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AB56-SA2,68,63 (c) Nothing in this subsection prevents an insurer offering an individual health
4benefit plan or a self-insured health plan from establishing premium discounts or
5rebates or modifying otherwise applicable cost sharing in return for adherence to
6programs of health promotion and disease prevention.
AB56-SA2,68,9 7(4) Premium rate variation. A health benefit plan offered on the individual or
8small employer market or a self-insured health plan may vary premium rates for a
9specific plan based only on the following considerations:
AB56-SA2,68,1010 (a) Whether the policy or plan covers an individual or a family.
AB56-SA2,68,1111 (b) Rating area in the state, as established by the commissioner.
AB56-SA2,68,1412 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over
13the age groups and the age bands shall be consistent with recommendations of the
14National Association of Insurance Commissioners.
AB56-SA2,68,1515 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
AB56-SA2,68,17 16(5) Annual and lifetime limits. An individual or group health benefit plan or
17a self-insured health plan may not establish any of the following:
AB56-SA2,68,1918 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
19of an enrollee under the plan.
AB56-SA2,68,2120 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent
21of an enrollee under the plan.
AB56-SA2,69,4 22(6) Short-term plans. This section and s. 632.76 apply to every short-term,
23limited-duration health insurance policy. In this subsection, “short-term,
24limited-duration health insurance policy” means health coverage that is provided
25under a contract with an insurer, has an expiration date specified in the contract that

1is less than 12 months after the original effective date of the contract, and, taking
2into account renewals or extensions, has a duration of no longer than 36 months in
3total. “Short-term, limited-duration health insurance policy” includes any
4short-term policy subject to s. 632.7495 (4).
AB56-SA2,2080i 5Section 2080i. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and
6amended to read:
AB56-SA2,69,137 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health
8benefit plan may, with respect to a participant or beneficiary under the plan, not
9impose a preexisting condition exclusion only if the exclusion relates to a condition,
10whether physical or mental, regardless of the cause of the condition, for which
11medical advice, diagnosis, care or treatment was recommended or received within
12the 6-month period ending on the participant's or beneficiary's enrollment date
13under the plan
on a participant or beneficiary under the plan.
AB56-SA2,2081i 14Section 2081i. 632.746 (1) (b) of the statutes is repealed.
AB56-SA2,2082i 15Section 2082i. 632.746 (2) (a) of the statutes is amended to read:
AB56-SA2,69,1916 632.746 (2) (a) An insurer offering a group health benefit plan may not treat
17impose a preexisting condition exclusion based on genetic information as a
18preexisting condition under sub. (1) without a diagnosis of a condition related to the
19information
.
AB56-SA2,2083i 20Section 2083i. 632.746 (2) (c), (d) and (e) of the statutes are repealed.
AB56-SA2,2084i 21Section 2084i. 632.746 (3) (a) of the statutes is repealed.
AB56-SA2,2085i 22Section 2085i. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).
AB56-SA2,2086i 23Section 2086i. 632.746 (3) (d) 2. and 3. of the statutes are repealed.
AB56-SA2,2087i 24Section 2087i. 632.746 (5) of the statutes is repealed.
AB56-SA2,2088i 25Section 2088i. 632.746 (8) (a) (intro.) of the statutes is amended to read:
AB56-SA2,70,4
1632.746 (8) (a) (intro.) A health maintenance organization that offers a group
2health benefit plan and that does not impose any preexisting condition exclusion
3under sub. (1)
with respect to a particular coverage option may impose an affiliation
4period for that coverage option, but only if all of the following apply:
AB56-SA2,2089i 5Section 2089i. 632.748 (2) of the statutes is amended to read:
AB56-SA2,70,126 632.748 (2) An insurer offering a group health benefit plan may not require any
7individual, as a condition of enrollment or continued enrollment under the plan, to
8pay, on the basis of any health status-related factor with respect to the individual
9or a dependent of the individual, a premium or contribution or a deductible,
10copayment, or coinsurance amount
that is greater than the premium or contribution
11or deductible, copayment, or coinsurance amount respectively for a similarly
12situated individual enrolled under the plan.
AB56-SA2,2090i 13Section 2090i. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to
14read:
AB56-SA2,70,2215 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years
16from the date of issue of the policy may be reduced or denied on the ground that a
17disease or physical condition existed prior to the effective date of coverage, unless the
18condition was excluded from coverage by name or specific description by a provision
19effective on the date of loss. This paragraph does not apply to a group health benefit
20plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance
21policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s.
