632.897(3)(e)
(e) This subsection does not require coverage of expenses which are covered by medicare.
632.897(4)(a)(a) A terminated insured who elects conversion coverage under
sub. (2) (b) or
(3) (c) or
(d), the spouse or dependent of such a terminated insured, if the terminated insured is eligible under
sub. (2) (b) 2. and the spouse or dependent was covered under the group policy, and a terminated insured eligible under
sub. (9) and his or her dependents are entitled to have the insurer issue to them, without evidence of insurability, individual coverage reasonably similar to the terminated coverage under the group policy or individual policy. Any probationary or waiting periods required by such individual coverage shall be considered as being met to the extent such limitations have been met under the prior group policy or individual policy.
632.897(4)(b)
(b) The commissioner shall promulgate, by rule, 3 plans of individual coverage varying in degree of covered benefits to be offered as individual conversion policies. The insurer provides reasonably similar individual coverage if a person is offered his or her choice of the plans promulgated by the commissioner or is offered a high limit comprehensive plan of benefits regularly provided by the insurer for conversions and approved for this purpose by the commissioner. This paragraph does not apply if the policy being converted is a long-term care insurance policy.
632.897(4)(bm)
(bm) The commissioner shall specify, by rule, the minimum standards that an individual conversion policy must satisfy if the policy being converted is a long-term care insurance policy. An insurer provides reasonably similar individual coverage to a person converting a long-term care insurance policy if the person is offered an individual conversion policy that complies with the rules promulgated under this paragraph.
632.897(4)(c)
(c) If the first premium for conversion coverage is tendered to the insurer within 30 days after the notice of termination of group coverage, the individual conversion policy shall be issued with an effective date of the day following the termination of group or individual coverage.
632.897(4)(d)
(d) This subsection does not require individual coverage to be offered by an insurer offering group policies only. This subsection does not require an insurer to issue, or continue in force, an individual conversion policy covering a terminated insured or his or her spouse or dependent if benefits provided or available to the covered person under
subds. 1. to
3., together with the converted policy's benefits, would result in overinsurance according to the insurer's standards for overinsurance, and these standards have been filed with and approved by the commissioner prior to use:
632.897(4)(d)1.
1. Similar benefits under another individual policy for which the terminated insured, spouse or dependent is eligible.
632.897(4)(d)2.
2. Similar benefits under a group policy for which the terminated insured, spouse or dependent is eligible.
632.897(4)(d)3.
3. Similar benefits for which the terminated insured, spouse or dependent is eligible by reason of any state or federal law.
632.897(5)
(5) A notification of the group continuation and individual conversion privileges shall be included in each certificate of coverage for a group policy as defined in
sub. (1) (c) 1.,
1m. or
3. and in any evidence of coverage provided by a group policy as defined in
sub. (1) (c) 2.
632.897(6)
(6) If the terminated insured elects to continue group coverage as provided in this section, the insurer may require conversion to individual coverage by the terminated insured and his or her spouse and dependents 18 months after the terminated insured elects the group coverage except as provided in
s. 103.10 (9) (d). The conditions, rights and procedures governing conversion under
sub. (4) (a) apply to this conversion.
632.897(8)
(8) Premium payments for continued group coverage required under this section shall be paid to the employer. The employer shall collect, and the insurer shall bill the employer for, those premiums. The insurer shall charge the claims experience of individuals covered under continued group coverage against the claims experience of the employer. An insurer is not required to issue a new certificate of insurance to an individual obtaining continued group coverage under this section.
632.897(9)(a)(a) No individual policy which provides coverage to the spouse of the insured may contain a provision for termination of coverage for the spouse solely as a result of a break in their marital relationship except by reason of the entry of a judgment of divorce or annulment of their marriage.
632.897(9)(b)
(b) Every individual policy which contains a provision for the termination of coverage of the spouse of the insured upon divorce or annulment shall contain a provision to the effect that upon divorce or annulment the former spouse has the right to obtain individual coverage under
sub. (4) and that coverage of the former spouse shall continue until he or she is notified of that right in accordance with
par. (c) if the premium for the coverage continues to be paid by or on behalf of the former spouse. This individual coverage shall provide to the former spouse the option to include dependent children previously covered.
