LRB-1968/1
PJK:nwn:ph
2009 - 2010 LEGISLATURE
March 4, 2009 - Introduced by Representatives Pasch, Richards, Berceau, Seidel,
Sherman, Young, Hraychuck
and Clark, cosponsored by Senators Vinehout,
Erpenbach, Robson, Lehman, Carpenter, Wirch, Taylor, Coggs, Hansen
and
Miller. Referred to Committee on Health and Healthcare Reform.
AB108,1,9 1An Act to renumber and amend 632.835 (3) (f), 632.835 (8) and 632.835 (9);
2to amend 632.746 (2) (e), 632.746 (3) (b), 632.835 (title), 632.835 (2) (a), 632.835
3(2) (b), 632.835 (2) (bg) 3., 632.835 (2) (c), 632.835 (3) (a), 632.835 (3) (e), 632.835
4(3m) (a), 632.835 (6m) (a) and 632.835 (7) (b); and to create 601.428, 632.835
5(1) (ag), 632.835 (1) (cm), 632.835 (2) (e), 632.835 (3) (f) 2., 632.835 (8) (b) and
6632.835 (9) (b) of the statutes; relating to: portability under group health
7benefit plans and independent review of insurance policy rescissions and
8preexisting condition exclusion denials under group and individual health
9benefit plans.
Analysis by the Legislative Reference Bureau
Under current law, for purposes of determining how long a preexisting
condition exclusion may be imposed under a group health benefit plan, if a person
who enrolls in the group health benefit plan had other coverage before that
enrollment, the person must be given credit for the time during which he or she was
previously covered when determining how long a preexisting condition exclusion
may be imposed under the new coverage. Previous coverage may not be counted for
the credit, however, if the person did not have coverage for a period of 63 or more days

before the person's new coverage commenced. This bill increases that amount of
time, so that a person may get credit for previous coverage if it ended up to 90 days,
rather than 63 days, before the person enrolled in the group health benefit plan.
Also under current law, every insurer that issues a group or individual health
benefit plan must have an internal grievance procedure under which an insured may
submit a written grievance and a grievance panel must investigate the grievance
and, if appropriate, take corrective action. In addition, every insurer that issues a
group or individual health benefit plan must have an independent review procedure
for review, after the internal grievance procedure has been exhausted, of certain
decisions that are adverse to an insured. The adverse decision must relate to the
insurer's denial of treatment or payment for treatment that the insurer determined
was experimental or to the insurer's denial, reduction, or termination of a health care
service or payment for a health care service on the basis that the health care service
did not meet the plan's requirements for medical necessity, appropriateness, health
care setting, level of care, or effectiveness. An independent review may be conducted
only by an independent review organization that has been certified by the
Commissioner of Insurance (commissioner).
The bill adds the rescission of a policy or certificate and a coverage denial
determination based on a preexisting condition exclusion to the types of adverse
decisions that are eligible for review under a group or individual health benefit plan's
independent review procedure. In addition, the bill requires every insurer that
issues individual health benefit plans to report to the commissioner annually the
number of individual health benefit plans issued by the insurer in the preceding year
and the number of individual health benefit plans with respect to which the insurer
initiated or completed a cancellation or rescission in the preceding year.
For further information see the state fiscal estimate, which will be printed as
an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB108, s. 1 1Section 1. 601.428 of the statutes is created to read:
AB108,2,7 2601.428 Cancellation and rescission reports. Beginning in 2009, every
3insurer that issues individual health insurance policies shall annually report to the
4commissioner the total number of individual health insurance policies that the
5insurer issued in the preceding year and the total number of individual health
6insurance policies with respect to which the insurer initiated or completed a
7cancellation or rescission in the preceding year.
AB108, s. 2
1Section 2. 632.746 (2) (e) of the statutes is amended to read:
AB108,3,72 632.746 (2) (e) Paragraphs (c) and (d) do not apply to an individual after the
3end of the first continuous period during which the individual was not covered under
4any creditable coverage for at least 63 90 days. For purposes of this paragraph, any
5waiting period or affiliation period for coverage under a group health plan or group
6health benefit plan shall not be taken into account in determining the period before
7enrollment in the group health plan or group health benefit plan.
