635.13(2) (2)Certification. A small employer insurer shall file with the commissioner on or before May 1 annually an actuarial opinion by a member of the American academy of actuaries certifying all of the following:
635.13(2)(a) (a) That the small employer insurer is in compliance with the rate provisions of s. 635.05.
635.13(2)(b) (b) That the small employer insurer's rating methods are based on generally accepted and sound actuarial principles, policies and procedures.
635.13(2)(c) (c) That the opinion is based on the actuary's examination of the small employer insurer's records and a review of the small employer insurer's actuarial assumptions and statistical methods used in setting rates and procedures used in implementing rating plans.
635.13 History History: 1991 a. 39, 250.
635.15 635.15 Temporary suspension of rate regulation. The commissioner may suspend the operation of all or any part of s. 635.05 with respect to one or more small employers for one or more rating periods upon the written request of a small employer insurer and a finding by the commissioner that the suspension is necessary in light of the financial condition of the small employer insurer or that the suspension would enhance the efficiency and fairness of the small employer health insurance market.
635.15 History History: 1991 a. 39, 250.
635.17 635.17 Coverage requirements for small employer plans.
635.17(1)(1)Underwriting, portability and preexisting conditions.
635.17(1)(a)(a) A health benefit plan subject to this subchapter may not deny, exclude or limit benefits for a covered individual for losses incurred more than 12 months after the effective date of the individual's coverage due to a preexisting condition. Such a health benefit plan may not define a preexisting condition more restrictively than any of the following:
635.17(1)(a)1. 1. A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 6 months immediately preceding the effective date of coverage.
635.17(1)(a)2. 2. A condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of coverage.
635.17(1)(a)3. 3. A pregnancy existing on the effective date of coverage.
635.17(1)(b)1.1. A health benefit plan subject to this subchapter shall waive any period applicable to a preexisting condition exclusion or limitation period with respect to particular services for the period that an individual was previously covered by qualifying coverage that provided benefits with respect to such services, if the qualifying coverage was continuous to a date not more than 30 days before the effective date of the new coverage.
635.17(1)(b)2. 2. Subdivision 1. does not prohibit the application of a waiting period to all new enrollees under the health benefit plan; however, a waiting period may not be counted when determining whether the qualifying coverage was continuous to a date not more than 30 days before the effective date of the new coverage. For the purpose of subd. 1., the new coverage shall be considered effective as of the date that it would be effective but for the waiting period.
635.17(1)(b)3. 3. Until June 1, 1993, subd. 1. does not apply to a health benefit plan that is not a basic health benefit plan if the previous qualifying coverage was a basic health benefit plan.
635.17(2) (2)Minimum participation of employes.
635.17(2)(a)(a) Except as provided in par. (d), requirements used by a small employer insurer in determining whether to provide coverage to a small employer, including requirements for minimum participation of eligible employes and minimum employer contributions, shall be applied uniformly among all small employers that apply for or receive coverage from the small employer insurer and that have the same number of eligible employes.
635.17(2)(b) (b) A small employer insurer may vary its minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group.
635.17(2)(c)1.1. Except as provided in subd. 2., in applying minimum participation requirements with respect to a small employer, a small employer insurer may not count eligible employes or their dependents who have other coverage that is qualifying coverage in determining whether the applicable percentage of participation is met.
635.17(2)(c)2. 2. If a small employer has 10 or fewer eligible employes, a small employer insurer may count eligible employes or their dependents who have coverage under another health benefit plan sponsored by that small employer in applying minimum participation requirements to determine whether the applicable percentage of participation is met.
635.17(2)(d) (d) A small employer insurer may not increase a requirement for minimum employe participation or a requirement for minimum employer contribution that applies to a small employer after the small employer has been accepted for coverage.
635.17(3) (3)Prohibited coverage practices.
635.17(3)(a)(a) If a small employer insurer offers coverage to a small employer, the small employer insurer shall offer coverage to all of the eligible employes of the small employer and their dependents. A small employer insurer may not offer coverage to only certain individuals in a small employer group or to only part of the group, except for an eligible employe who has not yet satisfied an applicable waiting period, if any.
