January 16, 2019 - Offered by Representative Rohrkaste.
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3“(ag) “Defined network plan” has the meaning given in s. 609.01 (1b).”.
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6“(ar) “Preexisting condition exclusion” means, with respect to coverage, a
7limitation or exclusion of benefits relating to a condition based on the fact that the
8condition was present before the date of enrollment for the coverage, whether or not
9any medical advice, diagnosis, care, or treatment was recommended or received
10before the date of enrollment for coverage.”.
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2“(b) A health benefit plan that is a defined network plan may do any of the
3following:
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1. Limit the employers that may apply for group health benefit plan coverage
5to those employers whose employees live, work, or reside in the service area for the
6defined network plan.
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2. Deny coverage to employers and individuals in the service area of the defined
8network plan if the defined network plan has demonstrated to the commissioner all
9of the following:
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a. The defined network plan does not have the capacity to deliver services
11adequately to enrollees of any additional groups or additional individuals because
12of its obligations to existing defined network plan enrollees.
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b. The defined network plan is denying coverage uniformly to all employers and
14individuals without regard to the claims experience or health status-related factor,
15as described under s. 632.748 (1) (a) 1. to 8., of the individuals, employers, employees,
16or dependents of individuals or employees.
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(c) A group or individual health benefit plan may deny coverage if the plan has
18demonstrated to the commissioner all of the following:
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1. The issuer of the health benefit plan does not have the financial reserves
20necessary to underwrite additional coverage.
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2. The group or individual health benefit plan is denying coverage uniformly
22to all employers and individuals without regard to the claims experience or health
23status-related factor, as described under s. 632.748 (1) (a) 1. to 8., of the individuals,
24employers, employees, or dependents of individuals or employees.
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1(d) A defined network plan that denies coverage under par. (b) 2. may not offer
2coverage within the service area of the defined network plan within 180 days after
3the date coverage is denied under par. (b) 2. An issuer of a health benefit plan that
4denies coverage under par. (c) may not offer coverage under a group or individual
5health benefit plan in this state within 180 days after the date coverage is denied
6under par. (c) or until the date the issuer of the health benefit plan demonstrates to
7the commissioner that the issuer has sufficient financial reserves to underwrite
8additional coverage, whichever is later.”.
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1714. Page 5, line 12: after “
Applicability." insert “(a) A health benefit plan that
18is considered a grandfathered health plan under
42 USC 18011 as of January 1, 2019,
19or has transitional status as of January 1, 2019, granted by the federal department
20of health and human services and the commissioner is not required to comply with
21sub. (2) or (3). An individual health benefit plan that is considered a grandfathered
22health plan under
42 USC 18011 as of January 1, 2019, or has transitional status as
1of January 1, 2019, granted by the federal department of health and human services
2and the commissioner is not required to comply with sub. (5).
