632.747(1)(a) (a) The employee has satisfied any applicable waiting period.
632.747(1)(b) (b) The employer agrees to pay the premium required for coverage of the employee under the group health benefit plan.
632.747(3) (3)State or municipal self-insured plans. If the state or a county, city, village, town or school district provides coverage under a self-insured health plan, it shall provide coverage under the self-insured health plan to an eligible employee who waived coverage during an enrollment period during which the employee was entitled to enroll in the self-insured health plan, regardless of health condition or claims experience, if all of the following apply:
632.747(3)(a) (a) The eligible employee was covered as a dependent under creditable coverage when he or she waived coverage under the self-insured health plan.
632.747(3)(b) (b) The eligible employee's coverage under the creditable coverage has terminated or will terminate due to a divorce from the insured under the creditable coverage, the death of the insured under the creditable coverage, loss of employment by the insured under the creditable coverage or involuntary loss of coverage under the creditable coverage by the insured under the creditable coverage.
632.747(3)(c) (c) The eligible employee applies for coverage under the self-insured health plan not more than 30 days after termination of his or her coverage under the creditable coverage.
632.747 History History: 1995 a. 289; 1997 a. 27.
632.748 632.748 Prohibiting discrimination.
632.748(1) (1)
632.748(1)(a)(a) Subject to subs. (3) and (4), an insurer may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under a group health benefit plan based on any of the following factors with respect to the individual or a dependent of the individual:
632.748(1)(a)1. 1. Health status.
632.748(1)(a)2. 2. Medical condition, including both physical and mental illnesses.
632.748(1)(a)3. 3. Claims experience.
632.748(1)(a)4. 4. Receipt of health care.
632.748(1)(a)5. 5. Medical history.
632.748(1)(a)6. 6. Genetic information.
632.748(1)(a)7. 7. Evidence of insurability, including conditions arising out of acts of domestic violence.
632.748(1)(a)8. 8. Disability.
632.748(1)(b) (b) For purposes of par. (a), rules for eligibility to enroll under a group health benefit plan include rules defining any applicable waiting periods for enrollment.
632.748(2) (2) An insurer offering a group health benefit plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor with respect to the individual or a dependent of the individual, a premium or contribution that is greater than the premium or contribution for a similarly situated individual enrolled under the plan.
632.748(3) (3) To the extent consistent with s. 632.746, sub. (1) shall not be construed to do any of the following:
632.748(3)(a) (a) Require a group health benefit plan to provide particular benefits other than those provided under the terms of the plan.
632.748(3)(b) (b) Prevent a group health benefit plan from establishing limitations or restrictions on the amount, level, extent or nature of benefits or coverage for similarly situated individuals enrolled under the plan.
632.748(4) (4) Nothing in sub. (1) shall be construed to do any of the following:
632.748(4)(a) (a) Restrict the amount that an insurer may charge an employer for coverage under a group health benefit plan.
632.748(4)(b) (b) Prevent an insurer offering a group health benefit plan from establishing premium discounts or rebates, or from modifying otherwise applicable copayments or deductibles, in return for adherence to programs of health promotion and disease prevention.
632.748(4)(c) (c) Provide an exception from, or limit, the rate regulation under s. 635.05.
632.748 History History: 1997 a. 27.
632.749 632.749 Contract termination and renewability.
632.749(1) (1)
632.749(1)(a) (a) Except as provided in subs. (2) to (4) and notwithstanding s. 631.36 (2) to (4m), an insurer that offers a group health benefit plan shall renew such coverage or continue such coverage in force at the option of the employer and, if applicable, plan sponsor.
632.749(1)(b) (b) At the time of coverage renewal, the insurer may modify a group health benefit plan issued in the large group market.
632.749(2) (2) Notwithstanding s. 631.36 (2) to (4m), an insurer may nonrenew or discontinue a group health benefit plan, but only if any of the following applies:
632.749(2)(a) (a) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the group health benefit plan or in a timely manner.
632.749(2)(b) (b) The plan sponsor has performed an act or engaged in a practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.
632.749(2)(c) (c) The plan sponsor has failed to comply with a material plan provision that is permitted under law relating to employer contribution or group participation rules.
632.749(2)(d) (d) The insurer is ceasing to offer coverage in the market in which the group health benefit plan is included in accordance with sub. (3) and any other applicable state law.
