632.745(4)(a)3.
3. Part A or part B of title XVIII of the federal Social Security Act.
632.745(4)(a)4.
4. Title XIX of the federal Social Security Act, except for coverage consisting solely of benefits under section 1928 of that act.
632.745(4)(a)6.
6. A medical care program of the federal Indian health service or of an American Indian tribal organization.
632.745(4)(a)8.
8. A health plan offered under
chapter 89 of title 5 of the United States Code.
632.745(4)(a)9.
9. A public health plan, as defined in regulations issued by the federal department of health and human services.
632.745(4)(b)
(b) "Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in section 2791 (c) of
P.L. 104-191.
632.745(5)(a)(a) Except as provided in
par. (b), "eligible employe" means an employe who works on a permanent 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 and a member of a limited liability company if the sole proprietor, business owner, partner or member is included as an employe under a health benefit plan of an employer, but the term does not include an employe who works on a temporary or substitute basis.
632.745(5)(b)
(b) For purposes of a group health benefit plan, or a self-insured health plan, that is offered by the state under
s. 40.51 (6) or by the group insurance board under
s. 40.51 (7), "eligible employe" has the meaning given in
s. 40.02 (25).
632.745(6)(a)1.
1. 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.
632.745(6)(b)
(b) For purposes of this definition, all of the following apply:
632.745(6)(b)1.
1. All persons treated as a single employer under subsection (b), (c), (m) or (o) of section
414 of the Internal Revenue Code of 1986 shall be treated as one employer.
632.745(7)
(7) "Enrollment date" means, with respect to an individual covered under a group health plan or health insurance, the date of enrollment of the individual under the plan or insurance or, if earlier, the first day of the waiting period for such enrollment.
632.745(8)
(8) "Federal continuation provision" means any of the following:
632.745(8)(a)
(a) Section
4980B of the Internal Revenue Code of 1986, except for section 4980B (f) (1) of that code insofar as it relates to pediatric vaccines.
632.745(8)(b)
(b) Part 6 of subtitle B of title I of the federal Employee Retirement Income Security Act of 1974, except for section 609 of that act.
632.745(9)
(9) "Group health benefit plan" means a health benefit plan that is issued by an insurer to or through an employer on behalf of a group consisting of at least 2 employes or a group including at least 2 eligible employes. The term includes individual health benefit plans covering eligible employes when 3 or more are sold to or through an employer.
632.745(10)
(10) "Group health plan" means any of the following:
632.745(10)(a)
(a) An employe welfare plan, as defined in section 3 (1) of the federal Employee Retirement Security Act of 1974, to the extent that the employe welfare plan provides medical care, including items and services paid for as medical care, to employes or to their dependents, as defined under the terms of the employe welfare plan, directly or through insurance, reimbursement or otherwise.
632.745(10)(b)
(b) Any program that would not otherwise be an employe welfare benefit plan and that is established or maintained by a partnership, to the extent that the program provides medical care, including items and services paid for as medical care, to present or former partners of the partnership or to their dependents, as defined under the terms of the program, directly or through insurance, reimbursement or otherwise.
632.745(11)(a)(a) Except as provided in
par. (b), "health benefit plan" means any hospital or medical policy or certificate.
632.745(11)(b)
(b) "Health benefit plan" does not include any of the following:
632.745(11)(b)1.
1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.
632.745(11)(b)3.
3. Liability insurance, including general liability insurance and automobile liability insurance.
632.745(11)(b)8.
8. Other similar insurance coverage, as specified in regulations issued by the federal department of health and human services, under which benefits for medical care are secondary or incidental to other insurance benefits.
632.745(11)(b)9.
9. If provided under a separate policy, certificate or contract of insurance, or if otherwise not an integral part of the policy, certificate or contract of insurance: limited-scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those benefits; and such other similar, limited benefits as are specified in regulations issued by the federal department of health and human services under section 2791 of
P.L. 104-191.
632.745(11)(b)10.
10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply:
632.745(11)(b)10.a.
a. The benefits are provided under a separate policy, certificate or contract of insurance.
632.745(11)(b)10.b.
b. There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.
632.745(11)(b)10.c.
c. Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.
632.745(11)(b)11.
11. Benefits that are provided under a separate policy, certificate or contract of insurance and that are medicare supplemental health insurance, as defined in section 1882 (g) (1) of the federal Social Security Act, coverage supplemental to the coverage provided under
chapter 55 of title 10 of the United States Code or similar supplemental coverage provided as supplemental to coverage under a group health plan.
632.745(12)
(12) "Health insurance" includes health benefit plans but does not include group health plans.
632.745(15)
(15) "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 health benefit plans covering individuals in this state or eligible employes of one or more employers in this state. The term includes a health maintenance organization, a preferred provider plan, as defined in
s. 609.01 (4), an insurer operating as a cooperative association organized under
ss. 185.981 to
185.985 and a limited service health organization, as defined in
s. 609.01 (3).
632.745(16)
(16) "Large employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 51 employes on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 51 employes on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 employes on the first day of the plan year.
632.745(17)
(17) "Large group market" means the health insurance market under which individuals obtain health insurance coverage on behalf of themselves and their dependents, directly or through any arrangement, under a group health benefit plan maintained by a large employer.
