AB312: Bill Text

AB312,12,23 (a) Claims payment policies and practices.

AB312,12,24 (b) Financial disclosures, periodically.

AB312,12,25 (c) Data on enrollment in the plan.

AB312,13,1 (d) Data on disenrollment in the plan.

AB312,13,2 (e) Data on the number of claims that are denied.

AB312,13,3 (f) Data on rating practices.

AB312,13,5 (g) Cost-sharing data and payments with respect to any out-of-network coverage.

AB312,13,6 (h) Enrollee and participant rights.

AB312,13,8 (i) Other information required by the secretary of the federal department of health and human services.

AB312,13,12 (2) Language of disclosures. (a) In this subsection, "plain language" means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because the language is concise, well-organized, and follows other best practices of plain language writing.

AB312,13,14 (b) A group or individual health benefit plan, as defined in s. 632.745 (11), shall submit the information required under sub. (1) in plain language.

AB312,13,20 (3) Cost-sharing transparency. A health benefit plan, as defined in s. 632.745 (11), shall make available on its Internet Web site and through another means for individuals without access to the Internet in a timely manner upon the individual's request a means to permit individuals to learn the amount of cost sharing under the individual's plan or coverage that the individual would be responsible for paying with respect to a specific item or service furnished by a participating provider.

AB312,13,22 (4) Applicability. This section does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

AB312, s. 23 Section 23. 632.7252 of the statutes is created to read:

AB312,14,6 632.7252 Uniform explanation of coverage. No later than March 23, 2012, every insurer that offers a health care plan, as defined in s. 628.36 (2) (a) 1., and the state, and every county, city, village, town, village, and school district that offers a self-insured health plan shall comply with 42 USC 300gg-15 and with the standards developed by the secretary of the federal department of health and human services under 42 USC 300gg-15 for compiling and providing to applicants, enrollees, and policyholders or certificate holders a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the plan.

AB312, s. 24 Section 24. 632.7254 of the statutes is created to read:

AB312,14,16 632.7254 Quality reporting. No later than March 23, 2012, every insurer that offers a health care plan, as defined in s. 628.36 (2) (a) 1., and the state, and every county, city, village, town, village, and school district that offers a self-insured health plan shall comply with 42 USC 300gg-15a and with the standards developed by the secretary of the federal department of health and human services under 42 USC 300gg-15a to require reporting for reimbursement structures that improve health outcomes, prevent hospital readmissions, improve patient safety and reduce medical errors, and implement wellness and health promotion activities. This section does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

AB312, s. 25 Section 25. 632.728 of the statutes is created to read:

AB312,14,19 632.728 Rates for individual and group health care plans. (1) In this section:

AB312,14,20 (a) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.

AB312,14,21 (b) "Self-insured health plan" has the meaning given in s. 632.85 (1) (c).

AB312,15,2 (2) Subject to sub. (3) and except as provided in sub. (4), for the purpose of setting premium rates for coverage under a group or individual health care plan or a self-insured health plan, an insurer, the state, a county, a city, a village, a town, or a school district, may only consider whether the plan covers an individual or a family and the age, tobacco use, and geographic location of any individual, including any dependent, who is be covered under the plan.

AB312,15,4 (3) (a) The rate under sub. (2) that is based on age may not vary more than 3 to 1 for adults.

AB312,15,6 (b) The rate under sub. (2) that is based on tobacco use may not vary more than 1.5 to 1.

AB312,15,8 (c) The commissioner shall establish one or more geographical rating areas for the purposes of setting premiums or rates under sub. (2).

AB312,15,10 (4) This section does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

AB312, s. 26 Section 26. 632.746 (1) (a) of the statutes is renumbered 632.746 (1m) and amended to read:

AB312,15,19 632.746 (1m) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not 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 on a participant or beneficiary under the plan.

AB312, s. 27 Section 27. 632.746 (1) (b) of the statutes is repealed.

AB312, s. 28 Section 28. 632.746 (2) (a) and (b) of the statutes are repealed.

AB312, s. 29 Section 29. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB312, s. 30 Section 30. 632.746 (2) (dm) of the statutes is created to read:

AB312,16,2 632.746 (2) (dm) An insurer offering a group health benefit plan may not impose a preexisting condition exclusion or otherwise discriminate against an individual who is under 19 years of age and who is a participant or beneficiary under the plan.

