AB312,12,2323 (a) Claims payment policies and practices.
AB312,12,2424 (b) Financial disclosures, periodically.
AB312,12,2525 (c) Data on enrollment in the plan.
AB312,13,1
1(d) Data on disenrollment in the plan.
AB312,13,22 (e) Data on the number of claims that are denied.
AB312,13,33 (f) Data on rating practices.
AB312,13,54 (g) Cost-sharing data and payments with respect to any out-of-network
5coverage.
AB312,13,66 (h) Enrollee and participant rights.
AB312,13,87 (i) Other information required by the secretary of the federal department of
8health and human services.
AB312,13,12 9(2) Language of disclosures. (a) In this subsection, "plain language" means
10language that the intended audience, including individuals with limited English
11proficiency, can readily understand and use because the language is concise,
12well-organized, and follows other best practices of plain language writing.
AB312,13,1413 (b) A group or individual health benefit plan, as defined in s. 632.745 (11), shall
14submit the information required under sub. (1) in plain language.
AB312,13,20 15(3) Cost-sharing transparency. A health benefit plan, as defined in s. 632.745
16(11), shall make available on its Internet Web site and through another means for
17individuals without access to the Internet in a timely manner upon the individual's
18request a means to permit individuals to learn the amount of cost sharing under the
19individual's plan or coverage that the individual would be responsible for paying with
20respect to a specific item or service furnished by a participating provider.
AB312,13,22 21(4) Applicability. This section does not apply to a grandfathered health plan,
22as defined in s. 632.758 (1).
AB312, s. 23 23Section 23. 632.7252 of the statutes is created to read:
AB312,14,6 24632.7252 Uniform explanation of coverage. No later than March 23, 2012,
25every insurer that offers a health care plan, as defined in s. 628.36 (2) (a) 1., and the

1state, and every county, city, village, town, village, and school district that offers a
2self-insured health plan shall comply with 42 USC 300gg-15 and with the standards
3developed by the secretary of the federal department of health and human services
4under 42 USC 300gg-15 for compiling and providing to applicants, enrollees, and
5policyholders or certificate holders a summary of benefits and coverage explanation
6that accurately describes the benefits and coverage under the plan.
AB312, s. 24 7Section 24. 632.7254 of the statutes is created to read:
AB312,14,16 8632.7254 Quality reporting. No later than March 23, 2012, every insurer
9that offers a health care plan, as defined in s. 628.36 (2) (a) 1., and the state, and every
10county, city, village, town, village, and school district that offers a self-insured health
11plan shall comply with 42 USC 300gg-15a and with the standards developed by the
12secretary of the federal department of health and human services under 42 USC
13300gg-15a
to require reporting for reimbursement structures that improve health
14outcomes, prevent hospital readmissions, improve patient safety and reduce medical
15errors, and implement wellness and health promotion activities. This section does
16not apply to a grandfathered health plan, as defined in s. 632.758 (1).
AB312, s. 25 17Section 25. 632.728 of the statutes is created to read:
AB312,14,19 18632.728 Rates for individual and group health care plans. (1) In this
19section:
AB312,14,2020 (a) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
AB312,14,2121 (b) "Self-insured health plan" has the meaning given in s. 632.85 (1) (c).
AB312,15,2 22(2) Subject to sub. (3) and except as provided in sub. (4), for the purpose of
23setting premium rates for coverage under a group or individual health care plan or
24a self-insured health plan, an insurer, the state, a county, a city, a village, a town,
25or a school district, may only consider whether the plan covers an individual or a

1family and the age, tobacco use, and geographic location of any individual, including
2any dependent, who is be covered under the plan.
AB312,15,4 3(3) (a) The rate under sub. (2) that is based on age may not vary more than 3
4to 1 for adults.
AB312,15,65 (b) The rate under sub. (2) that is based on tobacco use may not vary more than
61.5 to 1.
AB312,15,87 (c) The commissioner shall establish one or more geographical rating areas for
8the purposes of setting premiums or rates under sub. (2).
AB312,15,10 9(4) This section does not apply to a grandfathered health plan, as defined in
10s. 632.758 (1).
AB312, s. 26 11Section 26. 632.746 (1) (a) of the statutes is renumbered 632.746 (1m) and
12amended to read:
AB312,15,1913 632.746 (1m) Subject to subs. (2) and (3), an An insurer that offers a group
14health benefit plan may, with respect to a participant or beneficiary under the plan,
15not impose a preexisting condition exclusion only if the exclusion relates to a
16condition, whether physical or mental, regardless of the cause of the condition, for
17which medical advice, diagnosis, care or treatment was recommended or received
18within the 6-month period ending on the participant's or beneficiary's enrollment
19date under the plan
on a participant or beneficiary under the plan.
AB312, s. 27 20Section 27. 632.746 (1) (b) of the statutes is repealed.
AB312, s. 28 21Section 28. 632.746 (2) (a) and (b) of the statutes are repealed.
AB312, s. 29 22Section 29. 632.746 (2) (c), (d) and (e) of the statutes are repealed.
AB312, s. 30 23Section 30. 632.746 (2) (dm) of the statutes is created to read:
AB312,16,224 632.746 (2) (dm) An insurer offering a group health benefit plan may not
25impose a preexisting condition exclusion or otherwise discriminate against an

