On March 23, 2010, the federal government enacted the Patient Protection and
Affordable Care Act (PPACA), which, among other things, imposes requirements and
limitations on health insurance policies and health plans. This bill incorporates
some of those requirements and limitations of PPACA into state law.
Under current law, no insurer may rescind an insurance policy for a
misrepresentation made by a policyholder if the insurer had constructive or active
knowledge of the fact. An insurer may rescind a policy if it acquires knowledge of
sufficient facts to constitute grounds for rescission after the policy was issued only
if the insurer notifies the insured within 60 days after acquiring the knowledge of its
intent to rescind or within 120 days if the insurer needs to gather additional medical
information. This bill prohibits an insurer from rescinding a health benefit plan, or
a self-insured governmental health plan from recinding a self-insured plan, unless
the applicant for coverage committed fraud or made an intentional
misrepresentation of material fact with regard to obtaining coverage. The insurer
or governmental entity must provide notice before rescinding the plan.
Under current law, a policy or plan providing individual health insurance may
not reduce or deny coverage based on a preexisting disease or condition (preexisting
condition exclusion) after 12 months after the date of issue of the policy or plan unless
the condition was specifically excluded from coverage. The preexisting condition
that is excluded from coverage must have been one for which the individual received
or was recommended medical advice, diagnosis, care, or treatment within 12 months
before the coverage under the plan became effective. A group health benefit plan,
under current law may impose a preexisting condition exclusion on an individual's
coverage only if the condition being excluded was one for which the individual was
recommended or received medical advice, diagnosis, care, or treatment within six
months before the individual's enrollment date under the plan. This bill prohibits
an insurer under a group health benefit plan or an individual health insurance
policy, except for a grandfathered health plan providing individual health coverage,
from imposing a preexisting condition exclusion on a participant or beneficiary
under the plan who is under 19 years of age. A grandfathered health plan is a health
policy or plan in existence on March 23, 2010. As of January 1, 2014, this bill
prohibits an insurer that offers a group health benefit plan or an individual health
insurance policy, except for a grandfathered health plan providing individual health
coverage, from imposing a preexisting condition exclusion on any participant or
beneficiary under the plan, regardless of age.

Under the bill, every group health plan, except for a grandfathered health plan,
and every insurer providing a health insurance policy, and every self-insured
governmental health plan must provide coverage for all preventive care services as
defined in PPACA. The bill prohibits a plan or insurer from subjecting the coverage
of a preventive care service to a copayment or coinsurance.
This bill requires an individual or group health plan, except a grandfathered
health plan, to provide in plain language to the secretary of the federal department
of health and human services (DHHS), the commissioner of insurance, any insurance
exchange if the plan is sold through an exchange, and the public certain disclosures
including claims payment policies and practices, data on enrollment and
disenrollment in the plan, and enrollee and participant rights. A health benefit plan,
except a grandfathered health plan, is also required to make available upon request
on its Internet Web site, and through another means for those without Internet
access, a means to permit individuals to learn the amount of cost sharing required
under the plan for a specific item or service.
This bill requires that a group or individual health benefit plan, except for a
grandfathered health plan, that requires or provides for an individual or beneficiary
to designate a primary care provider must allow each individual or beneficiary to
designate any participating primary care provider who is available to accept that
individual or beneficiary.
Under current law, a health care plan or a self-insured governmental health
plan that provides coverage of any emergency medical services must provide
coverage of emergency medical services that are provided in a hospital emergency
facility and that are needed to evaluate or stabilize an emergency medical condition.
Current law prohibits the health care plan or self-insured governmental health plan
from requiring prior authorization for those emergency medical services. This bill
specifies that the services must be covered regardless whether the hospital
emergency facility is a participating provider in the health care plan or self-insured
governmental health plan. This bill also requires that the health care plan or
self-insured governmental health plan, except for a grandfathered health plan,
impose the same cost-sharing requirements on coverage for emergency medical
services provided by a nonparticipating provider as it imposes for a participating
provider.
With some exceptions, this bill prohibits a self-insured governmental health
plan or a health care plan, except for a grandfathered health plan, from restricting
benefits for a hospital stay for a mother or newborn to less than 48 hours for a vaginal
delivery or less than 96 hours for a cesarean section.