632.745(18)
(18) "Late enrollee" means, with respect to coverage under a group health plan or health insurance coverage, a participant, beneficiary or individual who enrolls under the plan or coverage at any time other than during any of the following:
632.745(18)(a)
(a) The first period in which the individual is eligible to enroll under the plan or coverage.
632.745(19)
(19) "Network plan" means health insurance coverage of an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer.
632.745(20)
(20) "Participant" has the meaning given in section 3 (7) of the federal Employee Retirement Income Security Act of 1974. "Participant" includes an individual who is, or may become, eligible to receive a benefit, or whose beneficiaries may be eligible to receive any such benefit, in connection with a group health plan or group health benefit plan if the individual is any of the following:
632.745(20)(a)
(a) A partner in relation to a partnership and the group health plan or group health benefit plan is maintained by the partnership.
632.745(20)(b)
(b) A self-employed individual with one or more employes who are participants in the group health plan or group health benefit plan and the group health plan or group health benefit plan is maintained by the self-employed individual.
632.745(21)
(21) "Placed for adoption" or "placement for adoption" means, with respect to the placement for adoption of a child with a person, the assumption and retention by the person of a legal obligation for the total or partial support of the child in anticipation of the adoption of the child. A child's placement for adoption with a person terminates upon the termination of the person's legal obligation for support.
632.745(22)
(22) "Plan sponsor" has the meaning given in section 3 (16) (B) of the federal Employee Retirement Income Security Act of 1974.
632.745(23)
(23) "Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage.
632.745(24)
(24) "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.
632.745(26)
(26) "Small group market" means the health insurance market under which individuals obtain health insurance coverage on behalf of themselves and their dependents, directly or through any arrangement, under a group health benefit plan maintained by, or obtained through, a small employer.
632.745(27)
(27) "Waiting period" means, with respect to a group health plan or health insurance coverage and an individual who is a potential participant or beneficiary in the group health plan or who is potentially covered by the health insurance coverage, the period that must pass with respect to the individual before the individual is eligible for benefits under the terms of the plan or coverage.
632.745 History
History: 1995 a. 289,
453;
1997 a. 27.
632.746
632.746
Preexisting condition; portability; restrictions; and special enrollment periods. 632.746(1)(a)(a) Subject to
subs. (2) and
(3), an insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant's or beneficiary's enrollment date under the plan.
632.746(1)(b)
(b) A preexisting condition exclusion under
par. (a) may not extend beyond 12 months, or 18 months with respect to a late enrollee, after the participant's or beneficiary's enrollment date under the plan.
632.746(2)(a)(a) An insurer offering a group health benefit plan may not treat genetic information as a preexisting condition under
sub. (1) without a diagnosis of a condition related to the information.
632.746(2)(b)
(b) An insurer offering a group health benefit plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition.
632.746(2)(c)
(c) Subject to
par. (e), an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is born.
632.746(2)(d)
(d) Subject to
par. (e), an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is adopted or placed for adoption before attaining the age of 18 years and who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is adopted or placed for adoption. This paragraph does not apply to coverage before the day on which the individual is adopted or placed for adoption.
632.746(2)(e)
(e) Paragraphs (c) and
(d) do not apply to an individual after the end of the first continuous period during which the individual was not covered under any creditable coverage for at least 63 days. For purposes of this paragraph, any waiting period or affiliation period for coverage under a group health plan or group health benefit plan shall not be taken into account in determining the period before enrollment in the group health plan or group health benefit plan.
632.746(3)(a)(a) The length of time during which any preexisting condition exclusion under
sub. (1) may be imposed shall be reduced by the aggregate of the participant's or beneficiary's periods of creditable coverage on his or her enrollment date under the group health benefit plan.
632.746(3)(b)
(b) With respect to enrollment of an individual under a group health plan or a group health benefit plan, a period of creditable coverage after which the individual was not covered under any creditable coverage for a period of at least 63 days before enrollment in the group health plan or group health benefit plan may not be counted. For purposes of this paragraph, any waiting period or affiliation period for coverage under the group health plan or group health benefit plan shall not be taken into account in determining the period before enrollment in the group health plan or group health benefit plan.
632.746(3)(c)
(c) No period of creditable coverage before July 1, 1996, may be counted. Individuals who need to establish creditable coverage for periods before July 1, 1996, and who would have such coverage but for this paragraph may be given credit for creditable coverage for such periods through the presentation of documents or other means provided by the federal secretary of health and human services, consistent with section 104 of
P.L. 104-191.
632.746(3)(d)1.1. An insurer offering a group health benefit plan shall count a period of creditable coverage without regard to the specific benefits for which the individual had coverage during the period.
632.746(3)(d)2.
2. Notwithstanding
subd. 1., an insurer offering a group health benefit plan may elect to apply
par. (a) on the basis of coverage of benefits within each of several classes or categories of benefits specified in regulations issued by the federal department of health and human services under
P.L. 104-191. The election shall be made on a uniform basis for all participants and beneficiaries. Under the election, an insurer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within the class or category.
632.746(3)(d)3.
3. An insurer that makes an election under
subd. 2. shall prominently state in any disclosure statements concerning the coverage offered, and to each employer at the time of the offer or sale of coverage, that the insurer has made the election and what the effect of the election is.
632.746(3)(e)
(e) Periods of creditable coverage shall be established through the presentation of certifications described in
sub. (4) or in any other manner specified in regulations issued by the federal department of health and human services under
P.L. 104-191.
