AB920: Bill Text Engrossed

AB920-engrossed,3,8 (b) A business owner, including the owner of a farm business.

AB920-engrossed,3,9 (c) A partner of a partnership.

AB920-engrossed,3,11 (d) A member of a limited liability company or a corporation defined under 26 USC 1361 (a) (1).

AB920-engrossed,4,2 (2) Employer groups; qualification. (a) Two or more employers that are members of the same chamber of commerce or industry-based association may form an employer group to establish and administer an employee health care benefit arrangement to jointly provide health care benefits on a self-funded basis to eligible employees of employers in the group and the dependents of those eligible employees.

AB920-engrossed,4,4 (am) To qualify under par. (b), an employer group shall satisfy all of the following:

AB920-engrossed,4,6 1. The employer group creates and maintains a formal organizational structure with a governing body and an indication of formality, such as having by-laws.

AB920-engrossed,4,10 2. The employers in the employer group control functions and activities of the employer group, including establishment and maintenance of the employee health care benefit arrangement, directly or indirectly through nomination and election of representatives that control the employer group or association.

AB920-engrossed,4,16 3. The chamber of commerce or industry-based association from which the employer group is formed is actively in existence for at least 5 years before providing evidence to the commissioner under par. (b), has at least 5 members for the 5 years before providing evidence to the commissioner under par. (b), and is formed and maintained in good faith for purposes other than obtaining or providing health benefits.

AB920-engrossed,4,23 (b) Employer groups that provide evidence to the commissioner of insurance that they have formed and are able to comply with the requirements of this section qualify to participate in the project under this section. When employer groups have qualified under this paragraph, the commissioner of insurance shall submit a notice to the legislative reference bureau for publication in the Wisconsin Administrative Register that lists the employer groups that have qualified and the date on which each group provided the necessary evidence of compliance.

AB920-engrossed,4,25 (3) Employer group duties and powers. (a) Each employer group qualified under sub. (2) (b) shall do all of the following:

AB920-engrossed,5,2 1. Determine all matters necessary for the administration and operation of its employee health care benefit arrangement.

AB920-engrossed,5,3 2. Designate an agent for service of process, notice, or demand.

AB920-engrossed,5,13 4. Employ or contract with an actuary to make recommendations, in accordance with generally accepted actuarial principles, as to the sufficient amount of funding for the employee health care benefit arrangement. The employer group shall ensure that the actuary making recommendations under this subdivision is in good standing with the Academy of Actuaries, has the skills and knowledge necessary to perform the analyses and make the recommendations, and is performing the analyses and certifications based on sound actuarial principles. The employer group satisfies the requirement under this subdivision if the employer group contracts with an insurer or a 3rd-party administrator that employs an actuary.

AB920-engrossed,5,24 5. Determine, based on the actuary's recommendations under subd. 4., the amount that each employer that is participating in the employer group shall contribute to self-fund the employee health care benefit arrangement; to pay administrative expenses, including the actuary's compensation; and to purchase excess or stop-loss coverage, as described under sub. (5) (b). The contribution amount under this subdivision may vary by employer based on criteria developed by the employer group. An employer group may require employers in the employer group to contribute payments for establishing a surplus fund and may levy an assessment whenever the amount of any loss or expense that is due exceeds the assets of the employer group or the surplus fund amount established by the employer group is impaired.

AB920-engrossed,6,7 6. Establish a minimum participation period for an employer's participation in the employer group, which shall be the same length for each employer participating in the employer group and may not be less than 3 years. An employer group may specify circumstances under which a participating employer may discontinue participation in the employer group before the minimum participation period established under this subdivision ends without forfeiting all or a portion of the amount paid by the employer under sub. (4) (a) 2.

AB920-engrossed,6,10 7. Annually submit a report to the commissioner of insurance describing the stability of the employer group and the finances of the employer group and containing any information specified by the commissioner by rule under sub. (5m).

AB920-engrossed,6,14 8. Specify in an agreement among the employers in the employer group or in the by-laws of the employer group the procedures to be followed by and responsibilities of the involved parties in the event of insolvency or pending insolvency of the employer group.

AB920-engrossed,6,21 (b) An employer group qualified under sub. (2) (b) may specify minimum participation requirements that an employer is required to satisfy to participate in the employer group. Except as provided under sub. (4) (b), an employer group qualified under sub. (2) (b) shall allow any employer that is a member of the same chamber of commerce or industry-based association as the other group members and that agrees to comply with the participation requirements specified under this paragraph to participate in the employer group.

AB920-engrossed,7,3 (c) If an employer group qualified under sub. (2) (b) seeks to contract with a 3rd-party administrator to administer any part of the health care benefit arrangement, the employer group shall contract with a 3rd-party administrator that is registered to do business in this state. A contract between an employer group and a 3rd-party administrator that relates to the administration of the payment of claims shall specify terms for the resolution of claims upon termination of the contract with that 3rd-party administrator.

AB920-engrossed,7,5 (4) Employer requirements. (a) An employer group qualified under sub. (2) (b) shall require each of its participating employers to do all of the following:

AB920-engrossed,7,8 1. Offer the same health care benefits, or health care benefit arrangements with a de minimis difference in actuarial value, to all of the employer's eligible employees and all of the eligible employees' dependents.