AB312, s. 31 Section 31. 632.746 (2) (dm) of the statutes, as created by 2011 Wisconsin Act .... (this act), is repealed.

AB312, s. 32 Section 32. 632.746 (3) (a) of the statutes is repealed.

AB312, s. 33 Section 33. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB312, s. 34 Section 34. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB312, s. 35 Section 35. 632.746 (5) (a) of the statutes is amended to read:

AB312,16,15 632.746 (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.

AB312, s. 36 Section 36. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB312,16,20 632.746 (8) (a) (intro.) 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:

AB312, s. 37 Section 37. 632.746 (10) (a) 1. of the statutes is amended to read:

AB312,17,3 632.746 (10) (a) 1. Except as provided in rules promulgated under subd. 3. or 4., if an insurer offers a group health benefit plan to an employer, the insurer shall offer coverage to all of the eligible employees of the employer and their dependents. Except as provided in rules promulgated under subd. 3. or 4., 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 employee who has not yet satisfied an applicable waiting period, if any.

AB312, s. 38 Section 38. 632.746 (10) (a) 4. of the statutes is repealed.

AB312, s. 39 Section 39. 632.7493 of the statutes is created to read:

AB312,17,10 632.7493 Guaranteed issue for individual health benefit plans. If an insurer offers an individual health benefit plan, the insurer shall offer coverage to an individual who applies for an individual health benefit plan and shall offer coverage to any dependents of that individual. This section does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

AB312, s. 40 Section 40. 632.7497 (3) (a) of the statutes is renumbered 632.7497 (3).

AB312, s. 41 Section 41. 632.7497 (3) (b) of the statutes is repealed.

AB312, s. 42 Section 42. 632.753 of the statutes is created to read:

AB312,17,20 632.753 Rescission prohibited. An insurer may not rescind a health benefit plan, as defined in 632.745 (11) (a), and the state or a county, city, village, town, or school district may not rescind a self-insured health plan, except if the applicant for the policy or plan committed fraud or made an intentional misrepresentation of material fact with regard to obtaining coverage under policy. The insurer or the state or a county, city, village, town, or school district shall provide notice to the enrollee before a rescission under this section.

AB312, s. 43 Section 43. 632.758 of the statutes is created to read:

AB312,17,25 632.758 Special treatment of grandfathered health plans. (1) Definition. In this section, "grandfathered health plan" means any group health plan or group or individual health insurance coverage in which an individual was enrolled on March 23, 2010.

AB312,18,6 (2) Preexisting condition exclusion. (a) No claim or loss incurred or disability commencing after 12 months from the date of issue of a grandfathered health plan that provides individual health insurance coverage may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB312,18,11 (b) A grandfathered health plan that provides individual health insurance coverage may not define a preexisting condition more restrictively than 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 12 months before the effective date of coverage.

AB312, s. 44 Section 44. 632.76 (2) (a) of the statutes is amended to read:

AB312,18,20 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.745 (24).

AB312, s. 45 Section 45. 632.76 (2) (ac) 1. of the statutes is amended to read:

AB312,19,2 632.76 (2) (ac) 1. Notwithstanding par. (a) and except as provided in subd. 4., no claim or loss incurred or disability commencing after 12 months from the date of issue of an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB312, s. 46 Section 46. 632.76 (2) (ac) 1. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is renumbered 632.76 (2) (am) and amended to read:

AB312,19,12 632.76 (2) (am) Notwithstanding par. (a) and except as provided in subd. 4., no claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss. This paragraph does not apply to a grandfathered health plan, as defined in s. 632.758 (1), that provides individual health insurance coverage.

AB312, s. 47 Section 47. 632.76 (2) (ac) 2. of the statutes is amended to read:

AB312,19,19 632.76 (2) (ac) 2. Except as provided in subd. subds. 3. and 4., an individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than 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 12 months before the effective date of coverage.

AB312, s. 48 Section 48. 632.76 (2) (ac) 2. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

AB312, s. 49 Section 49. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB312,20,2 632.76 (2) (ac) 3. (intro.) Except as provided in subd. 4. and except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy subject to s. 632.7495 (4) and (5):

AB312, s. 50 Section 50. 632.76 (2) (ac) 3. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

AB312, s. 51 Section 51. 632.76 (2) (ac) 4. of the statutes is created to read:

AB312,20,12 632.76 (2) (ac) 4. No individual disability insurance policy, as defined in s. 632.895 (1) (a), or self-insured health plan, as defined in 632.745 (24), may reduce or deny a claim for loss by a participant or beneficiary under the policy or plan who is under the age of 19 on the ground that a disease or physical condition existed prior to the effective date of coverage. This subdivision does not apply to a grandfathered health plan, as defined in s. 632.758 (1), that provides individual health insurance coverage.