632.749(2)(e) (e) In the case of a group health benefit plan that the insurer offers through a network plan, there is no longer an enrollee under the plan who resides, lives or works in the service area of the insurer or in an area in which the insurer is authorized to do business and, in the case of the small group market, the insurer would deny enrollment under the plan under s. 635.19 (2) (a) 1.
632.749(2)(f) (f) In the case of a group health benefit plan that is made available only through one or more bona fide associations, the employer ceases to be a member of the association on which the coverage is based. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of any covered individual.
632.749(3) (3)
632.749(3)(a)(a) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue offering in this state a particular type of group health benefit plan offered in either the large group market or the group market other than the large group market, but only if all of the following apply:
632.749(3)(a)1. 1. The insurer provides notice of the discontinuance to each employer and, if applicable, plan sponsor for whom the insurer provides coverage of this type in this state, and to the participants and beneficiaries covered under the coverage, at least 90 days before the date on which the coverage will be discontinued.
632.749(3)(a)2. 2. The insurer offers to each employer and, if applicable, plan sponsor for whom the insurer provides coverage of this type in this state the option to purchase from among all of the other group health benefit plans that the insurer offers in the market in which is included the type of group health benefit plan that is being discontinued, except that in the case of the large group market, the insurer must offer each employer and, if applicable, plan sponsor the option to purchase one other group health benefit plan that the insurer offers in the large group market.
632.749(3)(a)3. 3. In exercising the option to discontinue coverage of this particular type and in offering the option to purchase coverage under subd. 2., the insurer acts uniformly without regard to any health status-related factor of any covered participants or beneficiaries or any participants or beneficiaries who may become eligible for coverage.
632.749(3)(b) (b) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue offering in this state all group health benefit plans in the large group market or in the group market other than the large group market, or in both such group markets, but only if all of the following apply:
632.749(3)(b)1. 1. The insurer provides notice of the discontinuance to the commissioner and to each employer and, if applicable, plan sponsor for whom the insurer provides coverage of this type in this state, and to the participants and beneficiaries covered under the coverage, at least 180 days before the date on which the coverage will be discontinued.
632.749(3)(b)2. 2. All group health benefit plans issued or delivered for issuance in this state in the affected market or markets are discontinued and coverage under such group health benefit plans is not renewed.
632.749(3)(b)3. 3. The insurer does not issue or deliver for issuance in this state any group health benefit plan in the affected market or markets before 5 years after the day on which the last group health benefit plan is discontinued under subd. 2.
632.749(4) (4) This section does not apply to a group health benefit plan offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7).
632.749 History History: 1995 a. 289; 1997 a. 27.
632.7495 632.7495 Guaranteed renewability of individual health insurance coverage.
632.7495(1)(a)(a) Except as provided in subs. (2) to (4) and notwithstanding s. 631.36 (2) to (4m), an insurer that provides individual health benefit plan coverage shall renew such coverage or continue such coverage in force at the option of the insured individual and, if applicable, the association through which the individual has coverage.
632.7495(1)(b) (b) At the time of coverage renewal, the insurer may modify the individual health benefit plan coverage policy form as long as the modification is consistent with state law and effective on a uniform basis among all individuals with coverage under that policy form.
632.7495(2) (2) Notwithstanding s. 631.36 (2) to (4m), an insurer may nonrenew or discontinue the individual health benefit plan coverage of an individual, but only if any of the following applies:
632.7495(2)(a) (a) The individual or, if applicable, the association through which the individual has coverage has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or in a timely manner.
632.7495(2)(b) (b) The individual or, if applicable, the association through which the individual has coverage has performed an act or engaged in a practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the health insurance coverage.
632.7495(2)(c) (c) The insurer is ceasing to offer individual health benefit plan coverage in accordance with sub. (3) and any other applicable state law.
632.7495(2)(d) (d) In the case of individual health benefit plan coverage that the insurer offers through a network plan, the individual no longer resides, lives or works in the service area or in an area in which the insurer is authorized to do business. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of covered individuals.
632.7495(2)(e) (e) In the case of individual health benefit plan coverage that the insurer offers only through one or more bona fide associations, the individual ceases to be a member of the association on which the coverage is based. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of covered individuals.
632.7495(2)(f) (f) The individual is eligible for medicare and the commissioner by rule permits coverage to be terminated.
632.7495(3)(a)(a) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue offering in this state a particular type of individual health benefit plan coverage, but only if all of the following apply:
632.7495(3)(a)1. 1. The insurer provides notice of the discontinuance to each individual for whom the insurer provides coverage of this type in this state and, if applicable, to the association through which the individual has coverage at least 90 days before the date on which the coverage will be discontinued.