1individual who is under 19 years of age and who is a participant or beneficiary under
2the plan.
AB312, s. 31 3Section 31. 632.746 (2) (dm) of the statutes, as created by 2011 Wisconsin Act
4.... (this act), is repealed.
AB312, s. 32 5Section 32. 632.746 (3) (a) of the statutes is repealed.
AB312, s. 33 6Section 33. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).
AB312, s. 34 7Section 34. 632.746 (3) (d) 2. and 3. of the statutes are repealed.
AB312, s. 35 8Section 35. 632.746 (5) (a) of the statutes is amended to read:
AB312,16,159 632.746 (5) (a) If an insurer that made an election under sub. (3) (d) 2. enrolls
10an individual for coverage under a group health benefit plan and the individual
11provides a certification under sub. (4), upon the request of that insurer or the group
12health benefit plan the insurer that issued the certification shall promptly disclose
13to the requesting insurer or group health benefit plan information on coverage of
14classes or categories of health benefits available under the coverage on which the
15certification was based.
AB312, s. 36 16Section 36. 632.746 (8) (a) (intro.) of the statutes is amended to read:
AB312,16,2017 632.746 (8) (a) (intro.) A health maintenance organization that offers a group
18health benefit plan and that does not impose any preexisting condition exclusion
19under sub. (1)
with respect to a particular coverage option may impose an affiliation
20period for that coverage option, but only if all of the following apply:
AB312, s. 37 21Section 37. 632.746 (10) (a) 1. of the statutes is amended to read:
AB312,17,322 632.746 (10) (a) 1. Except as provided in rules promulgated under subd. 3. or
234.
, if an insurer offers a group health benefit plan to an employer, the insurer shall
24offer coverage to all of the eligible employees of the employer and their dependents.
25Except as provided in rules promulgated under subd. 3. or 4., an insurer may not offer

1coverage to only certain individuals in an employer group or to only part of the group,
2except for an eligible employee who has not yet satisfied an applicable waiting period,
3if any.
AB312, s. 38 4Section 38. 632.746 (10) (a) 4. of the statutes is repealed.
AB312, s. 39 5Section 39. 632.7493 of the statutes is created to read:
AB312,17,10 6632.7493 Guaranteed issue for individual health benefit plans. If an
7insurer offers an individual health benefit plan, the insurer shall offer coverage to
8an individual who applies for an individual health benefit plan and shall offer
9coverage to any dependents of that individual. This section does not apply to a
10grandfathered health plan, as defined in s. 632.758 (1).
AB312, s. 40 11Section 40. 632.7497 (3) (a) of the statutes is renumbered 632.7497 (3).
AB312, s. 41 12Section 41. 632.7497 (3) (b) of the statutes is repealed.
AB312, s. 42 13Section 42. 632.753 of the statutes is created to read:
AB312,17,20 14632.753 Rescission prohibited. An insurer may not rescind a health benefit
15plan, as defined in 632.745 (11) (a), and the state or a county, city, village, town, or
16school district may not rescind a self-insured health plan, except if the applicant for
17the policy or plan committed fraud or made an intentional misrepresentation of
18material fact with regard to obtaining coverage under policy. The insurer or the state
19or a county, city, village, town, or school district shall provide notice to the enrollee
20before a rescission under this section.
AB312, s. 43 21Section 43. 632.758 of the statutes is created to read:
AB312,17,25 22632.758 Special treatment of grandfathered health plans. (1)
23Definition. In this section, "grandfathered health plan" means any group health
24plan or group or individual health insurance coverage in which an individual was
25enrolled on March 23, 2010.
AB312,18,6
1(2) Preexisting condition exclusion. (a) No claim or loss incurred or disability
2commencing after 12 months from the date of issue of a grandfathered health plan
3that provides individual health insurance coverage may be reduced or denied on the
4ground that a disease or physical condition existed prior to the effective date of
5coverage, unless the condition was excluded from coverage by name or specific
6description by a provision effective on the date of the loss.
AB312,18,117 (b) A grandfathered health plan that provides individual health insurance
8coverage may not define a preexisting condition more restrictively than a condition,
9whether physical or mental, regardless of the cause of the condition, for which
10medical advice, diagnosis, care, or treatment was recommended or received within
1112 months before the effective date of coverage.
AB312, s. 44 12Section 44. 632.76 (2) (a) of the statutes is amended to read:
AB312,18,2013 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years
14from the date of issue of the policy may be reduced or denied on the ground that a
15disease or physical condition existed prior to the effective date of coverage, unless the
16condition was excluded from coverage by name or specific description by a provision
17effective on the date of loss. This paragraph does not apply to a group health benefit
18plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance
19policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s.
20632.745 (24)
.
AB312, s. 45 21Section 45. 632.76 (2) (ac) 1. of the statutes is amended to read:
AB312,19,222 632.76 (2) (ac) 1. Notwithstanding par. (a) and except as provided in subd. 4.,
23no claim or loss incurred or disability commencing after 12 months from the date of
24issue of an individual disability insurance policy, as defined in s. 632.895 (1) (a), may
25be reduced or denied on the ground that a disease or physical condition existed prior