632.897(9)(c)
(c) When the insurer is notified that the coverage of a spouse may be terminated because of a divorce or annulment, the insurer shall provide the former spouse written notification of the right to obtain individual coverage under
sub. (4), the premium amounts required and the manner, place and time in which premiums may be paid. This notice shall be given not less than 30 days before the former spouse's coverage would otherwise terminate. The premium shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of every person to be covered and to the type and amount of coverage provided. If the former spouse tenders the first monthly premium to the insurer within 30 days after the notice provided by this paragraph,
sub. (4) shall apply and the former spouse shall receive individual coverage commencing immediately upon termination of his or her coverage under the insured's policy.
632.897(10)(a)(a) No group policy or individual policy which provides coverage to dependent children of the group member or insured may deny eligibility for coverage to any child, or set a premium for any child which is different from that which is set for other dependent children, based solely on any of the following:
632.897(10)(a)1.
1. The fact that the child does not reside with the group member or insured or is dependent on another parent rather than the group member or insured.
632.897(10)(a)2.
2. The proportion of the child's support provided by the group member or insured.
632.897(10)(a)3.
3. The fact that the group member or insured does not claim the child as an exemption for federal income tax purposes under
26 USC 151 (c) (1) (B), or as an exemption for state income tax purposes under
s. 71.07 (8) (b) or under the laws of another state, if a court order under
s. 767.25 (4m) or
767.51 (3m) or the laws of another state assigns responsibility for the child's health care expenses to the group member or insured.
632.897(10)(a)5.
5. The fact that the child resides outside the insurer's geographical service area.
632.897(10)(am)
(am) If a court orders an individual to provide coverage for health care expenses for a child of the individual and the individual is eligible for family coverage under a group policy or individual policy, the insurer shall do all of the following:
632.897(10)(am)1.
1. Provide family coverage under the group policy or individual policy for the individual's child, if eligible for coverage, without regard to any enrollment period restrictions that may apply under the policy.
632.897(10)(am)2.
2. Provide family coverage under the group policy or individual policy for the individual's child, if eligible for coverage, upon application by the individual, the child's other parent, the department of health and family services or the county designee under
s. 59.53 (5).
632.897(10)(am)3.
3. After the child is covered under the group policy or individual policy, and as long as the individual is eligible for family coverage under the policy, continue to provide coverage for the child unless the insurer receives satisfactory written evidence that the court order is no longer in effect or that the child has coverage under another group policy or individual policy that provides comparable health care coverage.
632.897(10)(b)
(b) Paragraphs (a) and
(am) do not prohibit an insurer from determining the eligibility of a group member's or insured's child for coverage under the group policy or individual policy, or the premium for that coverage, based on factors that are not prohibited by
par. (a) 1. to
5. and that the insurer applies generally to determine the eligibility of children for coverage, and the premium for coverage, under the group policy or individual policy.
632.897(10)(bf)
(bf) If an insurer provides coverage under a group policy or an individual policy for a child of a group member or an insured who is not the custodial parent of the child, the insurer shall do all of the following:
632.897(10)(bf)1.
1. Provide to the custodial parent of the child information related to the child's enrollment.
632.897(10)(bf)2.
2. Permit the custodial parent of the child, a health care provider that provides services to the child or the department of health and family services to submit claims for covered services without the approval of the parent who is the group member or insured.
632.897(10)(bf)3.
3. Pay claims directly to the health care provider, the custodial parent of the child or the department of health and family services, as appropriate.
632.897(10)(c)
(c) This subsection applies to any group policy that would otherwise be exempt under
s. 600.01 (1) (b) 3. if at least 25 of the certificate holders or insureds are residents of this state.
632.897 Cross-reference
Cross-reference: See s.
49.45 (20) concerning exemption from continuation of group coverage.
632.897 Annotation
Employe retirement income security act preempts any state law that relates to employe benefit plans. General Split Corp. v. Mitchell, 523 F Supp. 427 (1981).
