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AB68-SSA1,1339,18 18(8) Continuity of care. (a) In this subsection:
AB68-SSA1,1339,1919 1. “Continuing care patient” means an individual who is any of the following:
AB68-SSA1,1339,2120 a. Undergoing a course of treatment for a serious and complex condition from
21a provider or facility.
AB68-SSA1,1339,2322 b. Undergoing a course of institutional or inpatient care from a provider or
23facility.
AB68-SSA1,1339,2524 c. Scheduled to undergo nonelective surgery, including receipt of postoperative
25care, from a provider or facility.
AB68-SSA1,1340,2
1d. Pregnant and undergoing a course of treatment for the pregnancy from a
2provider or facility.
AB68-SSA1,1340,43 e. Terminally ill and receiving treatment for the illness from a provider or
4facility.
AB68-SSA1,1340,55 2. “Serious and complex condition” means any of the following:
AB68-SSA1,1340,86 a. In the case of an acute illness, a condition that is serious enough to require
7specialized medical treatment to avoid the reasonable possibility of death or
8permanent harm.
AB68-SSA1,1340,119 b. In the case of a chronic illness or condition, a condition that is
10life-threatening, degenerative, potentially disabling, or congenital and requires
11specialized medical care over a prolonged period of time.
AB68-SSA1,1340,1712 (b) If an enrollee is a continuing care patient and is obtaining items or services
13from a participating provider or facility and the contract between the defined
14network plan, preferred provider plan, or self-insured governmental plan and the
15participating provider or facility is terminated or the coverage of benefits that
16include the items or services provided by the participating provider or facility are
17terminated by the plan, the plan shall do all of the following:
AB68-SSA1,1340,2018 1. Notify each enrollee of the termination of the contract or benefits and of the
19right for the enrollee to elect to continue transitional care from the provider or facility
20under this subsection.
AB68-SSA1,1340,2221 2. Provide the enrollee an opportunity to notify the plan of the need for
22transitional care.
AB68-SSA1,1341,423 3. Allow the enrollee to elect to continue to have the benefits provided under
24the plan under the same terms and conditions as would have applied to the item or
25service if the termination had not occurred for the course of treatment related to the

1enrollee's status as a continuing care patient beginning on the date on which the
2notice under subd. 1. is provided and ending 90 days after the date on which the
3notice under subd. 1. is provided or the date on which the enrollee is no longer a
4continuing care patient, whichever is earlier.
AB68-SSA1,1341,8 5(9) Rule making. The commissioner may promulgate any rules necessary to
6implement this section, including specifying the independent dispute resolution
7process. The commissioner may promulgate rules to modify the list of those items
8and services for which a provider may not balance bill under sub. (5) (c).
AB68-SSA1,2963 9Section 2963. 609.713 of the statutes is created to read:
AB68-SSA1,1341,11 10609.713 Essential health benefits; preventive services. Defined network
11plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).
AB68-SSA1,2964 12Section 2964. 609.719 of the statutes is created to read:
AB68-SSA1,1341,14 13609.719 Telehealth services. Limited service health organizations,
14preferred provider plans, and defined network plans are subject to s. 632.871.
AB68-SSA1,2965 15Section 2965 . 609.83 of the statutes is amended to read:
AB68-SSA1,1341,18 16609.83 Coverage of drugs and devices ; application of payments.
17Limited service health organizations, preferred provider plans, and defined network
18plans are subject to ss. 632.853, 632.862, and 632.895 (16t) and (16v).
AB68-SSA1,2966 19Section 2966 . 609.83 of the statutes, as affected by 2021 Wisconsin Act .... (this
20act), section 2965, is amended to read:
AB68-SSA1,1341,23 21609.83 Coverage of drugs and devices; application of payments.
22Limited service health organizations, preferred provider plans, and defined network
23plans are subject to ss. 632.853, 632.862, and 632.895 (6) (b), (16t), and (16v).