Under current law, every health insurance policy and self-insured
governmental health plan that provides coverage of mastectomies must provide
coverage of breast reconstruction of the affected tissue incident to a mastectomy. The
policy or plan may impose cost-sharing provisions on the breast reconstruction
coverage that apply generally under the policy or plan. This bill specifies that all
stages of breast reconstruction must be covered by a policy or plan. Under the bill,
the policy or plan must also cover surgery and reconstruction of the other breast than
the one on which the mastectomy was performed to produce a symmetrical

appearance and prostheses and physical complications of mastectomy. The bill also
specifies that all procedures covered must be provided in a manner determined in
consultation with the attending physician and the patient. A policy or plan is
required under the bill to provide written notice of the available coverage upon
enrollment in the policy and annually thereafter.
Under current law, every health insurance policy and every self-insured
governmental health plan that provides coverage for a full-time student dependent
of the insured, must continue to provide coverage for that dependent if, due to a
medically necessary leave of absence, the dependent is no longer a full-time student.
The policy or plan is not required to continue coverage unless the medical necessity
of the leave of absence is documented and certified by the attending physician. The
coverage continues until the dependent advises the policy or plan that he or she no
longer intends to return to school full time, becomes employed full time, obtains other
health care coverage, marries and is eligible for coverage as a spouse, reaches an age
where he or she is no longer eligible for dependent coverage, or has not returned to
school full time after one year since the continuation began or until the coverage of
the insured under which the dependent has coverage is discontinued or not renewed.
This bill specifies that a policy or plan must continue coverage only if the leave
commences while the individual is suffering from a serious illness or injury, the leave
is medically necessary, and the leave causes the individual to lose student status.
The bill specifies that the physician must also document that the dependent is
suffering from a serious illness. The bill requires dependent coverage to continue
until the coverage would otherwise end or until one year has elapsed since the
continuation began and the dependent has not returned to school full time, and the
bill eliminates the other situations under which the continued coverage requirement
ends. The bill also requires that every policy and plan provide a description of the
continued coverage during a medically necessary leave of absence with any notice
regarding a requirement for certification of student status for the dependent's
coverage. The dependent whose coverage is being continued during a medically
necessary leave of absence is entitled under the bill to the same coverage as a
full-time student who is not on leave.
Under current law, an insurer is required to provide consumers policies that are
coherent, written in commonly understood language, legible, appropriately divided
and captioned, and presented in a meaningful sequence. The commissioner of
insurance must make rules establishing standards for the understandability of
policies and may exempt types of policies from the specific understandability
requirements if the commissioner determines that the type of policy is generally
understood by those receiving it or those individuals are adequately protected. This
bill additionally requires that, no later than March 23, 2012, each health insurer,
health plan, and self-insured governmental health plan comply with the standards
that the secretary of the federal DHHS will create regarding compiling and providing
a summary of benefits and coverage explanation that accurately describes the
benefits and coverage under the plan.
This bill requires that no later than March 23, 2012, every health care plan,
except for a grandfathered health care plan, and self-insured governmental health

plan must comply with the standards developed by the secretary of the federal DHHS
regarding reporting for reimbursement structures to improve health outcomes and
other quality measures.
This bill prohibits an insurer or self-insured governmental health plan from
imposing a lifetime limit on the dollar value of benefits under the group or individual
health care plan or self-insured plan. Before January 1, 2014, an insurer under a
group or an individual health care plan, except for a grandfathered health plan
providing individual coverage, or a self-insured governmental health plan may
impose only a certain annual limit on the dollar value of benefits as defined by the
secretary of the federal DHHS. Starting on January 1, 2014, an insurer under a
group or individual health care plan, except for a grandfathered health plan
providing individual coverage, and a self-insured governmental health plan may not
impose an annual limit on the dollar value of benefits.
Under current law, if an insurer provides coverage under a group health benefit
plan, the insurer must provide coverage to any eligible employee who becomes an
eligible employee after the group coverage commences, and his or her dependents,
regardless of health condition or claims experience, with certain exceptions. A
self-insured governmental health plan must similarly provide coverage to an
eligible employee who waived coverage during an enrollment period, regardless of
health condition or claims experience, with certain exceptions. With certain
exceptions, under current law, an insurer offering a group health benefit plan must
renew coverage at the option of the employer. Current law also requires an insurer
that provides an individual health benefit plan to renew the coverage for the insured
at the option of the insured, with certain exceptions, but modifications to the
individual health benefit plan that comply with the law are allowed. This bill
requires any insurer that offers an individual health benefit plan, except for a
grandfathered health plan, to offer coverage to any individual, and his or her
dependents, that apply for coverage.
Under current law, insurers offering individual or group health insurance
policies or plans are not limited in what factors they use to set rates, or premiums,
except that they may not discriminate on the basis of race, color, creed, or national
origin and they may not under a group health insurance policy or plan charge a
higher rate based on a health status-related factor. Rates, under current law, may
be modified for individual risks. As of January 1, 2014, health care plans, except for
grandfathered health plans, and self-insured governmental health plans, when
setting premium rates, may only consider whether the plan covers an individual or
a family and the age, tobacco use, and geographic location of any individual covered
under the plan. Rates based on age or tobacco use may only vary a certain amount
under the bill.
