AB100-ASA1-AA8,452,19 (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:

AB100-ASA1-AA8,452,21 (a) A partner in relation to a partnership and the group health plan or group health benefit plan is maintained by the partnership.

AB100-ASA1-AA8,452,24 (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.

AB100-ASA1-AA8,453,5 (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.

AB100-ASA1-AA8,453,7 (22) "Plan sponsor" has the meaning given in section 3 (16) (B) of the federal Employee Retirement Income Security Act of 1974.

AB100-ASA1-AA8,453,10 (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.

AB100-ASA1-AA8,453,12 (24) "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.

AB100-ASA1-AA8,453,13 (25) "Small employer" has the meaning given in s. 635.02 (7).

AB100-ASA1-AA8,453,17 (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.

AB100-ASA1-AA8,453,22 (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.

AB100-ASA1-AA8, s. 4917m Section 4917m. 632.746 of the statutes is created to read:

AB100-ASA1-AA8,454,6 632.746 Preexisting condition; portability; restrictions; and special enrollment periods. (1) (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.

AB100-ASA1-AA8,454,9 (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.

AB100-ASA1-AA8,454,12 (2) (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.

AB100-ASA1-AA8,454,14 (b) An insurer offering a group health benefit plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition.

AB100-ASA1-AA8,454,18 (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.

AB100-ASA1-AA8,454,25 (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.

AB100-ASA1-AA8,455,6 (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.

AB100-ASA1-AA8,455,10 (3) (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.

AB100-ASA1-AA8,455,18 (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.

AB100-ASA1-AA8,455,24 (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.

AB100-ASA1-AA8,456,3 (d) 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.

AB100-ASA1-AA8,456,10 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.

AB100-ASA1-AA8,456,14 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.

AB100-ASA1-AA8,456,17 (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.

AB100-ASA1-AA8,456,20 (4) (a) On and after October 1, 1996, an insurer that provides health benefit plan coverage shall provide the certification described in par. (b) upon the happening of any of the following events:

AB100-ASA1-AA8,456,25 1. An individual ceases to be covered under the health benefit plan or otherwise becomes covered under a federal continuation provision. The certification required under this subdivision may be provided, to the extent practicable, at a time consistent with notices required under any applicable federal continuation provision or s. 632.897.

AB100-ASA1-AA8,457,1 2. An individual ceases to be covered under a federal continuation provision.

AB100-ASA1-AA8,457,4 3. Upon the request of an individual that is made not later than 24 months after the date of the cessation of the individual's coverage under subd. 1. or 2., whichever is later.