22632.85 (1) (c)
.
AB56-SA2,71,323 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability
24commencing after 12 months from the date of issue of under an individual disability
25insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the

1ground that a disease or physical condition existed prior to the effective date of
2coverage, unless the condition was excluded from coverage by name or specific
3description by a provision effective on the date of the loss
.
AB56-SA2,71,104 2. Except as provided in subd. 3., an An individual disability insurance policy,
5as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495
6(4) and (5),
may not define a preexisting condition more restrictively than a condition
7that was present before the date of enrollment for the coverage, whether physical or
8mental, regardless of the cause of the condition, for which and regardless of whether
9medical advice, diagnosis, care, or treatment was recommended or received within
1012 months before the effective date of coverage
.
AB56-SA2,2091i 11Section 2091i. 632.76 (2) (ac) 3. of the statutes is repealed.
AB56-SA2,2092i 12Section 2092i. 632.795 (4) (a) of the statutes is amended to read:
AB56-SA2,71,2413 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the
14same policy form and for the same premium as it originally offered in the most recent
15enrollment period, subject only to the medical underwriting used in that enrollment
16period. Unless otherwise prescribed by rule, the insurer may apply deductibles,
17preexisting condition limitations, waiting periods , or other limits only to the extent
18that they would have been applicable had coverage been extended at the time of the
19most recent enrollment period and with credit for the satisfaction or partial
20satisfaction of similar provisions under the liquidated insurer's policy or plan. The
21insurer may exclude coverage of claims that are payable by a solvent insurer under
22insolvency coverage required by the commissioner or by the insurance regulator of
23another jurisdiction. Coverage shall be effective on the date that the liquidated
24insurer's coverage terminates.
AB56-SA2,2093k 25Section 2093k. 632.796 of the statutes is created to read:
AB56-SA2,72,2
1632.796 Drug cost report. (1) Definition. In this section, “disability
2insurance policy” has the meaning given in s. 632.895 (1) (a).
AB56-SA2,72,8 3(2) Report required. Annually, at the time the insurer files its rate request
4with the commissioner, each insurer that offers a disability insurance policy that
5covers prescription drugs shall submit to the commissioner a report that identifies
6the 25 prescription drugs that are the highest cost to the insurer and the 25
7prescription drugs that have the highest cost increases over the 12 months before the
8submission of the report.
AB56-SA2,2094k 9Section 2094k. 632.865 (3) of the statutes is created to read:
AB56-SA2,72,1210 632.865 (3) Registration required. (a) No person may perform any activities
11of a pharmacy benefit manager in this state without first registering with the
12commissioner under this subsection.
AB56-SA2,72,1513 (b) The commissioner shall establish a registration procedure for pharmacy
14benefit managers. The commissioner may promulgate any rules necessary to
15implement the registration procedure under this paragraph.
AB56-SA2,2095k 16Section 2095k. 632.866 of the statutes is created to read:
AB56-SA2,72,17 17632.866 Prescription drug cost reporting. (1) Definitions. In this section:
AB56-SA2,72,1918 (a) “Brand-name drug” means a prescription drug approved under 21 USC 355
19(b) or 42 USC 262.
AB56-SA2,72,2120 (b) “Covered hospital” means an entity described in 42 USC 256b (a) (4) (L) to
21(N) that participates in the federal drug-pricing program under 42 USC 256b.
AB56-SA2,72,2222 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
AB56-SA2,72,2323 (d) “Generic drug” means a prescription drug approved under 21 USC 355 (j).
AB56-SA2,73,3
1(e) “Manufacturer” has the meaning given in s. 450.01 (12). “Manufacturer”
2does not include an entity that is engaged only in the dispensing, as defined in s.
3450.01 (7), of a brand-name drug or a generic drug.
AB56-SA2,73,74 (f) “Manufacturer-sponsored assistance program” means a program offered by
5a manufacturer or an intermediary under contract with a manufacturer through
6which a brand-name drug or a generic drug is provided to a patient at no charge or
7at a discount.
AB56-SA2,73,118 (g) “Margin” means, for a covered hospital, the difference between the net cost
9of a brand-name drug or generic drug covered under the federal drug-pricing
10program under 42 USC 256b and the net payment by the covered hospital for that
11brand-name drug or generic drug.