For further information see the state and local 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:
SB206, s. 1
1Section 1 . 40.51 (8) of the statutes is amended to read:
SB206,6,62 40.51 (8) Every health care coverage plan offered by the state under sub. (6)
3shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.723,
4632.7252, 632.7254,
632.746 (1) to (8) and (10), 632.747, 632.748, 632.753, 632.798,
5632.83, 632.835, 632.85, 632.853, 632.855, 632.865, 632.87 (3) to (6), 632.883,
6632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.
SB206, s. 2 7Section 2 . 40.51 (8) of the statutes, as affected by 2011 Wisconsin Act .... (this
8act), is amended to read:
SB206,6,139 40.51 (8) Every health care coverage plan offered by the state under sub. (6)
10shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.723,
11632.7252, 632.7254, 632.728, 632.746 (1) (1m) to (8) and (10), 632.747, 632.748,
12632.753, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.865, 632.87 (3) to
13(6), 632.883, 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.
SB206, s. 3 14Section 3 . 40.51 (8m) of the statutes is amended to read:
SB206,6,1915 40.51 (8m) Every health care coverage plan offered by the group insurance
16board under sub. (7) shall comply with ss. 631.95, 632.723, 632.7252, 632.7254,
17632.746 (1) to (8) and (10), 632.747, 632.748, 632.753, 632.798, 632.83, 632.835,
18632.85, 632.853, 632.855, 632.865, 632.87 (5m), 632.883, 632.885, 632.89, and
19632.895 (11) to (17).
SB206, s. 4 20Section 4 . 40.51 (8m) of the statutes, as affected by 2011 Wisconsin Act .... (this
21act), is amended to read:
SB206,7,222 40.51 (8m) Every health care coverage plan offered by the group insurance
23board under sub. (7) shall comply with ss. 631.95, 632.723, 632.7252, 632.7254,
24632.728, 632.746 (1) (1m) to (8) and (10), 632.747, 632.753, 632.748, 632.798, 632.83,

1632.835, 632.85, 632.853, 632.855, 632.865, 632.87 (5m), 632.883, 632.885, 632.89,
2and 632.895 (11) to (17).
SB206, s. 5 3Section 5 . 66.0137 (4) of the statutes is amended to read:
SB206,7,104 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
5a village provides health care benefits under its home rule power, or if a town
6provides health care benefits, to its officers and employees on a self-insured basis,
7the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
8632.723, 632.7252, 632.7254, 632.746 (2) (dm) and (10) (a) 2. and (b) 2., 632.747 (3),
9632.753, 632.798, 632.85, 632.853, 632.855, 632.865, 632.87 (4), (5), and to (6),
10632.883, 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
SB206, s. 6 11Section 6 . 66.0137 (4) of the statutes, as affected by 2011 Wisconsin Act ....
12(this act), is amended to read:
SB206,7,1913 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
14a village provides health care benefits under its home rule power, or if a town
15provides health care benefits, to its officers and employees on a self-insured basis,
16the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
17632.723, 632.7252, 632.7254, 632.728, 632.746 (2) (dm) (1m) and (10) (a) 2. and (b)
182., 632.747 (3), 632.753, 632.798, 632.85, 632.853, 632.855, 632.865, 632.87 (4) to (6),
19632.883, 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
SB206, s. 7 20Section 7 . 120.13 (2) (g) of the statutes is amended to read:
SB206,7,2521 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
2249.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.723, 632.7252, 632.7254, 632.746 (2)
23(dm) and
(10) (a) 2. and (b) 2., 632.747 (3), 632.753, 632.798, 632.85, 632.853,
24632.855, 632.865, 632.87 (4), (5), and to (6), 632.883, 632.885, 632.89, 632.895 (9) to
25(17), 632.896, and 767.513 (4).
SB206, s. 8
1Section 8 . 120.13 (2) (g) of the statutes, as affected by 2011 Wisconsin Act ....
2(this act), is amended to read:
SB206,8,73 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
449.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.723, 632.7252, 632.7254, 632.728,
5632.746 (2) (dm) (1m) and (10) (a) 2. and (b) 2., 632.747 (3), 632.753, 632.798, 632.85,
6632.853, 632.855, 632.865, 632.87 (4) to (6), 632.883, 632.885, 632.89, 632.895 (9) to
7(17), 632.896, and 767.513 (4).