632.897 Annotation
Wisconsin health insurance continuation/conversion law. Michal, WBB February 1982.
632.898
632.898
Medical savings accounts. 632.898(1)(a)
(a) "Account administrator" means any of the following:
632.898(1)(a)1.
1. A financial institution, the accounts of which are insured by the Federal Deposit Insurance Corporation or the national credit union share insurance fund.
632.898(1)(a)6.
6. A certified public accountant licensed to practice in this state.
632.898(1)(a)8.
8. An employer that participates in the program under this section.
632.898(1)(c)
(c) "High cost-share health plan" means any health insurance policy, certificate or contract with deductibles, copayments or other cost-sharing provisions of at least $1,500 if the insured's coverage is single or at least $3,000 if the insured's coverage is family.
632.898(2)(a)(a) An employer that, in providing health insurance coverage for its employes, offers its employes a choice of health benefit plan options that includes a high cost-share health plan may establish a medical savings account for an employe who chooses a high cost-share health plan.
632.898(2)(b)
(b) The medical savings account shall be established as a separate account in the employe's name and shall be the employe's property. The account may be established with any account administrator that is approved by the commissioner to administer medical savings accounts. The commissioner shall approve an account administrator to administer medical savings accounts if the account administrator insures the principal of the medical savings account against loss from any cause, including loss due to market fluctuation. Whenever an employer establishes a medical savings account on behalf of an employe, the employer shall notify the department of revenue, in the manner prescribed by the department of revenue, of the establishment of the account, the employe's name and social security number, the name and address of the account administrator and any other information that the department of revenue may require.
632.898(2)(c)
(c) Only an employer under
par. (a), whether that employer established the account or is a succeeding employer of an employe for whom a medical savings account has been established, may make deposits in the medical savings account of an employe who chooses a high cost-share health plan. Except as provided in
par. (d), such an employer shall deposit in the account the difference between what the employer pays on behalf of the employe, or the employe and his or her dependents, for the high cost-share health plan and what the employer would pay on behalf of the employe, or the employe and his or her dependents, for the most expensive health benefit plan that the employer offers that is not a high cost-share health plan. Except as provided in
sub. (4) (a), no other deposits may be made in the account.
632.898(2)(d)
(d) An employer that establishes a medical savings account on behalf of an employe is not required to deposit in the account more than $2,000 per year for the employe if the employe's coverage is single, or more than $2,000 per year for the employe, $2,000 per year for the employe's spouse or $1,000 per year for each nonspouse dependent of the employe if the employe's coverage is family. Beginning in 1998, the amounts specified in this paragraph shall be increased each year in the manner provided in
s. 71.05 (6) (b) 22. [24.].
632.898 Note
NOTE: The bracketed language indicates the correct cross-reference. Corrective legislation is pending.
632.898(2)(e)
(e) An employe who chooses a high cost-share health plan and for whom a medical savings account is established is not eligible for coverage under a different health benefit plan offered by the employer before the end of the policy term of the high cost-share health plan.
632.898(3)(a)(a) A self-employed person who purchases a high cost-share health plan may establish a medical savings account in his or her name. Upon establishing a medical savings account, a self-employed person shall notify the department of revenue, in the manner prescribed by the department of revenue, of the establishment of the account, the self-employed person's name and social security number, the name and address of the account administrator and any other information that the department of revenue may require.
632.898(3)(b)
(b) Except as provided in
par. (c), a self-employed person who establishes a medical savings account shall deposit in the account the difference between what the self-employed person pays for the high cost-share health plan, including coverage for his or her dependents, and what the self-employed person would pay for a more expensive health benefit plan, including coverage for his or her dependents. Except as provided in
sub. (4) (b), no other deposits may be made in the account.
632.898(3)(c)
(c) A self-employed person who establishes a medical savings account is not required to deposit in the account more than $2,000 per year for himself or herself if the self-employed person's coverage is single, or more than $2,000 per year for himself or herself, $2,000 per year for his or her spouse or $1,000 per year for each nonspouse dependent if the self-employed person's coverage is family. Beginning in 1998, the amounts specified in this paragraph shall be increased each year in the manner provided in
s. 71.05 (6) (b) 22. [24.].