AB56-SA2,73,1312 (h) “Net payment” means the amount paid for a brand-name drug or generic
13drug after all discounts and rebates have been applied.
AB56-SA2,73,1414 (i) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
AB56-SA2,73,1815 (j) “Wholesale acquisition cost” means the most recently reported
16manufacturer list or catalog price for a brand-name drug or a generic drug available
17to wholesalers or direct purchasers in the United States, before application of
18discounts, rebates, or reductions in price.
AB56-SA2,73,24 19(2) Price increase or introduction notice; justification report. (a) A
20manufacturer shall notify the commissioner if it is increasing the wholesale
21acquisition cost of a brand-name drug on the market in this state by more than 10
22percent or by more than $10,000 during any 12-month period or if it intends to
23introduce to market in this state a brand-name drug that has an annual wholesale
24acquisition cost of $30,000 or more.
AB56-SA2,74,4
1(b) A manufacturer shall notify the commissioner if it is increasing the
2wholesale acquisition cost of a generic drug by more than 25 percent or by more than
3$300 during any 12-month period or if it intends to introduce to market a generic
4drug that has an annual wholesale acquisition cost of $3,000 or more.
AB56-SA2,74,105 (c) The manufacturer shall provide the notice under par. (a) or (b) in writing
6at least 30 days before the planned effective date of the cost increase or drug
7introduction with a justification that includes all documents and research related to
8the manufacturer's selection of the cost increase or introduction price and a
9description of life cycle management, market competition and context, and
10estimated value or cost-effectiveness of the product.
AB56-SA2,74,14 11(3) Net prices paid by pharmacy benefit managers. By March 1 annually, the
12manufacturer shall report to the commissioner the value of price concessions,
13expressed as a percentage of the wholesale acquisition cost, provided to each
14pharmacy benefit manager for each drug sold in this state.
AB56-SA2,74,19 15(4) Rebates and price concessions. By March 1 annually, each pharmacy
16benefit manager shall report to the commissioner the amount received from
17manufacturers as drug rebates and the value of price concessions, expressed as a
18percentage of the wholesale acquisition cost, provided by manufacturers for each
19drug.
AB56-SA2,74,24 20(5) Hospital margin spending. By March 1 annually, each covered hospital
21operating in this state shall report to the commissioner the per unit margin for each
22drug covered under the federal drug pricing program under 42 USC 256b dispensed
23in the previous year multiplied by the number of units dispensed at that margin and
24how the margin revenue was used.
AB56-SA2,75,4
1(6) Manufacturer-sponsored assistance programs. By March 1 annually,
2each manufacturer shall provide the commissioner with a description of each
3manufacturer-sponsored patient assistance program in effect during the previous
4year that includes all of the following:
AB56-SA2,75,55 (a) The terms of the programs.
AB56-SA2,75,66 (b) The number of prescriptions provided to state residents under the program.
AB56-SA2,75,87 (c) The total market value of assistance provided to residents of this state under
8the program.
AB56-SA2,75,13 9(7) Certification and penalties for noncompliance. Each manufacturer and
10covered hospital that is required to report under this section shall certify each report
11as accurate under the penalty of perjury. A manufacturer or covered hospital that
12fails to submit a report required under this section is subject to a forfeiture of no more
13than $10,000 each day the report is overdue.
AB56-SA2,75,17 14(8) Hearing and public reporting. (a) The commissioner shall publicly post
15manufacturer price justification documents and covered hospital documentation of
16how each hospital spends the margin revenue. The commissioner shall keep any
17trade secret or proprietary information confidential.
AB56-SA2,75,2518 (b) The commissioner shall analyze data collected under this section and
19publish annually a report on emerging trends in prescription prices and price
20increases, and shall annually conduct a public hearing based on the analysis under
21this paragraph. The report under this paragraph shall include analysis of
22manufacturer prices and price increases, analysis of hospital-specific margins and
23how that revenue is spent or allocated on a hospital-specific basis, and analysis of
24how pharmacy benefit manager discounts and net costs compare to retail prices paid
25by patients.
AB56-SA2,76,8
1(9) Allowing cost disclosure to insured. The commissioner shall ensure that
2every disability insurance policy that covers prescription drugs or biological products
3does not restrict a pharmacy or pharmacist that dispenses a prescription drug or
4biological product from informing and does not penalize a pharmacy or pharmacist
5for informing an insured under a policy of a difference between the negotiated price
6of, or copayment or coinsurance for, the drug or biological product under the policy
7and the price the insured would pay for the drug or biological product if the insured
8obtained the drug or biological product without using any health insurance coverage.
