632.897(1)(c)1m.
1m. A long-term care insurance policy issued by an insurer to a policyholder on behalf of a group;
632.897(1)(c)2.
2. An uninsured plan or program whereby a health maintenance organization, limited service health organization, preferred provider plan, labor union, religious community or other sponsor contracts to provide hospital or medical coverage to members of a group on either an expense incurred or service basis, other than for specified diseases or for accidental injuries; or
632.897(1)(c)3.
3. A plan or program whereby a sponsor arranges for the mass marketing of franchise insurance to members of a group related to one another through their relationship with the sponsor.
632.897(1)(cm)
(cm) “Individual policy" means an insurance policy whereby an insured receives hospital or medical coverage on either an expense incurred or service basis, other than for specified diseases or for accidental injuries, and a long-term care insurance policy.
632.897(1)(d)
(d) “Insurer" means the insurer in the case of a group policy as defined in par.
(c) 1.,
1m. or
3. and the sponsor in the case of a group policy as defined in par.
(c) 2. 632.897(1)(e)
(e) “Medicare" means coverage under both part A and part B of Title XVIII of the federal social security act,
42 USC 1395 et seq., as amended.
632.897(1)(f)
(f) “Terminated insured" means a person entitled to elect continued or conversion coverage under sub.
(2) (b) or
(9).
632.897(1m)
(1m) Except as provided in sub.
(10), this section applies to any group policy which would otherwise be exempt under s.
600.01 (1) (b) 3. if at least 150 of the certificate holders or insureds are residents of this state.
632.897(2)(a)(a) No group policy which provides coverage to the spouse of the group member may contain a provision for termination of coverage for the spouse solely as a result of a break in their marital relationship except by reason of the entry of a judgment of divorce or annulment of their marriage.
632.897(2)(b)
(b) An insurer issuing or renewing a group policy on or after May 14, 1980 and every insurer on and after the date which is 2 years after May 14, 1980 shall permit the following persons who have been continuously covered under a group policy for at least 3 months to elect to continue group policy coverage under sub.
(3) or to convert to individual coverage under sub.
(4):
632.897(2)(b)1.
1. The former spouse of a group member who otherwise would terminate coverage because of divorce or annulment.
632.897(2)(b)2.
2. A group member who would otherwise terminate eligibility for coverage under the group policy other than a group member who terminates eligibility for coverage due to discharge for misconduct shown in connection with his or her employment.
632.897(2)(b)3.
3. The spouse or dependent of a group member if the group member dies while covered by the group policy and the spouse or dependent was also covered.
632.897(2)(c)
(c) Group policy coverage of a terminated insured who is entitled under par.
(b) to elect continued group policy coverage or conversion to individual coverage and coverage of the spouse and dependents of the terminated insured provided for in the group policy continues until the terminated insured is notified under par.
(d) of the right to elect continued or conversion coverage if the premium for the coverage continues to be paid.
632.897(2)(d)
(d) If the employer is notified to terminate the coverage for any of the reasons provided under par.
(b), the employer shall provide the terminated insured written notification of the right to continue group coverage or convert to individual coverage and the payment amounts required for either continued or converted coverage including the manner, place and time in which the payments shall be made. This notice shall be given not more than 5 days after the employer receives notice to terminate coverage. The payment amount for continued group coverage may not exceed the group rate in effect for a group member, including an employer's contribution, if any, for a group policy as defined in sub.
(1) (c) 1. or
1m. or the equivalent value of the monthly contribution of a group member to a group policy as defined in sub.
(1) (c) 2. or the equivalent value of the monthly premium for franchise insurance as defined in sub.
(1) (c) 3. The premium for converted coverage shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risks of each person to be covered under that policy and to the type and amount of coverage provided. The notice may be sent to the terminated insured's home address as shown on the records of the employer.
632.897(3)(a)(a) If the terminated insured or, with respect to a minor, the parent or guardian of the terminated insured, elects to continue group coverage and tenders to the employer the amount required within 30 days after receiving notice under sub.
(2) (d), coverage of the terminated insured and, if the terminated insured is eligible for continued coverage under sub.
(2) (b) 2., coverage of the covered spouse and dependents of the terminated insured shall continue without interruption and may not terminate unless one of the following occurs:
632.897(3)(a)1.
1. The terminated insured establishes residence outside this state.
632.897(3)(a)2.
2. The terminated insured fails to make timely payment of a required premium amount.
632.897(3)(a)3.
3. The terminated insured is eligible for continued coverage under sub.
(2) (b) 1. and the group member through whom the former spouse originally obtained coverage is no longer eligible for coverage by the group policy.
632.897(3)(a)4.
4. The terminated insured becomes eligible for similar coverage under another group policy.
632.897(3)(b)
(b) If the coverage of the terminated insured is terminated under par.
(a) 3. and the group member through whom the terminated insured originally obtained coverage becomes eligible for coverage by a replacement group policy providing coverage to the same group, the former spouse shall have the right to coverage by the replacement group policy as provided in this subsection.
632.897(3)(c)
(c) If the right of the terminated insured to continue group policy coverage is terminated under par.
(a) 3. and the group member does not become eligible for coverage by a replacement group policy, the terminated insured has the right to convert to individual coverage under sub.
(4), unless sub.
(4) (d) applies.
632.897(3)(d)
(d) If the right of the terminated insured to continue group policy coverage is terminated under par.
(a) 1. the terminated insured, and a spouse or dependent of the terminated insured, if the terminated insured was eligible for continued group coverage under sub.
(2) (b) 2. and the spouse or dependent was covered under the group policy, have the right to convert to individual coverage under sub.
(4), unless sub.
(4) (d) applies.
632.897(3)(e)
(e) This subsection does not require coverage of expenses which are covered by medicare.
632.897(4)(a)(a) A terminated insured who elects conversion coverage under sub.
(2) (b) or
(3) (c) or
(d), the spouse or dependent of such a terminated insured, if the terminated insured is eligible under sub.
(2) (b) 2. and the spouse or dependent was covered under the group policy, and a terminated insured eligible under sub.
(9) and his or her dependents are entitled to have the insurer issue to them, without evidence of insurability, individual coverage reasonably similar to the terminated coverage under the group policy or individual policy. Any probationary or waiting periods required by such individual coverage shall be considered as being met to the extent such limitations have been met under the prior group policy or individual policy.