Amendment AA2-ASA2-AB68

AB68-ASA2-AA2,80,11 8. Disability.

AB68-ASA2-AA2,80,18 (b) An insurer offering an individual health benefit plan or a self-insured health 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 under par. (a) with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.

AB68-ASA2-AA2,80,22 (c) Nothing in this subsection prevents an insurer offering an individual health benefit plan or a self-insured health plan from establishing premium discounts or rebates or modifying otherwise applicable cost sharing in return for adherence to programs of health promotion and disease prevention.

AB68-ASA2-AA2,80,25 (4) Premium rate variation. A health benefit plan offered on the individual or small employer market or a self-insured health plan may vary premium rates for a specific plan based only on the following considerations:

AB68-ASA2-AA2,81,1 (a) Whether the policy or plan covers an individual or a family.

AB68-ASA2-AA2,81,2 (b) Rating area in the state, as established by the commissioner.

AB68-ASA2-AA2,81,5 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over the age groups and the age bands shall be consistent with recommendations of the National Association of Insurance Commissioners.

AB68-ASA2-AA2,81,6 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68-ASA2-AA2,81,11 (5) Statewide risk pool. An insurer offering a health benefit plan may not segregate enrollees into risk pools other than a single statewide risk pool for the individual market and a single statewide risk pool for the small employer market or a single statewide risk pool that combines the individual and small employer markets.

AB68-ASA2-AA2,81,13 (6) Annual and lifetime limits. An individual or group health benefit plan or a self-insured health plan may not establish any of the following:

AB68-ASA2-AA2,81,15 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-ASA2-AA2,81,17 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-ASA2-AA2,81,21 (7) Cost sharing maximum. A health benefit plan offered on the individual or small employer market may not require an enrollee under the plan to pay more in cost sharing than the maximum amount calculated under 42 USC 18022 (c), including the annual indexing of the limits.

AB68-ASA2-AA2,81,24 (8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the proportion, expressed as a percentage, of premium revenues spent by a health benefit plan on clinical services and quality improvement.

AB68-ASA2-AA2,82,2 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB68-ASA2-AA2,82,4 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB68-ASA2-AA2,82,8 (9) Actuarial values of plan tiers. Any health benefit plan offered on the individual or small employer market shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to at least 60 percent of the full actuarial value of the benefits provided under the plan.

AB68-ASA2-AA2,412p Section 412p. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB68-ASA2-AA2,82,17 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not 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 on a participant or beneficiary under the plan.

AB68-ASA2-AA2,412q Section 412q. 632.746 (1) (b) of the statutes is repealed.

AB68-ASA2-AA2,412r Section 412r. 632.746 (2) (a) of the statutes is amended to read:

AB68-ASA2-AA2,82,23 632.746 (2) (a) An insurer offering a group health benefit plan may not treat impose a preexisting condition exclusion based on genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

AB68-ASA2-AA2,412s Section 412s. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB68-ASA2-AA2,412t Section 412t. 632.746 (3) (a) of the statutes is repealed.

AB68-ASA2-AA2,412u Section 412u. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB68-ASA2-AA2,412v Section 412v. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB68-ASA2-AA2,412w Section 412w. 632.746 (5) of the statutes is repealed.

AB68-ASA2-AA2,412x Section 412x. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB68-ASA2-AA2,83,8 632.746 (8) (a) (intro.) 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:

AB68-ASA2-AA2,412y Section 412y. 632.748 (2) of the statutes is amended to read:

AB68-ASA2-AA2,83,16 632.748 (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 or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.

AB68-ASA2-AA2,412yc Section 412yc. 632.7495 (4) (b) of the statutes is amended to read:

AB68-ASA2-AA2,83,18 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

AB68-ASA2-AA2,412ye Section 412ye. 632.7495 (4) (c) of the statutes is amended to read:

AB68-ASA2-AA2,83,24 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 6 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB68-ASA2-AA2,412yg Section 412yg. 632.7496 of the statutes is created to read:

AB68-ASA2-AA2,84,3 632.7496 Coverage requirements for short-term plans. (1) Definition. In this section, “short-term, limited duration plan” means an individual health benefit plan described in s. 632.7495 (4) that an insurer is not required to renew.

AB68-ASA2-AA2,84,6 (2) Guaranteed issue. Every short-term, limited duration plan shall accept every individual in this state who applies for coverage whether or not any individual has a preexisting condition.

AB68-ASA2-AA2,84,11 (3) Prohibiting discrimination based on health status. (a) A short-term, limited duration plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB68-ASA2-AA2,84,12 1. Health status.

AB68-ASA2-AA2,84,13 2. Medical condition, including both physical and mental illnesses.

AB68-ASA2-AA2,84,14 3. Claims experience.

AB68-ASA2-AA2,84,15 4. Receipt of health care.

AB68-ASA2-AA2,84,16 5. Medical history.

AB68-ASA2-AA2,84,17 6. Genetic information.

AB68-ASA2-AA2,84,19 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68-ASA2-AA2,84,20 8. Disability.

AB68-ASA2-AA2,85,2 (b) A short-term, limited duration 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 under par. (a) with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.