632.7495(3)(a)2. 2. The insurer offers to each individual for whom the insurer provides coverage of this type in this state and, if applicable, to the association through which the individual has coverage the option to purchase any other type of individual health insurance coverage that the insurer offers for individuals.
632.7495(3)(a)3. 3. In electing to discontinue coverage of this particular type and in offering the option to purchase coverage under subd. 2., the insurer acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for the type of coverage described under subd. 2.
632.7495(3)(b) (b) Notwithstanding s. 631.36 (2) to (4m), an insurer may discontinue offering individual health benefit plan coverage in this state, but only if all of the following apply:
632.7495(3)(b)1. 1. The insurer provides notice of the discontinuance to the commissioner and to each individual for whom the insurer provides individual health benefit plan coverage in this state and, if applicable, to the association through which the individual has coverage at least 180 days before the date on which the coverage will be discontinued.
632.7495(3)(b)2. 2. All individual health benefit plan coverage issued or delivered for issuance in this state is discontinued and coverage under such coverage is not renewed.
632.7495(3)(b)3. 3. The insurer does not issue or deliver for issuance in this state any individual health benefit plan coverage before 5 years after the day on which the last individual health benefit plan coverage is discontinued under subd. 2.
632.7495(4) (4) Notwithstanding subs. (1) and (2) and s. 631.36 (4), an insurer is not required to renew individual health benefit plan coverage that is marketed and designed to provide short-term coverage as a bridge between coverages.
632.7495 History History: 1997 a. 27, 237.
632.75 632.75 Prohibited provisions for disability insurance.
632.75(1)(1)Death presumed from extended absence. Section 813.22 (1) applies to any disability insurance policy providing a death benefit.
632.75(2) (2)Dividends conditioned on continuation of policy or payment of premiums. Except on the first or second anniversary, no dividend payable on a disability insurance policy may be made contingent on the continuation of the policy or on premium payments.
632.75(3) (3)Prohibition of exclusion from coverage of certain dependent children. No disability insurance policy issued or renewed on or after April 30, 1980, may exclude or terminate from coverage any dependent child of an insured person or group member solely because the child does not reside with the insured person or group member. This subsection does not apply to a group policy, as defined in s. 632.897 (1) (c), or an individual policy, as defined in s. 632.897 (1) (cm), that is subject to s. 632.897 (10).
632.75(4) (4)Out-of-state service providers. Except as provided in s. 628.36, no disability insurance policy may exclude or limit coverage of health care services provided outside this state, if the services are provided within 75 miles of the insured's residence in a facility licensed or approved by the state where the facility is located.
632.75(5) (5)Payments for hospital services. No insurer may reimburse a hospital for patient health care costs at a rate exceeding the rate established under ch. 54, 1985 stats., or s. 146.60, 1983 stats., for care provided prior to July 1, 1987.
632.755 632.755 Public assistance and early intervention services.
632.755(1g)(1g)
632.755(1g)(a)(a) A disability insurance policy may not exclude a person or a person's dependent from coverage because the person or the dependent is eligible for assistance under ch. 49 or because the dependent is eligible for early intervention services under s. 51.44.
632.755(1g)(b) (b) A disability insurance policy may not terminate its coverage of a person or a person's dependent because the person or the dependent is eligible for assistance under ch. 49 or because the dependent is eligible for early intervention services under s. 51.44.
632.755(1g)(c) (c) A disability insurance policy may not provide different benefits of coverage to a person or the person's dependent because the person or the dependent is eligible for assistance under ch. 49 or because the dependent is eligible for early intervention services under s. 51.44 than it provides to persons and their dependents who are not eligible for assistance under ch. 49 or for early intervention services under s. 51.44.
632.755(2) (2) Benefits provided by a disability insurance policy shall be primary to those benefits provided under ch. 49 or under s. 51.44 or 253.05.
632.76 632.76 Incontestability for disability insurance.
632.76(1)(1)Avoidance for misrepresentations. No statement made by an applicant in the application for individual disability insurance coverage and no statement made respecting the person's insurability by a person insured under a group policy, except fraudulent misrepresentation, is a basis for avoidance of the policy or denial of a claim for loss incurred or disability commencing after the coverage has been in effect for 2 years. The policy may provide for incontestability even with respect to fraudulent misstatements.
632.76(2) (2)Preexisting diseases.
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