SB206, s. 9 8Section 9 . 185.983 (1) (intro.) of the statutes is amended to read:
SB206,8,179 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
10cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
11646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
12601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
13631.95, 632.72 (2), 632.723, 632.7252, 632.7254, 632.745 to 632.749, 632.753,
14632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.865, 632.87 (2),
15(2m), (3), (4), (5), and
to (6), 632.883, 632.885, 632.89, 632.895 (5) and (8) to (17),
16632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the
17sponsoring association shall:
SB206, s. 10 18Section 10 . 185.983 (1) (intro.) of the statutes, as affected by 2011 Wisconsin
19Act .... (this act), is amended to read:
SB206,9,320 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
21cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
22646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
23601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
24631.95, 632.72 (2), 632.723, 632.7252, 632.7254, 632.728, 632.745 to 632.749,
25632.753, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.865,

1632.87 (2) to (6), 632.883, 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and
2632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association
3shall:
SB206, s. 11 4Section 11. 609.22 (3) of the statutes is amended to read:
SB206,9,125 609.22 (3) Primary provider selection. A Except as provided in s. 632.865,
6a
defined network plan that is not a preferred provider plan shall permit each
7enrollee to select his or her own primary provider from a list of participating primary
8care physicians and any other participating providers that are authorized by the
9defined network plan to serve as primary providers. The list shall be updated on an
10ongoing basis and shall include a sufficient number of primary care physicians and
11any other participating providers authorized by the plan to serve as primary
12providers who are accepting new enrollees.
SB206, s. 12 13Section 12. 609.845 of the statutes is created to read:
SB206,9,18 14609.845 Coverage requirements and limitations; preventive care;
15maternal and newborn care; quality; standardization.
Limited service health
16organizations, preferred provider plans, and defined network plans are subject to ss.
17632.723, 632.7252, 632.7254, 632.746 (2) (dm) or 632.76 (2) (ac) 4., 632.753, 632.865,
18632.87 (5m), 632.883, and 632.895 (13m).
SB206, s. 13 19Section 13 . 609.845 of the statutes, as created by 2011 Wisconsin Act .... (this
20act), is amended to read:
SB206,9,25 21609.845 Coverage requirements and limitations; preventive care;
22maternal and newborn care; quality; standardization.
Limited service health
23organizations, preferred provider plans, and defined network plans are subject to ss.
24632.723, 632.7252, 632.7254, 632.728, 632.746 (2) (dm) (1m) or 632.76 (2) (ac) 4.,
25632.7493, 632.753, 632.865, 632.87 (5m), 632.883, and 632.895 (13m).
SB206, s. 14
1Section 14. 625.12 (1) (a) and (e) of the statutes are amended to read:
SB206,10,32 625.12 (1) (a) Past and prospective loss and expense experience within and
3outside of this state, except as provided in s. 632.728.
SB206,10,54 (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including
5the judgment of technical personnel.
SB206, s. 15 6Section 15. 625.12 (2) of the statutes is amended to read:
SB206,10,157 625.12 (2) Classification. Risks Except as provided in s. 632.728, risks may
8be classified in any reasonable way for the establishment of rates and minimum
9premiums, except that no classifications may be based on race, color, creed or
10national origin, and classifications in automobile insurance may not be based on
11physical condition or developmental disability as defined in s. 51.01 (5). Subject to
12s. ss. 632.365 and 632.728, rates thus produced may be modified for individual risks
13in accordance with rating plans or schedules that establish reasonable standards for
14measuring probable variations in hazards, expenses, or both. Rates may also be
15modified for individual risks under s. 625.13 (2).
SB206, s. 16 16Section 16. 625.15 (1) of the statutes is amended to read:
SB206,10,2417 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may
18itself establish rates and supplementary rate information for one or more market
19segments based on the factors in s. 625.12 and, if the rates are for motor vehicle
20liability insurance, subject to s. 632.365, or the insurer may use rates and
21supplementary rate information prepared by a rate service organization, with
22average expense factors determined by the rate service organization or with such
23modification for its own expense and loss experience as the credibility of that
24experience allows.
SB206, s. 17 25Section 17. 628.34 (3) (a) of the statutes is amended to read:
SB206,11,7
1628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
2charging different premiums or by offering different terms of coverage except on the
3basis of classifications related to the nature and the degree of the risk covered or the
4expenses involved, subject to ss. 632.365, 632.728, 632.746 and 632.748. Rates are
5not unfairly discriminatory if they are averaged broadly among persons insured
6under a group, blanket or franchise policy, and terms are not unfairly discriminatory
7merely because they are more favorable than in a similar individual policy.