AB56-SA2,2097i 9Section 2097i. 632.895 (8) (d) of the statutes is amended to read:
AB56-SA2,76,1610 632.895 (8) (d) Coverage is required under this subsection despite whether the
11woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c), and
12(e), coverage under this subsection may only be subject to exclusions and limitations,
13including deductibles, copayments and restrictions on excessive charges, that are
14applied to other radiological examinations covered under the disability insurance
15policy. Coverage under this subsection may not be subject to any deductibles,
16copayments, or coinsurance.
AB56-SA2,2098i 17Section 2098i. 632.895 (13m) of the statutes is created to read:
AB56-SA2,76,1918 632.895 (13m) Preventive services. (a) In this section, “self-insured health
19plan” has the meaning given in s. 632.85 (1) (c).
AB56-SA2,76,2220 (b) Every disability insurance policy, except any disability insurance policy that
21is described in s. 632.745 (11) (b) 1. to 12., and every self-insured health plan shall
22provide coverage for all of the following preventive services:
AB56-SA2,76,2323 1. Mammography in accordance with sub. (8).
AB56-SA2,76,2524 2. Genetic breast cancer screening and counseling and preventive medication
25for adult women at high risk for breast cancer.
AB56-SA2,77,2
13. Papanicolaou test for cancer screening for women 21 years of age or older
2with an intact cervix.
AB56-SA2,77,43 4. Human papillomavirus testing for women who have attained the age of 30
4years but have not attained the age of 66 years.
AB56-SA2,77,55 5. Colorectal cancer screening in accordance with sub. (16m).
AB56-SA2,77,86 6. Annual tomography for lung cancer screening for adults who have attained
7the age of 55 years but have not attained the age of 80 years and who have health
8histories demonstrating a risk for lung cancer.
AB56-SA2,77,109 7. Skin cancer screening for individuals who have attained the age of 10 years
10but have not attained the age of 22 years.
AB56-SA2,77,1211 8. Counseling for skin cancer prevention for adults who have attained the age
12of 18 years but have not attained the age of 25 years.
AB56-SA2,77,1413 9. Abdominal aortic aneurysm screening for men who have attained the age of
1465 years but have not attained the age of 75 years and who have ever smoked.
AB56-SA2,77,1715 10. Hypertension screening for adults and blood pressure testing for adults, for
16children under the age of 3 years who are at high risk for hypertension, and for
17children 3 years of age or older.
AB56-SA2,77,1918 11. Lipid disorder screening for minors 2 years of age or older, adults 20 years
19of age or older at high risk for lipid disorders, and all men 35 years of age or older.
AB56-SA2,77,2220 12. Aspirin therapy for cardiovascular health for adults who have attained the
21age of 55 years but have not attained the age of 80 years and for men who have
22attained the age of 45 years but have not attained the age of 55 years.
AB56-SA2,77,2423 13. Behavioral counseling for cardiovascular health for adults who are
24overweight or obese and who have risk factors for cardiovascular disease.
AB56-SA2,77,2525 14. Type II diabetes screening for adults with elevated blood pressure.
AB56-SA2,78,2
115. Depression screening for minors 11 years of age or older and for adults when
2follow-up supports are available.
AB56-SA2,78,43 16. Hepatitis B screening for minors at high risk for infection and adults at high
4risk for infection.
AB56-SA2,78,65 17. Hepatitis C screening for adults at high risk for infection and one-time
6hepatitis C screening for adults born in any year from 1945 to 1965.
AB56-SA2,78,107 18. Obesity screening and management for all minors and adults with a body
8mass index indicating obesity, counseling and behavioral interventions for obese
9minors who are 6 years of age or older, and referral for intervention for obesity for
10adults with a body mass index of 30 kilograms per square meter or higher.
AB56-SA2,78,1211 19. Osteoporosis screening for all women 65 years of age or older and for women
12at high risk for osteoporosis under the age of 65 years.
AB56-SA2,78,1313 20. Immunizations in accordance with sub. (14).
AB56-SA2,78,1614 21. Anemia screening for individuals 6 months of age or older and iron
15supplements for individuals at high risk for anemia and who have attained the age
16of 6 months but have not attained the age of 12 months.
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