635.17(3)(b) (b) A small employer insurer may not modify a health benefit plan with respect to a small employer or an eligible employe or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the health benefit plan.
Effective date note NOTE: This section is repealed eff. 5-1-97 by 1995 Wis. Act 289.
635.17 History History: 1991 a. 250; 1995 a. 289, 412.
635.18 635.18 Fair marketing standards.
635.18(1)(1) Every small employer insurer shall actively market health benefit plan coverage, including basic health benefit plans, to small employers in the state. If a small employer insurer denies coverage to a small employer under a health benefit plan that is not a basic health benefit plan on the basis of the health status or claims experience of the small employer or its eligible employes or their dependents, the small employer insurer shall offer the small employer the opportunity to purchase a basic health benefit plan.
635.18(2) (2)
635.18(2)(a)(a) Except as provided in par. (b), a small employer insurer or an intermediary may not, directly or indirectly, do any of the following:
635.18(2)(a)1. 1. Discourage a small employer from applying, or direct a small employer not to apply, for coverage with the small employer insurer because of the health status, claims experience, industry, occupation or geographic location of the small employer.
635.18(2)(a)2. 2. Encourage or direct a small employer to seek coverage from another insurer because of the health status, claims experience, industry, occupation or geographic location of the small employer.
635.18(2)(b) (b) Paragraph (a) does not prohibit a small employer insurer or an intermediary from providing a small employer with information about an established geographic service area or a restricted network provision of the small employer insurer.
635.18(3) (3)
635.18(3)(a)(a) Except as provided in par. (b), a small employer insurer may not, directly or indirectly, enter into any contract, agreement or arrangement with an intermediary that provides for or results in compensation to an intermediary for the sale of a health benefit plan that varies according to the health status, claims experience, industry, occupation or geographic location of the small employer or eligible employes or dependents.
635.18(3)(b) (b) Payment of compensation on the basis of percentage of premium is not a violation of par. (a) if the percentage does not vary based on the health status, claims experience, industry, occupation or geographic area of the small employer or eligible employes or dependents.
635.18(3)(c) (c) A small employer insurer shall provide reasonable compensation to an intermediary, if any, for the sale of a basic health benefit plan.
635.18(4) (4) A small employer insurer may not terminate, fail to renew or limit its contract or agreement of representation with an intermediary for any reason related to the health status, claims experience, occupation or geographic location of the small employers or eligible employes or their dependents placed by the intermediary with the small employer insurer.
635.18(5) (5) A small employer insurer or an intermediary may not induce or otherwise encourage a small employer to separate or otherwise exclude an employe from health coverage or benefits provided in connection with the employe's employment.
635.18(6) (6) Denial by a small employer insurer of an application for coverage from a small employer shall be in writing and shall state the reason or reasons for the denial.
635.18(7) (7) A 3rd-party administrator that enters into a contract, agreement or other arrangement with a small employer insurer to provide administrative, marketing or other services related to the offering of health benefit plans to small employers in this state is subject to this subchapter as if it were a small employer insurer.
635.18(8) (8) The commissioner may by rule establish additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers in this state.
635.18 History History: 1991 a. 250, 315.
subch. II of ch. 635 SUBCHAPTER II
SMALL EMPLOYER HEALTH INSURANCE PLAN
635.20 635.20 Definitions. In this subchapter:
635.20(1) (1) "Basic benefits" means the minimum benefits established by the plan board under ss. 635.21 and 635.23 (1) (a), and includes all health insurance mandates to the extent determined by the plan board under s. 635.23 (1) (b).
635.20(1c) (1c) "Dependent" has the meaning given in s. 635.02 (3c).
635.20(1m) (1m) "Eligible employe" has the meaning given in s. 635.02 (3f).
635.20(2) (2) "Eligible employer" means an employer that satisfies the requirements of s. 635.25 (1).
635.20(5) (5) "Health care provider" has the meaning given in s. 146.81 (1).
635.20(5m) (5m) "Health insurance mandate" has the meaning given in s. 601.423 (1).
635.20(10) (10) "Plan" means the health insurance plan for individuals employed by small employers that is created under s. 635.21 and that consists of a policy under this subchapter containing the basic benefits.