632.898 Note
NOTE: The bracketed language indicates the correct cross-reference. Corrective legislation is pending.
632.898(4)(a)(a) If an employe with a medical savings account under this section becomes self-employed and purchases a high cost-share health plan, he or she may make deposits in the account as provided in
sub. (3).
632.898(4)(b)
(b) If a self-employed person with a medical savings account under this section becomes employed by an employer described in
sub. (2) (a) and chooses a high cost-share health plan, the employer may make deposits in the account as provided in
sub. (2).
632.898(5)(a)(a) Amounts deposited in an account under this section and any interest, dividends or other gain that accrues on amounts deposited in the account may be used only for any of the following:
632.898(5)(a)2.
2. To pay long-term care expenses of the employe or self-employed person or any of the employe's or self-employed person's dependents.
632.898(5)(a)3.
3. To purchase a long-term care insurance policy for the employe or self-employed person or any of the employe's or self-employed person's dependents.
632.898(5)(b)
(b) An employe or self-employed person with a medical savings account shall provide information about the use of the account funds, in the manner prescribed by the department of revenue, in conjunction with the filing of his or her Wisconsin income tax return.
632.898(5)(c)
(c) Paragraph (a) does not apply after the death of the employe or self-employed person.
632.898(6)(a)(a) A person that provides medical care, long-term care or a long-term care insurance policy, the cost of which is to be paid with funds in a medical savings account, shall bill the employe or self-employed person who is the holder of the account directly, rather than billing the account administrator of the medical savings account.
632.898(6)(b)
(b) The account administrator of a medical savings account shall do all of the following:
632.898(6)(b)1.
1. Permit withdrawals from the account at least once a month.
632.898(6)(b)2.
2. Issue an account statement to the holder of the account at least quarterly.
632.898(7)
(7) If the federal government enacts legislation providing for a federal income tax exemption for amounts deposited in an account established under this section and for any interest, dividends or other gain that accrues in the account if redeposited in the account, the commissioner shall conduct a study, to be completed within 4 years after the enactment of the federal legislation, of individuals and groups that had coverage under a high cost-share health plan and that terminated that coverage in order to enroll in a health benefit plan that was not a high cost-share health plan. If as a result of the study the commissioner determines that
s. 632.745 (1) (f) 2. is not necessary for the purpose for which it was intended, the commissioner shall certify that determination to the revisor of statutes. Upon the certification, the revisor of statutes shall publish notice in the Wisconsin administrative register of the determination, the date of the certification and that after 30 days after the date of the certification
s. 632.745 (1) (f) 2. is not effective.
632.898 History
History: 1995 a. 453.
FRATERNAL INSURANCE
632.91
632.91
Definition. In this subchapter, "insured employe" means an employe of a fraternal or of a subsidiary or other affiliate of a fraternal who is provided insurance benefits by the fraternal under
s. 614.10 (2) (c) but is not a member of the fraternal.
632.91 History
History: 1989 a. 336;
1991 a. 189.
632.93
632.93
The fraternal contract. 632.93(1)
(1)
Issuance of certificate. A fraternal shall issue to each benefit member and insured employe a policy or certificate specifying the benefits provided and containing at least in substance all sections of the laws of the fraternal which might result in the termination of coverage or the reduction of benefits. The policy or certificate, any riders or endorsements attached thereto, the laws of the fraternal, and the application and declarations made in connection therewith and signed by the applicant, constitute the agreement between the fraternal and the member or insured employe, and the policy or certificate shall so state.
632.93(2)
(2) Changes in laws of fraternals. Except as provided in
s. 614.24 (1m), any changes in the laws of a fraternal made subsequent to the issuance of a policy or certificate bind the member, beneficiary and insured employe as if they had been in force at the time of the application, so long as they do not destroy or diminish benefits promised in the policy or certificate.
632.93(3)
(3) Proof of terms. Copies of any documents mentioned in
subs. (1) and
(2), certified by the secretary or corresponding officer of the fraternal, are evidence of the terms and conditions of the contract.