1to the effective date of coverage, unless the condition was excluded from coverage by
2name or specific description by a provision effective on the date of the loss.
AB312, s. 46 3Section 46. 632.76 (2) (ac) 1. of the statutes, as affected by 2011 Wisconsin Act
4.... (this act), is renumbered 632.76 (2) (am) and amended to read:
AB312,19,125 632.76 (2) (am) Notwithstanding par. (a) and except as provided in subd. 4., no
6claim or loss incurred or disability commencing after 12 months from the date of issue
7of
under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may
8be reduced or denied on the ground that a disease or physical condition existed prior
9to the effective date of coverage, unless the condition was excluded from coverage by
10name or specific description by a provision effective on the date of the loss
. This
11paragraph does not apply to a grandfathered health plan, as defined in s. 632.758 (1),
12that provides individual health insurance coverage
.
AB312, s. 47 13Section 47. 632.76 (2) (ac) 2. of the statutes is amended to read:
AB312,19,1914 632.76 (2) (ac) 2. Except as provided in subd. subds. 3. and 4., an individual
15disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term
16policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more
17restrictively than a condition, whether physical or mental, regardless of the cause
18of the condition, for which medical advice, diagnosis, care, or treatment was
19recommended or received within 12 months before the effective date of coverage.
AB312, s. 48 20Section 48. 632.76 (2) (ac) 2. of the statutes, as affected by 2011 Wisconsin Act
21.... (this act), is repealed.
AB312, s. 49 22Section 49. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:
AB312,20,223 632.76 (2) (ac) 3. (intro.) Except as provided in subd. 4. and except as the
24commissioner provides by rule under s. 632.7495 (5), all of the following apply to an

1individual disability insurance policy that is a short-term policy subject to s.
2632.7495 (4) and (5):
AB312, s. 50 3Section 50. 632.76 (2) (ac) 3. of the statutes, as affected by 2011 Wisconsin Act
4.... (this act), is repealed.
AB312, s. 51 5Section 51. 632.76 (2) (ac) 4. of the statutes is created to read:
AB312,20,126 632.76 (2) (ac) 4. No individual disability insurance policy, as defined in s.
7632.895 (1) (a), or self-insured health plan, as defined in 632.745 (24), may reduce
8or deny a claim for loss by a participant or beneficiary under the policy or plan who
9is under the age of 19 on the ground that a disease or physical condition existed prior
10to the effective date of coverage. This subdivision does not apply to a grandfathered
11health plan, as defined in s. 632.758 (1), that provides individual health insurance
12coverage.
AB312, s. 52 13Section 52. 632.76 (2) (ac) 4. of the statutes, as affected by 2011 Wisconsin Act
14.... (this act), is repealed.
AB312, s. 53 15Section 53. 632.76 (2) (b) of the statutes is amended to read:
AB312,21,816 632.76 (2) (b) Notwithstanding par. (a), no claim for loss incurred or disability
17commencing after 6 months from the date of issue of a medicare supplement policy,
18medicare replacement policy or long-term care insurance policy may be reduced or
19denied on the ground that a disease or physical condition existed prior to the effective
20date of coverage. Notwithstanding par. (ac) 2., a A medicare supplement policy,
21medicare replacement policy, or long-term care insurance policy may not define a
22preexisting condition more restrictively than a condition for which medical advice
23was given or treatment was recommended by or received from a physician within 6
24months before the effective date of coverage. Notwithstanding par. (a), if on the basis
25of information contained in an application for insurance a medicare supplement