AB108, s. 3 8Section 3. 632.746 (3) (b) of the statutes is amended to read:
AB108,3,169 632.746 (3) (b) With respect to enrollment of an individual under a group health
10plan or a group health benefit plan, a period of creditable coverage after which the
11individual was not covered under any creditable coverage for a period of at least 63
1290 days before enrollment in the group health plan or group health benefit plan may
13not be counted. For purposes of this paragraph, any waiting period or affiliation
14period for coverage under the group health plan or group health benefit plan shall
15not be taken into account in determining the period before enrollment in the group
16health plan or group health benefit plan.
AB108, s. 4 17Section 4. 632.835 (title) of the statutes is amended to read:
AB108,3,19 18632.835 (title) Independent review of adverse and experimental
19treatment
coverage denial determinations.
AB108, s. 5 20Section 5. 632.835 (1) (ag) of the statutes is created to read:
AB108,3,2321 632.835 (1) (ag) "Coverage denial determination" means an adverse
22determination, an experimental treatment determination, a preexisting condition
23exclusion denial determination, or the rescission of a policy or certificate.
AB108, s. 6 24Section 6. 632.835 (1) (cm) of the statutes is created to read:
AB108,4,4
1632.835 (1) (cm) "Preexisting condition exclusion denial determination" means
2a determination by or on behalf of an insurer that issues a health benefit plan
3denying or terminating treatment or payment for treatment on the basis of a
4preexisting condition exclusion, as defined in s. 632.745 (23).
AB108, s. 7 5Section 7. 632.835 (2) (a) of the statutes is amended to read:
AB108,4,106 632.835 (2) (a) Every insurer that issues a health benefit plan shall establish
7an independent review procedure whereby an insured under the health benefit plan,
8or his or her authorized representative, may request and obtain an independent
9review of an adverse determination or an experimental treatment a coverage denial
10determination made with respect to the insured.
AB108, s. 8 11Section 8. 632.835 (2) (b) of the statutes is amended to read:
AB108,4,1912 632.835 (2) (b) If an adverse determination or an experimental treatment a
13coverage denial
determination is made, the insurer involved in the determination
14shall provide notice to the insured of the insured's right to obtain the independent
15review required under this section, how to request the review, and the time within
16which the review must be requested. The notice shall include a current listing of
17independent review organizations certified under sub. (4). An independent review
18under this section may be conducted only by an independent review organization
19certified under sub. (4) and selected by the insured.
AB108, s. 9 20Section 9. 632.835 (2) (bg) 3. of the statutes is amended to read:
AB108,5,521 632.835 (2) (bg) 3. For any adverse determination or experimental treatment
22coverage denial determination for which an explanation of benefits is not provided
23to the insured, the insurer provides a notice that the insured may have a right to an
24independent review after the internal grievance process and that an insured may be
25entitled to expedited, independent review with respect to an urgent matter. The

1notice shall also include a reference to the section of the policy or certificate that
2contains the description of the independent review procedure as required under
3subd. 1. The notice shall provide a toll-free telephone number and website, if
4appropriate, where consumers may obtain additional information regarding
5internal grievance and independent review processes.
AB108, s. 10 6Section 10. 632.835 (2) (c) of the statutes is amended to read:
AB108,5,127 632.835 (2) (c) Except as provided in par. (d), an insured must exhaust the
8internal grievance procedure under s. 632.83 before the insured may request an
9independent review under this section. Except as provided in sub. (9) (a), an insured
10who uses the internal grievance procedure must request an independent review as
11provided in sub. (3) (a) within 4 months after the insured receives notice of the
12disposition of his or her grievance under s. 632.83 (3) (d).
