632.746(7)(a)3.
3. An individual who has met any waiting period applicable to becoming a participant under the plan, who is eligible to be enrolled under the plan and who failed to enroll during a previous enrollment period or such an individual's spouse, or both, may be enrolled under the plan.
632.746(7)(b)
(b) An insurer under
par. (a) is required to provide for a special enrollment period if all of the following apply:
632.746(7)(b)1.
1. The group health benefit plan makes coverage available for dependents of participants under the plan.
632.746(7)(b)2.
2. The individual is a participant under the plan, or the individual has met any waiting period applicable to becoming a participant under the plan and is eligible to be enrolled under the plan but failed to enroll during a previous enrollment period.
632.746(7)(b)3.
3. A person becomes a dependent of the individual through marriage, birth, adoption or placement for adoption.
632.746(7)(c)
(c) A special enrollment period provided for under this subsection shall be for a period of not less than 30 days and shall begin on the later of either of the following:
632.746(7)(c)1.
1. The date dependent coverage is made available under the group health benefit plan.
632.746(7)(c)2.
2. The date of the marriage, birth, adoption or placement for adoption described in
par. (a), whichever is applicable.
632.746(7)(d)
(d) If an individual seeks to enroll a dependent during the first 30 days of a special enrollment period, the coverage of the dependent shall become effective on the following date:
632.746(7)(d)1.
1. If the person becomes a dependent through marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received.
632.746(7)(d)2.
2. If the person becomes a dependent through birth, the date of birth.
632.746(7)(d)3.
3. If the person becomes a dependent through adoption or placement for adoption, the date of the adoption or placement for adoption.
632.746(7m)(a)(a) In this subsection, "terms of the group health benefit plan" does not include any requirements under the group health benefit plan related to enrollment periods or waiting periods.
632.746(7m)(b)
(b) An insurer offering a group health benefit plan shall permit, as provided in
par. (c), an employee who is not enrolled but who is eligible for coverage under the terms of the group health benefit plan, or a participant's or employee's dependent who is not enrolled but who is eligible for coverage under the terms of the group health benefit plan, to enroll for coverage under the terms of the plan if all of the following apply:
632.746(7m)(b)1.
1. The employee or dependent is eligible for benefits under the Medical Assistance program under
s. 49.471 or
49.472 or for coverage under the Badger Care health care program under
s. 49.665.
632.746(7m)(b)2.
2. The department of health services will purchase coverage under the group health benefit plan on behalf of the employee or dependent because the department of health services has determined that paying the portion of the premium for which the employee is responsible will not be more costly than providing the medical assistance or the coverage under the Badger Care health care program, whichever is applicable.
632.746(7m)(c)
(c) An insurer permitting an employee or dependent to enroll under this subsection shall provide for an enrollment period of not less than 30 days, beginning on the date on which the department of health services makes the determination under
par. (b) 2.
632.746(8)(a)(a) A health maintenance organization that offers a group health benefit plan and that does not impose any preexisting condition exclusion under
sub. (1) with respect to a particular coverage option may impose an affiliation period for that coverage option, but only if all of the following apply:
632.746(8)(a)1.
1. The affiliation period is applied uniformly without regard to any health status-related factors.
632.746(8)(a)2.
2. The affiliation period does not exceed 2 months, or 3 months with respect to a late enrollee.
632.746(8)(b)
(b) A health maintenance organization that imposes an affiliation period under this subsection is not required to provide health care services or benefits during the affiliation period. A health maintenance organization may not charge a premium to a participant or beneficiary for any coverage that is provided during an affiliation period. An affiliation period shall begin on the enrollment date and run concurrently with any waiting period under the group health benefit plan.
632.746(8)(c)
(c) A health maintenance organization under
par. (a) may use methods other than those described in
par. (a) to address adverse selection, if the methods are approved by the commissioner.
