632.747(1)
(1)
Employee becomes eligible after commencement of coverage. Unless otherwise permitted by rule of the commissioner, if an insurer provides coverage under a group health benefit plan, the insurer shall provide coverage under the group health benefit plan to an eligible employee who becomes eligible for coverage after the commencement of the employer's coverage, and to the eligible employee's dependents, regardless of health condition or claims experience, if all of the following apply:
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)(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)2.
2. Medical condition, including both physical and mental illnesses.
632.748(1)(a)7.
7. Evidence of insurability, including conditions arising out of acts of domestic violence.
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 History
History: 1997 a. 27.
632.749
632.749
Contract termination and renewability. 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)(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) Except as the commissioner may provide by rule under
sub. (5) and notwithstanding
subs. (1) and
(2) and
s. 631.36 (4), an insurer is not required to renew individual health benefit plan coverage that complies with all of the following:
632.7495(4)(a)
(a) The coverage is marketed and designed to provide short-term coverage as a bridge between coverages.
632.7495(4)(b)
(b) The coverage has a term of not more than 12 months.
632.7495(4)(c)
(c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.
632.7495(5)
(5) The commissioner shall promulgate rules governing disclosures related to, and may promulgate rules setting standards for, the sale of individual health benefit plans that an insurer is not required to renew under
sub. (4).
632.7495 History
History: 1997 a. 27,
237;
2009 a. 28.
632.7497
632.7497
Modifications at renewal. 632.7497(1)
(1) In this section, "individual major medical or comprehensive health benefit plan" includes coverage under a group policy that is underwritten on an individual basis and issued to individuals or families.
632.7497(2)
(2) An insurer that issues an individual major medical or comprehensive health benefit plan shall, at the time of a coverage renewal, at the request of an insured, permit the insured to do either of the following:
632.7497(2)(a)
(a) Change his or her coverage to any of the following:
632.7497(2)(a)1.
1. A different but comparable individual major medical or comprehensive health benefit plan currently offered by the insurer.
632.7497(2)(a)2.
2. An individual major medical or comprehensive health benefit plan currently offered by the insurer with more limited benefits.
632.7497(2)(a)3.
3. An individual major medical or comprehensive health benefit plan currently offered by the insurer with higher deductibles.
632.7497(2)(b)
(b) Modify his or her existing coverage by electing an optional higher deductible, if any, under the individual major medical or comprehensive health benefit plan.
632.7497(3)(a)(a) The insurer may not impose any new preexisting condition exclusion under the new or modified coverage under
sub. (2) that did not apply to the insured's original coverage and shall allow the insured credit under the new or modified coverage for the period of original coverage.
632.7497(3)(b)
(b) For the new or modified coverage, the insurer may not rate for health status other than on the insured's health status at the time the insured applied for the original coverage and as the insured disclosed on the original application.