AB312, s. 52 Section 52. 632.76 (2) (ac) 4. of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

AB312, s. 53 Section 53. 632.76 (2) (b) of the statutes is amended to read:

AB312,21,8 632.76 (2) (b) Notwithstanding par. (a), no claim for loss incurred or disability commencing after 6 months from the date of issue of a medicare supplement policy, medicare replacement policy or long-term care insurance policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage. Notwithstanding par. (ac) 2., a A medicare supplement policy, medicare replacement policy, or long-term care insurance policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. Notwithstanding par. (a), if on the basis of information contained in an application for insurance a medicare supplement policy, medicare replacement policy, or long-term care insurance policy excludes from coverage a condition by name or specific description, the exclusion must terminate no later than 6 months after the date of issue of the medicare supplement policy, medicare replacement policy, or long-term care insurance policy. The commissioner may by rule exempt from this paragraph certain classes of medicare supplement policies, medicare replacement policies, and long-term care insurance policies, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.

AB312, s. 54 Section 54. 632.795 (4) (a) of the statutes is amended to read:

AB312,21,21 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods , or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.

AB312, s. 55 Section 55. 632.85 (2) of the statutes is amended to read:

AB312,22,3 632.85 (2) If a health care plan or a self-insured health plan provides coverage of any emergency medical services, the health care plan or self-insured health plan shall provide coverage of emergency medical services that are provided in a hospital emergency facility, regardless whether that facility is a participating provider with respect to the plan, and that are needed to evaluate or stabilize, as defined in section 1867 of the federal Social Security Act, an emergency medical condition.

AB312, s. 56 Section 56. 632.85 (4) of the statutes is created to read:

AB312,22,10 632.85 (4) A health care plan or self-insured health plan that is required to provide the coverage under sub. (2) shall impose the same cost-sharing requirements on coverage for emergency medical services provided by a nonparticipating provider as it imposes for services provided by a participating provider. This subsection does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

AB312, s. 57 Section 57. 632.865 of the statutes is created to read:

AB312,22,18 632.865 Choice of primary care provider. A group or individual health benefit plan, as defined in s. 632.745 (11), that requires or provides for the designation by any individual or beneficiary covered under the plan of a participating primary care provider shall allow each individual or beneficiary to designate any participating primary care provider who is available to accept that individual or beneficiary. This section does not apply to a grandfathered health plan, as defined in s. 632.758 (1).

AB312, s. 58 Section 58. 632.87 (5m) of the statutes is created to read:

AB312,22,23 632.87 (5m) (a) 1. Except as provided in subd. 2. and par. (d), no health care plan, as defined in s. 628.36 (2) (a) 1., that provides coverage for hospital lengths of stay in connection with childbirth for a mother or a newborn child may do any of the following:

AB312,23,3 a. Restrict benefits under the plan for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours.

AB312,23,6 b. Restrict benefits under the plan for any hospital length of stay in connection with childbirth for the mother or newborn child, following a cesarean section, to less than 96 hours.

AB312,23,8 c. Require that a provider obtain authorization from the plan for prescribing any length of stay required under subd. 1. a. or b.

AB312,23,12 2. Subdivision 1. does not apply to a health care plan in any case in which the decision to discharge the mother or her newborn child before the minimum length of stay described under subd. 1. a. or b. is made by an attending provider in consultation with the mother.

AB312,23,14 (b) No health care plan, as defined in s. 628.36 (2) (a) 1., may do any of the following:

AB312,23,17 1. Deny to the mother or her newborn child eligibility, or continued eligibility, to enroll in or renew coverage under the plan solely for the purpose of avoiding the requirements of this subsection.

AB312,23,19 2. Provide monetary payments or rebates to mothers to encourage mothers to accept less than the minimum protections available under this subsection.

AB312,23,22 3. Penalize a provider or reduce or limit the reimbursement of a provider because the provider provided care to an individual in accordance with this subsection.