AB108, s. 11 13Section 11. 632.835 (2) (e) of the statutes is created to read:
AB108,5,1614 632.835 (2) (e) Nothing in this section requires an insured to request an
15independent review before commencing a civil action relating to a coverage denial
16determination.
AB108, s. 12 17Section 12. 632.835 (3) (a) of the statutes is amended to read:
AB108,6,518 632.835 (3) (a) To request an independent review, an insured or his or her
19authorized representative shall provide timely written notice of the request for
20independent review, and of the independent review organization selected, to the
21insurer that made or on whose behalf was made the adverse or experimental
22treatment
coverage denial determination. The insurer shall immediately notify the
23commissioner and the independent review organization selected by the insured of
24the request for independent review. The insured or his or her authorized
25representative must pay a $25 fee to the independent review organization. If the

1insured prevails on the review, in whole or in part, the entire amount paid by the
2insured or his or her authorized representative shall be refunded by the insurer to
3the insured or his or her authorized representative. For each independent review in
4which it is involved, an insurer shall pay a fee to the independent review
5organization.
AB108, s. 13 6Section 13. 632.835 (3) (e) of the statutes is amended to read:
AB108,6,177 632.835 (3) (e) In addition to the information under pars. (b) and (c), the
8independent review organization may accept for consideration any typed or printed,
9verifiable medical or scientific evidence that the independent review organization
10determines is relevant, regardless of whether the evidence has been submitted for
11consideration at any time previously. The insurer and the insured shall submit to
12the other party to the independent review any information submitted to the
13independent review organization under this paragraph and pars. (b) and (c). If, on
14the basis of any additional information, the insurer reconsiders the insured's
15grievance and determines that the treatment that was the subject of the grievance
16should be covered, or that the policy or certificate that was rescinded should be
17reinstated,
the independent review is terminated.
AB108, s. 14 18Section 14. 632.835 (3) (f) of the statutes is renumbered 632.835 (3) (f) 1. and
19amended to read:
AB108,7,220 632.835 (3) (f) 1. If the independent review is not terminated under par. (e), the
21independent review organization shall, within 30 business days after the expiration
22of all time limits that apply in the matter, make a decision on the basis of the
23documents and information submitted under this subsection. The decision shall be
24in writing, signed on behalf of the independent review organization and served by
25personal delivery or by mailing a copy to the insured or his or her authorized

1representative and to the insurer. A Except as provided in subd. 2., a decision of an
2independent review organization is binding on the insured and the insurer.
AB108, s. 15 3Section 15. 632.835 (3) (f) 2. of the statutes is created to read:
AB108,7,64 632.835 (3) (f) 2. A decision of an independent review organization regarding
5a preexisting condition exclusion denial determination or a rescission is not binding
6on the insured.
AB108, s. 16 7Section 16. 632.835 (3m) (a) of the statutes is amended to read:
AB108,7,118 632.835 (3m) (a) A decision of an independent review organization regarding
9an adverse determination or a preexisting condition exclusion denial determination
10must be consistent with the terms of the health benefit plan under which the adverse
11determination or preexisting condition exclusion denial determination was made.
AB108, s. 17 12Section 17. 632.835 (6m) (a) of the statutes is amended to read:
AB108,7,1613 632.835 (6m) (a) Be Unless the review relates to a rescission, be a health care
14provider who is expert in treating the medical condition that is the subject of the
15review and who is knowledgeable about the treatment that is the subject of the
16review through current, actual clinical experience.
AB108, s. 18 17Section 18. 632.835 (7) (b) of the statutes is amended to read:
AB108,7,2218 632.835 (7) (b) A health benefit plan that is the subject of an independent
19review and the insurer that issued the health benefit plan shall not be liable to any
20person for damages attributable to the insurer's or plan's actions taken in compliance
21with any decision regarding an adverse determination or an experimental treatment
22determination
rendered by a certified independent review organization.
AB108, s. 19 23Section 19. 632.835 (8) of the statutes is renumbered 632.835 (8) (a) and
24amended to read:
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