AB920-engrossed,7,13 2. Participate for at least the minimum participation period specified by the employer group under sub. (3) (a) 6. An employer group may require employers that desire to participate in the employer group to pay an amount that is forfeited to the employer group if the employer's participation terminates voluntarily or involuntarily before the employer's minimum participation period ends.

AB920-engrossed,7,17 (b) Subject to any policy created by the employer group regarding late payments, an employer group qualified under sub. (2) (b) shall terminate an employer's participation in the employer group if the employer fails to pay a contribution required by the employer group under sub. (3) (a) 5.

AB920-engrossed,7,20 (c) An employer group qualified under sub. (2) (b) shall hold an employer whose participation in the employer group terminates voluntarily or involuntarily responsible for all of the following:

AB920-engrossed,7,22 1. Any contribution amounts required during the employer's period of participation.

AB920-engrossed,7,25 2. The employer's proportionate share of the cost of any claims payable by the employer group that were incurred before the termination of the employer's participation.

AB920-engrossed,8,5 (5) Covered benefits; payment of claims. (a) An employer group may provide a choice of health care benefit plans to employers but each employer that participates in the employer group shall offer the same health care benefits, or health care arrangement with a de minimis difference in actuarial value, to all employees and dependents of the employer.

AB920-engrossed,8,14 (am) 1. An employer group qualified under sub. (2) (b) may not exclude coverage under a health care benefit arrangement for diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license if the health care benefit arrangement covers diagnosis and treatment of a condition or complaint by a licensed physician or osteopath, even if different nomenclature is used to describe the condition or complaint. The health care benefit arrangement may not require examination by or referral from a physician before allowing coverage of chiropractic care under this paragraph. This paragraph does not prohibit any of the following:

AB920-engrossed,8,17 a. Application of deductibles or coinsurance under the health care benefit arrangement to chiropractic care if deductibles or coinsurance apply equally to physician care.

AB920-engrossed,8,20 b. Application of cost containment or quality assurance measures to chiropractic services in a manner that is consistent with cost containment or quality assurance measures applied to physician services.

AB920-engrossed,8,24 2. An employer group qualified under sub. (2) (b) may not do any of the following under a health care benefit arrangement that covers diagnosis and treatment of conditions or complaints by a licensed chiropractor within the scope of the chiropractor's professional license:

AB920-engrossed,9,5 a. Restrict or terminate coverage for the treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license other than on the basis of an examination, evaluation, or recommendation by another licensed chiropractor or a peer review committee that includes a licensed chiropractor.

AB920-engrossed,9,7 b. Exclude or restrict coverage of a health condition under the health care benefit arrangement solely because the condition may be treated by a chiropractor.

AB920-engrossed,9,11 (ar) Each employer group qualified under sub. (2) (b) shall offer under each employee health care benefit arrangement coverage of individuals, conditions, and services as described in ss. 631.89, 631.93 (2), 631.95, 632.85 (2), 632.867, 632.87, 632.88, 632.885, 632.89 (2), 632.895, 632.896, and 632.897.

AB920-engrossed,9,19 (b) An employer group qualified under sub. (2) (b) shall pay no more than $50,000 in benefits on a self-funded basis incurred in a calendar year for each individual covered under its employee health care benefit arrangement, unless the employer group is financially capable of paying more than $50,000 in benefits per individual per calendar year as confirmed by an independent actuary. Each employer group shall obtain excess or stop-loss coverage through an insurer authorized to do business in this state in an amount that is sufficient to pay claims that exceed the amount that the employer group will pay on a self-funded basis.

AB920-engrossed,9,23 (c) If an employer group qualified under sub. (2) (b) ceases operating its employee health care benefit arrangement, the employer group is responsible for paying eligible claims incurred during the time in which the employee health benefit arrangement was operating.

AB920-engrossed,9,25 (5m) Commissioner oversight. (a) The commissioner of insurance may examine the solvency of an employer group qualified under sub. (2) (b), including the surplus funds available to the employer group and the levels and cost of reinsurance, using statutory accounting principles. The commissioner may promulgate rules regarding the solvency of employer groups qualified under sub. (2) (b). The commissioner may require an employer group to take corrective action, issue an order, or initiate an enforcement proceeding described under s. 601.41 (4) to remedy a violation of rules promulgated under this paragraph.

AB920-engrossed,10,10 (b) If, after the effective date of this paragraph .... [LRB inserts date], the federal department of labor publishes a final rule allowing states regulatory authority over association health plans, the commissioner of insurance may promulgate rules to implement the federal law.

AB920-engrossed,10,16 (6) Exemption from insurance regulation. Notwithstanding 29 USC 1144 (b) (6) (A) and except as provided in sub. (5m), chs. 600 to 646 and any rules promulgated under chs. 600 to 646 do not apply to an employer group or an employee health care benefit arrangement under this section. An employer group may not be considered an insurer, and an employee health care benefit arrangement may not be considered an insurance contract, for any purpose under the statutes.

AB920-engrossed,2 Section 2. 600.01 (1) (b) 13. of the statutes is created to read:

AB920-engrossed,10,19 600.01 (1) (b) 13. Any employer group or employee health care benefit arrangement under s. 146.79.

AB920-engrossed,3 Section 3. 601.415 (14) of the statutes is created to read:

AB920-engrossed,10,22 601.415 (14) Qualification of employer groups. The commissioner shall qualify employer groups as specified under s. 146.79 (2) (b).

AB920-engrossed,10,23 (End)