CHAPTER 635
SMALL EMPLOYER HEALTH INSURANCE
SUBCHAPTER I
GENERAL PROVISIONS
635.07 Contract termination and renewability.
635.09 Prohibited denial of coverage.
635.11 Disclosure of rating factors and renewability provisions.
635.13 Annual certification of compliance.
635.15 Temporary suspension of rate regulation.
635.17 Coverage requirements for small employer plans.
635.18 Fair marketing standards.
SUBCHAPTER II
SMALL EMPLOYER HEALTH INSURANCE PLAN
635.21 Establishment of plan.
635.23 Duties of plan board.
635.25 Eligibility for participation in plan.
635.254 Employer premium contribution.
635.272 Payments to health care providers.
635.28 Liability of state and plan board.
635.29 Exemption from required coverage.
635.31 Chapters
600 to
655 applicable.
Ch. 635 Annotation
Cross-references: See definitions in ss. 600.03 and 628.02.
GENERAL PROVISIONS
635.01
635.01
Scope. This subchapter applies to all group health insurance plans, policies or certificates, written on risks or operations in this state, providing coverage for employes of a small employer, or employes of a small employer and the employer, and to individual health insurance policies, written on risks or operations in this state, providing coverage for employes of a small employer, or employes of a small employer and the employer when 3 or more are sold to a small employer.
635.01 History
History: 1991 a. 39.
635.02
635.02
Definitions. In this subchapter:
635.02(1)
(1) "Base premium rate" means the lowest premium rate chargeable under a rating system to small employers with similar case characteristics and the same or similar benefit design characteristics in the same class of business.
635.02(1c)
(1c) "Basic health benefit plan" means the small employer health insurance plan under
subch. II.
635.02(1m)
(1m) "Benefit design characteristics" means covered services, cost sharing, utilization management, managed care networks and other features that differentiate plan or coverage designs.
635.02(2)
(2) "Case characteristics" means the demographic, actuarially based characteristics of the employes of a small employer, and the employer, if covered, such as age, sex, geographic location and occupation, used by a small employer insurer to determine premium rates for a small employer. "Case characteristics" does not include loss or claim history, health status, duration of coverage or other factors related to claim experience.
635.02(3)
(3) "Class of business" means all or a distinct grouping of small employers determined in accordance with rules promulgated by the commissioner under
s. 635.05 (4).
635.02(3c)
(3c) "Dependent" means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.
635.02(3f)
(3f) "Eligible employe" means an employe who works on a full-time basis and has a normal work week of 30 or more hours. The term includes a sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership, a member of a limited liability company and an independent contractor if the sole proprietor, business owner, partner, member or independent contractor is included as an employe under a health benefit plan of a small employer, but the term does not include an employe who works on a part-time, temporary or substitute basis.
635.02(3j)
(3j) "Established geographic service area" means a geographic area within which a small employer insurer provides coverage and that has been approved by the commissioner.
635.02(3m)
(3m) "Health benefit plan" means any hospital or medical policy or certificate. "Health benefit plan" does not include accident-only, credit, dental, vision, medicare supplement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, automobile medical payment insurance or other insurance exempted by rule of the commissioner.
635.02(4m)
(4m) "Midpoint rate" means the arithmetic average of the base premium rate and the corresponding highest premium rate.
635.02(5)
(5) "New business premium rate" means the premium rate charged or offered to small employers with similar case characteristics in the same class of business for newly issued health insurance with the same or similar benefit design characteristics.
635.02(5m)(a)(a) "Qualifying coverage" means benefits or coverage provided under any of the following:
635.02(5m)(a)2.
2. An employer-based health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under a basic health benefit plan.
635.02(5m)(a)3.
3. An individual health insurance policy that provides benefits similar to or exceeding benefits provided under a basic health benefit plan, if the policy has been in effect for at least one year.
635.02(5m)(b)
(b) Notwithstanding
par. (a) 2. and
3., "qualifying coverage" does not include a high cost-share health plan, as defined in
s. 632.898 (1) (c), that is linked to a medical savings account, as described in
s. 632.898, if any of the following applies:
635.02(5m)(b)1.
1. The health benefit plan that is the individual's new coverage and the health benefit plan that is the individual's previous coverage are provided by the same small employer.
635.02(5m)(b)2.
2. The health benefit plan that is the individual's new coverage is provided by a small employer that is not the same employer that provided the health benefit plan that was the individual's previous coverage, the small employer that provides the individual's new coverage offers its eligible employes a choice of health benefit plan options that includes a high cost-share health plan, as defined in
s. 632.898 (1) (c), and the individual's new coverage is not a high cost-share health plan.
635.02(6)
(6) "Rating period" means the period, determined by a small employer insurer, during which a premium rate established by the small employer insurer remains in effect.
635.02(6m)
(6m) "Restricted network provision" means a provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on obtaining services or articles from health care providers that have contracted with the small employer insurer to provide health care services or articles to covered individuals.
635.02(7)
(7) "Small employer" means any of the following:
635.02(7)(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.
635.02(7)(b)
(b) A village or town that provides or that is eligible under
s. 635.25 (1) to provide coverage to its eligible employes under a basic health benefit plan.
635.02(8)
(8) "Small employer insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers group health benefit plans covering eligible employes of one or more small employers in this state, or that sells 3 or more individual health benefit plans to a small employer, covering eligible employes of the small employer. The term includes a health maintenance organization, as defined in
s. 609.01 (2), a preferred provider plan, as defined in
s. 609.01 (4), and an insurer operating as a cooperative association organized under
ss. 185.981 to
185.985, but does not include a limited service health organization, as defined in
s. 609.01 (3).