632.746(9)(a)(a) Except as provided in
pars. (b) and
(c), requirements used by an insurer in determining whether to provide coverage under a group health benefit plan to an employer, including requirements for minimum participation of eligible employees and minimum employer contributions, shall be applied uniformly among all employers that apply for or receive coverage from the insurer.
632.746(9)(b)1.
1. Vary its minimum participation requirements or minimum employer contribution requirements only by the size of the employer group based on the number of eligible employees.
632.746(9)(b)2.
2. Unless the commissioner by rule permits more frequent change, increase the minimum participation requirements or minimum employer contribution requirements no more than one time during a calendar year and, except as otherwise permitted under this subsection, only if the requirements are applied uniformly to all employers applying for coverage and to all renewing employers effective on the date of renewal.
632.746(9)(b)3.
3. Except as limited or restricted by rule of the commissioner, establish separate participation requirements or employer contribution requirements that uniformly apply to all employers that provide a choice of coverage to employees or their dependents. Except as limited or restricted by rule of the commissioner, an insurer may establish separate uniform requirements based on the number or type of choice of coverage provided by the employer.
632.746(9)(c)
(c) Except as provided in
par. (b), an insurer may vary requirements used by the insurer in determining whether to provide coverage under a group health benefit plan to a large employer, but only if the requirements are applied uniformly among all large employers that have the same number of eligible employees.
632.746(9)(d)
(d) In applying minimum participation requirements with respect to an employer, an insurer may not count eligible employees who have other coverage that is creditable coverage in determining whether the applicable percentage of participation is met, except that an insurer may count eligible employees who have coverage under another health benefit plan that is sponsored by that employer and that is creditable coverage.
632.746(9)(e)
(e) This subsection 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).
632.746(10)(a)1.1. Except as provided in rules promulgated under
subd. 3. or
4., if an insurer offers a group health benefit plan to an employer, the insurer shall offer coverage to all of the eligible employees of the employer and their dependents. Except as provided in rules promulgated under
subd. 3. or
4., an insurer may not offer coverage to only certain individuals in an employer group or to only part of the group, except for an eligible employee who has not yet satisfied an applicable waiting period, if any.
632.746(10)(a)2.
2. Except as provided in rules promulgated under
subd. 3., if the state or a county, city, village, town or school district offers coverage under a self-insured health plan, it shall offer coverage to all of its eligible employees and their dependents. Except as provided in rules promulgated under
subd. 3., the state or a county, city, village, town or school district may not offer coverage to only certain individuals in the employer group or to only part of the group, except for an eligible employee who has not yet satisfied an applicable waiting period, if any.
632.746(10)(a)3.
3. The secretary of employee trust funds, with the approval of the group insurance board, shall promulgate rules related to offering coverage to eligible employees under a group health benefit plan, or a self-insured health plan, offered by the state under
s. 40.51 (6) or by the group insurance board under
s. 40.51 (7). The rules shall conform to the intent of
subds. 1. and
2. and may not allow the state or the group insurance board to refuse to offer coverage to an eligible employee or dependent for reasons related to health condition.
632.746(10)(a)4.
4. The commissioner may promulgate rules permitting exceptions to the requirement under
subd. 1. for classes of eligible employees or their dependents. No rule promulgated under this subdivision may permit an insurer to refuse to offer to provide coverage to an eligible employee or his or her dependent for reasons related to health condition.
632.746(10)(b)1.1. An insurer may not modify a group health benefit plan with respect to an employer or an eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the group health benefit plan.
632.746(10)(b)2.
2. The state or a county, city, village, town or school district may not modify a self-insured health plan with respect to an eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the self-insured health plan.
632.746(10)(b)3.
3. Nothing in this paragraph limits the authority of the group insurance board to fulfill its obligations as trustee under
s. 40.03 (6) (d) or to design or modify procedures or provisions pertaining to enrollment, premium transmitted or coverage of eligible employees for health care benefits under
s. 40.51 (1).
632.747
632.747
Guaranteed acceptance. 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.