AB68-ASA2-AA2,85,4 (4) Premium rate variation. A short-term, limited duration plan may vary premium rates for a specific plan based only on the following considerations:

AB68-ASA2-AA2,85,5 (a) Whether the policy or plan covers an individual or a family.

AB68-ASA2-AA2,85,6 (b) Rating area in the state, as established by the commissioner.

AB68-ASA2-AA2,85,9 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over the age groups and the age bands shall be consistent with recommendations of the National Association of Insurance Commissioners.

AB68-ASA2-AA2,85,10 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68-ASA2-AA2,85,12 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

AB68-ASA2-AA2,85,14 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-ASA2-AA2,85,16 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan for the initial or cumulative duration of the plan.

AB68-ASA2-AA2,412yj Section 412yj. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB68-ASA2-AA2,86,2 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c).

AB68-ASA2-AA2,86,8 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB68-ASA2-AA2,86,15 2. Except as provided in subd. 3., an An individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition that was present before the date of enrollment for the coverage, whether physical or mental, regardless of the cause of the condition, for which and regardless of whether medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB68-ASA2-AA2,412ym Section 412ym. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB68-ASA2-AA2,86,19 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term, limited duration policy subject to s. 632.7495 (4) and (5):

AB68-ASA2-AA2,412yp Section 412yp. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

AB68-ASA2-AA2,87,2 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB68-ASA2-AA2,412ys Section 412ys. 632.795 (4) (a) of the statutes is amended to read:

AB68-ASA2-AA2,87,15 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods , or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.

AB68-ASA2-AA2,412yu Section 412yu. 632.796 of the statutes is created to read:

AB68-ASA2-AA2,87,18 632.796 Drug cost report. (1) Definition. In this section, “disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68-ASA2-AA2,87,24 (2) Report required. Annually, at the time the insurer files its rate request with the commissioner, each insurer that offers a disability insurance policy that covers prescription drugs shall submit to the commissioner a report that identifies the 25 prescription drugs that are the highest cost to the insurer and the 25 prescription drugs that have the highest cost increases over the 12 months before the submission of the report.

AB68-ASA2-AA2,412yw Section 412yw. 632.862 of the statutes is created to read:

AB68-ASA2-AA2,88,2 632.862 Application of prescription drug payments. (1) Definitions. In this section:

AB68-ASA2-AA2,88,3 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

AB68-ASA2-AA2,88,4 (b) “Brand name drug” means any of the following:

AB68-ASA2-AA2,88,6 1. A prescription drug that contains a brand name and that has no generic equivalent.

AB68-ASA2-AA2,88,10 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or the self-insured health plan or authorization from a physician to obtain the prescription drug under the policy or plan.

AB68-ASA2-AA2,88,11 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68-ASA2-AA2,88,12 (d) “Prescription drug” has the meaning given in s. 450.01 (20)

AB68-ASA2-AA2,88,13 (e) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68-ASA2-AA2,88,19 (2) Application of discounts. A disability insurance policy that offers a prescription drug benefit or a self-insured health plan shall apply to any calculation of an out-of-pocket maximum and to any deductible of the policy or plan for an enrollee the amount that any discount provided by the manufacturer of a brand name drug reduces the cost sharing amount charged to an enrollee for that brand name drug.

AB68-ASA2-AA2,412yz Section 412yz. 632.8655 of the statutes is created to read:

AB68-ASA2-AA2,88,22 632.8655 Prescription drug cost reporting. (1) Definitions. In this section:

AB68-ASA2-AA2,88,24 (a) “Brand-name drug” means a prescription drug approved under 21 USC 355 (b) or 42 USC 262.

AB68-ASA2-AA2,89,2 (b) “Covered hospital” means an entity described in 42 USC 256b (a) (4) (L) to (N) that participates in the federal drug pricing program under 42 USC 256b.

AB68-ASA2-AA2,89,3 (c) “Generic drug” means a prescription drug approved under 21 USC 355 (j).

AB68-ASA2-AA2,89,7 (d) “Margin” means, for a covered hospital, the difference between the net cost of a brand-name drug or generic drug covered under the federal drug pricing program under 42 USC 256b and the net payment by the covered hospital for that brand-name drug or generic drug.

AB68-ASA2-AA2,89,9 (e) “Net payment” means the amount paid for a brand-name drug or generic drug after all discounts and rebates have been applied.

AB68-ASA2-AA2,89,14 (2) Hospital margin spending. By March 1 annually, each covered hospital operating in this state shall report to the commissioner the per unit margin for each drug covered under the federal drug pricing program under 42 USC 256b dispensed in the previous year multiplied by the number of units dispensed at that margin and how the margin revenue was used.

AB68-ASA2-AA2,89,20 (3) Public reporting. The commissioner shall publicly post covered hospital documentation of how each hospital spends the margin revenue. The commissioner shall analyze data collected under this section and publish annually a report including an analysis on hospital-specific margins and how that revenue is spent or allocated on a hospital-specific basis. The commissioner shall keep any trade secret or proprietary information confidential.

AB68-ASA2-AA2,412z Section 412z. 632.8665 of the statutes is created to read: