB218,36,8 6. Genetic information.

SB218,36,10 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

SB218,36,11 8. Disability.

SB218,36,13 (b) For purposes of par. (a), rules for eligibility to enroll under a group health benefit plan include rules defining any applicable waiting periods for enrollment.

SB218,36,18 (2) An insurer offering a group health benefit plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor with respect to the individual or a dependent of the individual, a premium or contribution that is greater than the premium or contribution for a similarly situated individual enrolled under the plan.

SB218,36,20 (3) To the extent consistent with s. 635.03, sub. (1) shall not be construed to do any of the following:

SB218,36,22 (a) Require a group health benefit plan to provide particular benefits other than those provided under the terms of the plan.

SB218,36,25 (b) Prevent a group health benefit plan from establishing limitations or restrictions on the amount, level, extent or nature of benefits or coverage for similarly situated individuals enrolled under the plan.

SB218,37,1 (4) Nothing in sub. (1) shall be construed to do any of the following:

SB218,37,3 (a) Restrict the amount that an insurer may charge an employer for coverage under a group health benefit plan.

SB218,37,7 (b) Prevent an insurer offering a group health benefit plan from establishing premium discounts or rebates, or from modifying otherwise applicable copayments or deductibles, in return for adherence to programs of health promotion and disease prevention.

SB218,37,8 (c) Provide an exception from, or limit, the rate regulation under s. 635.09.

SB218, s. 45 Section 45. 635.06 of the statutes is created to read:

SB218,37,14 635.06 Guaranteed issue for group health benefit plans. (1) Except as provided in subs. (3) and (4), an insurer shall provide coverage under a group health benefit plan 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:

SB218,37,15 (a) The insurer has in force a group health benefit plan.

SB218,37,17 (b) The employer agrees to pay the premium required for coverage under the group health benefit plan.

SB218,37,20 (c) 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.

SB218,37,22 (2) An insurer that provides coverage under sub. (1) may impose payment security provisions that are reasonably related to the risk covered.

SB218,38,2 (3) (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 one individual health benefit plan providing family coverage.

SB218,38,5 (b) Subsection (1) does 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.

SB218,38,9 (c) Subsection (1) does not require an insurer that provides coverage to an employer under a group health benefit plan to issue a different group health benefit plan to the employer before the expiration of the agreed term of the group health benefit plan under which the employer has coverage.

SB218,38,13 (d) 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 sub. (1) to that single category or those limited categories of employers.

SB218,38,17 (e) The commissioner may exempt an insurer from the requirements of sub. (1) if the commissioner determines that it is in the public interest to exempt the insurer from the requirements under sub. (1) because the insurer is in financially hazardous condition.

SB218,38,22 (f) If an employer loses coverage under a group health benefit plan for failure to pay a premium when due, an insurer that is otherwise required to provide coverage under sub. (1) may refuse to issue a group health benefit plan to that employer during the 12-month period beginning on the day on which the employer lost coverage.

SB218,39,3 (g) An insurer that previously issued group health benefit plans but, prior to the effective date of this paragraph .... [revisor inserts date], discontinued offering such plans to small employers, shall within 60 days after the effective date of this paragraph .... [revisor inserts date], again offer group health benefit plans to small employers or be subject to the requirements under s. 635.16 as if the insurer had elected to not renew a group health benefit plan.

SB218,39,6 (4) (a) In this subsection, "high-risk individual" means an individual with a high-risk medical condition who has coverage under a group health benefit plan with a premium rate at the insurer's highest premium rate level.

SB218,39,9 (b) An insurer that is otherwise required to provide coverage under sub. (1) shall be exempt from the requirement under sub. (1) for the remainder of a calendar year after all of the following occur:

SB218,39,11 1. The number of high-risk individuals covered by the insurer at least equals the threshold level determined under par. (e) 3.

SB218,39,18 2. The insurer applies for exemption from the requirement under sub. (1) by certifying its qualification under subd. 1. to the commissioner and the commissioner, within 30 days after the insurer submits its certifying information, makes no objection and does not request additional information. If the commissioner does timely object or request additional information, the insurer shall be exempt from the requirements under sub. (1) 30 days after the commissioner objects or the insurer submits the additional information if the commissioner takes no further action.

SB218,39,22 (c) Whenever an insurer becomes exempt from the requirement under sub. (1) by satisfying the criteria under par. (b), the commissioner shall provide notice of that exemption to all insurers offering group health benefit plans to employers in this state and to all insurance agents listed under s. 628.11 by those insurers.

SB218,39,25 (d) An insurer that satisfies the criterion under par. (b) 1. is not required to apply for exemption from the requirement under sub. (1). An insurer that does not apply for exemption shall remain subject to the requirement under sub. (1).

SB218,40,3 (e) In consultation with the committee on risk adjustment, the commissioner shall promulgate rules for the operation of the risk adjustment mechanism under this subsection, including rules that specify at least all of the following:

SB218,40,5 1. What diagnostic conditions constitute high risk medical conditions for purposes of the definition of a high-risk individual.

SB218,40,7 2. How to determine an insurer's highest premium rate level for purposes of the definition of a high-risk individual.

SB218,40,9 3. What percentage of an insurer's total enrollment under group health benefit plans issued by the insurer constitutes the threshold level for purposes of par. (b) 1.

SB218, s. 46 Section 46. 635.08 of the statutes is created to read:

SB218,40,13 635.08 Coverage requirements for individual health benefit plans. (1) (a) In this section, "qualifying coverage" means benefits or coverage provided under any of the following:

SB218,40,16 1. A group health benefit plan, group health plan or self-insured health plan that provides benefits similar to or exceeding benefits provided under the health benefit plan for which the individual is applying.

SB218,40,20 2. An individual health benefit plan that provides benefits similar to or exceeding benefits provided under the health benefit plan for which the individual is applying, if the individual health benefit plan has been in effect for at least one year.

SB218,41,2 (b) Notwithstanding par. (a), "qualifying coverage" does not include a high cost-share health plan, as defined in s. 632.898 (1) (c), that is linked to a medical savings account, as described in s. 632.898, if the employer that provides the individual's new coverage offers its eligible employes a choice of health benefit plan options that includes a high cost-share health plan, as defined in s. 632.898 (1) (c), and the individual's new coverage is not a high cost-share health plan.

SB218,41,5 (2) (a) An individual health benefit plan may not impose a preexisting condition exclusion with respect to a covered individual for losses incurred more than 12 months after the individual's enrollment date under the plan.

SB218,41,7 (b) An individual health benefit plan may not define a preexisting condition more restrictively than any of the following:

SB218,41,11 1. A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 18 months immediately preceding the individual's enrollment date under the plan and for which the individual did not seek medical advice, diagnosis, care or treatment.

SB218,41,14 2. A condition for which medical advice, diagnosis, care or treatment was recommended or received during the 18 months immediately preceding the individual's enrollment date under the plan.

SB218,41,17 (c) Notwithstanding pars. (a) and (b), an individual health benefit plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition.

SB218,41,20 (3) (a) Except as provided in pars. (b) and (g), an insurer shall provide coverage under an individual health benefit plan to an individual who is a resident of this state, regardless of health condition or claims experience, if all of the following apply:

SB218,41,21 1. The insurer has in force an individual health benefit plan.

SB218,41,23 2. The individual agrees to pay the premium required for coverage under the individual health benefit plan.

SB218,42,3 3. 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.

SB218,42,5 4. The individual was covered under qualifying coverage that terminated not more than 31 days before the individual applied for the new coverage.

SB218,42,11 5. If the individual's qualifying coverage under subd. 4. was coverage under sub. (1) (a) 1., the individual had been covered under continuation coverage, as defined in s. 252.16 (1) (a), for the maximum allowable period; the individual is not now eligible for coverage under any group health benefit plan, group health plan or self-insured health plan; and the individual was an eligible employe for at least 6 months immediately before applying for the new coverage.

SB218,42,14 (b) 1. Paragraph (a) does 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.

SB218,42,18 2. Paragraph (a) does not require an insurer that provides coverage to an individual under an individual health benefit plan to issue a different individual health benefit plan to the individual before the expiration of the agreed term of the individual health benefit plan under which the individual has coverage.

SB218,42,22 3. An insurer that offers health care coverage exclusively to a single category or limited categories of individuals may, with prior approval of the commissioner, limit its compliance with par. (a) to the single category or those limited categories of individuals.

SB218,43,2 4. The commissioner may exempt an insurer from the requirement under par. (a) if the commissioner determines that it is in the public interest to exempt the insurer from the requirement under par. (a) because the insurer is in financially hazardous condition.

SB218,43,6 (c) An insurer that issues an individual health benefit plan to an individual described in par. (a) shall provide coverage under the individual health benefit plan for any dependents of the individual who had coverage under the individual's qualifying coverage under par. (a) 4.

SB218,43,10 (d) An individual health benefit plan that is issued to an individual described in par. (a) may not restrict or modify coverage with respect to the individual except to the extent that the individual's qualifying coverage under par. (a) 4. was restricted or modified.

SB218,43,13 (e) The maximum lifetime benefits available under an individual health benefit plan that is issued to an individual described in par. (a) may be reduced by the total benefits paid under the individual's qualifying coverage under par. (a) 4.

SB218,43,18 (f) An individual health benefit plan that is issued to an individual described in par. (a) shall waive any period applicable to a preexisting condition exclusion period with respect to particular services for the period that the individual was covered with respect to such services under the individual's qualifying coverage under par. (a) 4.

SB218,43,21 (g) An insurer that is otherwise required to provide coverage under par. (a) shall be exempt from the requirement under par. (a) for the remainder of a calendar year after all of the following occur:

SB218,44,2 1. The total number of individuals described under par. (a) and their dependents who are covered by the insurer equals at least 1% of the total number of individuals and their dependents covered under all individual health benefit plans issued by the insurer that were in effect on December 31 of the preceding year and that were qualifying coverage under sub. (1) (a) 2.

SB218,44,4 2. The insurer applies for exemption from the requirement under par. (a) by submitting to the commissioner certification that includes all of the following:

SB218,44,7 a. The total number of individuals and their dependents covered under all individual health benefit plans issued by the insurer that were in effect on December 31 of the preceding year and that were qualifying coverage under sub. (1) (a) 2.