635.20(11) (11) "Plan board" means the small employer insurance board.
635.20(12) (12) "Small employer" means any of the following:
635.20(12)(a) (a) An individual, firm, corporation, partnership, limited liability company or association that is actively engaged in a business enterprise in this state, including a farm business, and that employs in this state not fewer than 2 nor more than 25 eligible employes. In determining the number of eligible employes, employers that are affiliated, or that are eligible to file a combined tax return for purposes of state taxation, shall be considered one employer.
635.20(12)(b) (b) A village or town that employs not fewer than 2 nor more than 10 eligible employes and that has not provided health insurance coverage to its eligible employes at any time during the past 12 months.
635.20(13) (13) "Small employer insurer" has the meaning given in s. 635.02 (8).
635.20 History History: 1991 a. 250; 1993 a. 112.
635.21 635.21 Establishment of plan. There is established a plan of health insurance coverage for individuals employed by small employers. The plan board shall formulate, supervise and modify the plan as needed, and shall promulgate rules regarding the establishment and administration of the plan.
635.21 History History: 1991 a. 250.
635.23 635.23 Duties of plan board.
635.23(1) (1) The plan board shall:
635.23(1)(a) (a) By rule determine the basic benefits that small employer insurers may offer to eligible employers for providing coverage to eligible employes and their dependents.
635.23(1)(b) (b) By rule establish the extent to which the plan shall comply with the health insurance mandates, without elimination of any of those mandates.
635.23(1)(c) (c) By rule formulate minimum benefit standards for policies providing the basic benefits.
635.23(1)(d) (d) By rule establish employer eligibility requirements for participation in the plan.
635.23(1)(dm) (dm) By rule establish deductibles, copayment and maximum payment requirements for policies providing the basic benefits.
635.23(1)(dp) (dp) By rule determine whether employers participating in the plan may impose a probationary or waiting period on employes who become eligible for coverage after the commencement of the employer's coverage. The plan board may not allow for a probationary or waiting period that exceeds 90 days.
635.23(1)(dr) (dr) By rule determine enrollment periods, if any, for employer or employe coverage under the plan.
635.23(1)(e) (e) Annually submit a report to the chief clerk of each house of the legislature, for distribution under s. 13.172 (3) to the appropriate standing committees, summarizing the activities of the plan board and the operation of the plan in the preceding year, and including but not limited to all of the following:
635.23(1)(e)1. 1. The number of small employers participating in the plan.
635.23(1)(e)2. 2. The number of employes and dependents participating in the plan.
635.23(1)(e)3. 3. An evaluation of the plan's operation and effectiveness.
635.23(1m) (1m) The plan board may by rule establish plan features in addition to those specified in sub. (1).
635.23(1r) (1r) All aspects of the composition and operation of the plan that are established by the plan board shall be established by rule.
635.23(2) (2) All rules promulgated by the plan board are subject to approval by the commissioner.
635.23(3) (3) All final decisions of the plan board under this section concerning the formulation, supervision and modification of the plan shall be adopted by a vote of not less than 8 members of the plan board's current voting membership.
635.23(4) (4) In the formulation of the plan, for the purpose of cost containment the plan board shall encourage the use, to the extent possible, of the services of health care providers other than physicians. The plan board shall report any recommendations on ways to encourage the use of the services of health care providers other than physicians to the chief clerk of each house of the legislature for distribution under s. 13.172 (3) to the standing committees with jurisdiction over health insurance.
635.23(5) (5) The plan board may submit any recommendations for legislation to improve the plan to the chief clerk of each house of the legislature for distribution under s. 13.172 (3) to the standing committees with jurisdiction over health insurance.
635.23 History History: 1991 a. 250.
635.25 635.25 Eligibility for participation in plan.
635.25(1) (1)Employers.
635.25(1)(a)(a) To be eligible to participate in the plan by purchasing a policy under this subchapter containing the basic benefits, an employer:
635.25(1)(a)1. 1. Must be a small employer; and
635.25(1)(a)2. 2. Must comply with any other eligibility requirements specified by the plan board.
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