SB206, s. 18 8Section 18. 631.11 (4) (a) and (b) of the statutes are amended to read:
SB206,11,169 631.11 (4) (a) Knowledge when policy issued. No Except as provided in s.
10632.753, no
misrepresentation made by or on behalf of a policyholder and no breach
11of an affirmative warranty or failure of a condition constitutes grounds for rescission
12of, or affects an insurer's obligations under, an insurance policy if at the time the
13policy is issued the insurer has either constructive knowledge of the facts under s.
14631.09 (1) or actual knowledge. If the application is in the handwriting of the
15applicant, the insurer does not have constructive knowledge under s. 631.09 (1)
16merely because of the agent's knowledge.
SB206,11,2417 (b) Knowledge acquired after policy issued. If Except as provided in s. 632.753,
18after issuance of an insurance policy an insurer acquires knowledge of sufficient facts
19to constitute grounds for rescission of the policy under this section or a general
20defense to all claims under the policy, the insurer may not rescind the policy and the
21defense is not available unless the insurer notifies the insured within 60 days after
22acquiring such knowledge of its intention to either rescind the policy or defend
23against a claim if one should arise, or within 120 days if the insurer determines that
24it is necessary to secure additional medical information.
SB206, s. 19 25Section 19. 631.22 (2) of the statutes is amended to read:
SB206,12,7
1631.22 (2) An Subject to s. 632.7252, an insurer may provide a consumer
2insurance policy which is delivered to a person obtaining insurance coverage and is
3not exempt under sub. (5) only if the consumer insurance policy is coherent, written
4in commonly understood language, legible, appropriately divided and captioned by
5its various sections and presented in a meaningful sequence. The commissioner shall
6promulgate rules establishing standards for the determination of compliance with
7this subsection.
SB206, s. 20 8Section 20. 631.22 (5) of the statutes is amended to read:
SB206,12,139 631.22 (5) The Except as provided in s. 632.7252, the commissioner may by rule
10exempt a type of consumer insurance policy from the application of this section if the
11commissioner finds that type of consumer insurance policy is generally understood
12by persons to whom it is delivered or that those persons are otherwise adequately
13protected.
SB206, s. 21 14Section 21. 631.95 (3) (a) of the statutes is repealed.
SB206, s. 22 15Section 22. 632.723 of the statutes is created to read:
SB206,12,22 16632.723 Transparency in coverage. (1) Required information. Except as
17provided in sub. (4), in addition to other required disclosures, a group or individual
18health benefit plan, as defined in s. 632.745 (11), shall provide the following
19information to the secretary of the federal department of health and human services
20and to the commissioner; provide the following information to any insurance
21exchange, if the plan is sold through an insurance exchange; and make the following
22information available to the public:
SB206,12,2323 (a) Claims payment policies and practices.
SB206,12,2424 (b) Financial disclosures, periodically.
SB206,12,2525 (c) Data on enrollment in the plan.
SB206,13,1
1(d) Data on disenrollment in the plan.
SB206,13,22 (e) Data on the number of claims that are denied.
SB206,13,33 (f) Data on rating practices.
SB206,13,54 (g) Cost-sharing data and payments with respect to any out-of-network
5coverage.
SB206,13,66 (h) Enrollee and participant rights.
SB206,13,87 (i) Other information required by the secretary of the federal department of
8health and human services.
SB206,13,12 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.
SB206,13,1413 (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.
SB206,13,20 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.
SB206,13,22 21(4) Applicability. This section does not apply to a grandfathered health plan,
22as defined in s. 632.758 (1).
SB206, s. 23 23Section 23. 632.7252 of the statutes is created to read:
SB206,14,6 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.
SB206, s. 24 7Section 24. 632.7254 of the statutes is created to read:
SB206,14,16 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).
SB206, s. 25 17Section 25. 632.728 of the statutes is created to read:
SB206,14,19 18632.728 Rates for individual and group health care plans. (1) In this
19section:
SB206,14,2020 (a) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
SB206,14,2121 (b) "Self-insured health plan" has the meaning given in s. 632.85 (1) (c).
SB206,15,2 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.
SB206,15,4 3(3) (a) The rate under sub. (2) that is based on age may not vary more than 3
4to 1 for adults.
SB206,15,65 (b) The rate under sub. (2) that is based on tobacco use may not vary more than
61.5 to 1.
SB206,15,87 (c) The commissioner shall establish one or more geographical rating areas for
8the purposes of setting premiums or rates under sub. (2).
SB206,15,10 9(4) This section does not apply to a grandfathered health plan, as defined in
10s. 632.758 (1).
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