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.
632.93(5)
(5) Grace period. Every fraternal certificate shall contain a provision entitling the member or insured employe to a grace period of not less than one month, or 30 days at the fraternal's option, for the payment of any premium due except the first, during which the death benefit shall continue in force. A fraternal may specify in the grace period provision that the overdue premium will be deducted from the death benefit in the event of death before it is paid.
632.93(6)
(6) Compliance with other provisions. If a fraternal's laws provide for expulsion or suspension of a member for any reason other than nonpayment of premium or under
s. 632.46, the fraternal's insurance certificate shall contain a provision that if a member is expelled or suspended for any reason other than nonpayment of premium or under
s. 632.46, the expelled member has the right to maintain the policy in force by continuing payment of the required premium.
632.93(7)
(7) Scope of application. This section applies to all contracts made by a fraternal beginning 6 months after December 18, 1979. A fraternal may elect to have this section apply at an earlier date, so long as it applies simultaneously to all such contracts and the fraternal gives the commissioner at least 30 days' notice of intention to adopt this section.
632.95
632.95
Fraud in obtaining membership. Subject to
s. 632.46, any certificate of membership secured by misrepresentation in or with reference to any application for membership or documentary or other proof for the purpose of obtaining membership in or noninsurance benefit from the fraternal is void, if the fraternal relied on it and it is either material or fraudulent.
632.95 History
History: 1975 c. 373.
632.95 Annotation
Legislative Council Note, 1975: This section continues the contractual portion of s. 208.38, edited with a change in meaning, to include nonfraudulent but material misrepresentation, and also to subject the provision to the rule of incontestability provided in s. 632.46. [Bill 643-S]
632.96
632.96
Beneficiaries in fraternal contracts. 632.96(1)
(1) Any member or insured employe may designate as beneficiary any person permitted by the laws of the fraternal. Those laws shall authorize the designation of the member's or insured employe's estate as beneficiary.
632.96 History
History: 1975 c. 373,
421;
1989 a. 336.
632.96 Annotation
Legislative Council Note, 1975: Sub. (1) states a rule slightly more restrictive of the range of permitted beneficiaries than for commercial life insurance; this reflects the nature of the fraternal. Sub. (2) applies the general provision for life insurance, subject to sub. (1). [Bill 643-S]
MISCELLANEOUS