1policy, medicare replacement policy, or long-term care insurance policy excludes
2from coverage a condition by name or specific description, the exclusion must
3terminate no later than 6 months after the date of issue of the medicare supplement
4policy, medicare replacement policy, or long-term care insurance policy. The
5commissioner may by rule exempt from this paragraph certain classes of medicare
6supplement policies, medicare replacement policies, and long-term care insurance
7policies, if the commissioner finds the exemption is not adverse to the interests of
8policyholders and certificate holders.
AB312, s. 54 9Section 54. 632.795 (4) (a) of the statutes is amended to read:
AB312,21,2110 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the
11same policy form and for the same premium as it originally offered in the most recent
12enrollment period, subject only to the medical underwriting used in that enrollment
13period. Unless otherwise prescribed by rule, the insurer may apply deductibles,
14preexisting condition limitations, waiting periods , or other limits only to the extent
15that they would have been applicable had coverage been extended at the time of the
16most recent enrollment period and with credit for the satisfaction or partial
17satisfaction of similar provisions under the liquidated insurer's policy or plan. The
18insurer may exclude coverage of claims that are payable by a solvent insurer under
19insolvency coverage required by the commissioner or by the insurance regulator of
20another jurisdiction. Coverage shall be effective on the date that the liquidated
21insurer's coverage terminates.
AB312, s. 55 22Section 55. 632.85 (2) of the statutes is amended to read:
AB312,22,323 632.85 (2) If a health care plan or a self-insured health plan provides coverage
24of any emergency medical services, the health care plan or self-insured health plan
25shall provide coverage of emergency medical services that are provided in a hospital

1emergency facility, regardless whether that facility is a participating provider with
2respect to the plan,
and that are needed to evaluate or stabilize, as defined in section
31867 of the federal Social Security Act, an emergency medical condition.
AB312, s. 56 4Section 56. 632.85 (4) of the statutes is created to read:
AB312,22,105 632.85 (4) A health care plan or self-insured health plan that is required to
6provide the coverage under sub. (2) shall impose the same cost-sharing
7requirements on coverage for emergency medical services provided by a
8nonparticipating provider as it imposes for services provided by a participating
9provider. This subsection does not apply to a grandfathered health plan, as defined
10in s. 632.758 (1).
AB312, s. 57 11Section 57. 632.865 of the statutes is created to read:
AB312,22,18 12632.865 Choice of primary care provider. A group or individual health
13benefit plan, as defined in s. 632.745 (11), that requires or provides for the
14designation by any individual or beneficiary covered under the plan of a
15participating primary care provider shall allow each individual or beneficiary to
16designate any participating primary care provider who is available to accept that
17individual or beneficiary. This section does not apply to a grandfathered health plan,
18as defined in s. 632.758 (1).
AB312, s. 58 19Section 58. 632.87 (5m) of the statutes is created to read:
AB312,22,2320 632.87 (5m) (a) 1. Except as provided in subd. 2. and par. (d), no health care
21plan, as defined in s. 628.36 (2) (a) 1., that provides coverage for hospital lengths of
22stay in connection with childbirth for a mother or a newborn child may do any of the
23following:
AB312,23,3
1a. Restrict benefits under the plan for any hospital length of stay in connection
2with childbirth for the mother or newborn child, following a normal vaginal delivery,
3to less than 48 hours.
AB312,23,64 b. Restrict benefits under the plan for any hospital length of stay in connection
5with childbirth for the mother or newborn child, following a cesarean section, to less
6than 96 hours.
AB312,23,87 c. Require that a provider obtain authorization from the plan for prescribing
8any length of stay required under subd. 1. a. or b.
AB312,23,129 2. Subdivision 1. does not apply to a health care plan in any case in which the
10decision to discharge the mother or her newborn child before the minimum length
11of stay described under subd. 1. a. or b. is made by an attending provider in
12consultation with the mother.
AB312,23,1413 (b) No health care plan, as defined in s. 628.36 (2) (a) 1., may do any of the
14following:
AB312,23,1715 1. Deny to the mother or her newborn child eligibility, or continued eligibility,
16to enroll in or renew coverage under the plan solely for the purpose of avoiding the
17requirements of this subsection.
AB312,23,1918 2. Provide monetary payments or rebates to mothers to encourage mothers to
19accept less than the minimum protections available under this subsection.
AB312,23,2220 3. Penalize a provider or reduce or limit the reimbursement of a provider
21because the provider provided care to an individual in accordance with this
22subsection.
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