AB68-SSA1,2967 24Section 2967. 609.847 of the statutes is created to read:
AB68-SSA1,1342,3
1609.847 Preexisting condition discrimination and certain benefit
2limits prohibited.
Limited service health organizations, preferred provider plans,
3and defined network plans are subject to s. 632.728.
AB68-SSA1,2968 4Section 2968. 625.12 (1) (a) of the statutes is amended to read:
AB68-SSA1,1342,65 625.12 (1) (a) Past and prospective loss and expense experience within and
6outside of this state, except as provided in s. 632.728.
AB68-SSA1,2969 7Section 2969. 625.12 (1) (e) of the statutes is amended to read:
AB68-SSA1,1342,98 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors,
9including the judgment of technical personnel.
AB68-SSA1,2970 10Section 2970. 625.12 (2) of the statutes is amended to read:
AB68-SSA1,1342,1911 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729,
12risks may be classified in any reasonable way for the establishment of rates and
13minimum premiums, except that no classifications may be based on race, color, creed
14or national origin, and classifications in automobile insurance may not be based on
15physical condition or developmental disability as defined in s. 51.01 (5). Subject to
16ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for
17individual risks in accordance with rating plans or schedules that establish
18reasonable standards for measuring probable variations in hazards, expenses, or
19both. Rates may also be modified for individual risks under s. 625.13 (2).
AB68-SSA1,2971 20Section 2971. 625.15 (1) of the statutes is amended to read:
AB68-SSA1,1343,321 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may
22itself establish rates and supplementary rate information for one or more market
23segments based on the factors in s. 625.12 and, if the rates are for motor vehicle
24liability insurance, subject to s. 632.365, or the insurer may use rates and
25supplementary rate information prepared by a rate service organization, with

1average expense factors determined by the rate service organization or with such
2modification for its own expense and loss experience as the credibility of that
3experience allows.
AB68-SSA1,2972 4Section 2972 . 628.34 (3) (a) of the statutes is amended to read:
AB68-SSA1,1343,125 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
6charging different premiums or by offering different terms of coverage except on the
7basis of classifications related to the nature and the degree of the risk covered or the
8expenses involved, subject to ss. 632.365, 632.729, 632.746 and, 632.748, and
9632.7496
. Rates are not unfairly discriminatory if they are averaged broadly among
10persons insured under a group, blanket or franchise policy, and terms are not
11unfairly discriminatory merely because they are more favorable than in a similar
12individual policy.
AB68-SSA1,2973 13Section 2973 . 628.34 (3) (a) of the statutes, as affected by 2021 Wisconsin Act
14.... (this act), is amended to read:
AB68-SSA1,1343,2215 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
16charging different premiums or by offering different terms of coverage except on the
17basis of classifications related to the nature and the degree of the risk covered or the
18expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746, 632.748, and
19632.7496. Rates are not unfairly discriminatory if they are averaged broadly among
20persons insured under a group, blanket or franchise policy, and terms are not
21unfairly discriminatory merely because they are more favorable than in a similar
22individual policy.
AB68-SSA1,2974 23Section 2974. 628.495 of the statutes is created to read:
AB68-SSA1,1344,3
1628.495 Pharmacy benefit management broker and consultant
2licenses.
(1) Definition. In this section, “pharmacy benefit manager” has the
3meaning given in s. 632.865 (1) (c).
AB68-SSA1,1344,6 4(2) License required. No person may serve as a pharmacy benefit
5management broker or consultant or any other person who procures the services of
6a pharmacy benefit manager on behalf of a client without a license.
AB68-SSA1,1344,9 7(3) Rules. The commissioner may promulgate rules to establish criteria and
8procedures for initial licensure and renewal of licensure and to implement licensure
9under this section.
AB68-SSA1,2975 10Section 2975 . 632.35 of the statutes is amended to read:
AB68-SSA1,1344,15 11632.35 Prohibited rejection, cancellation and nonrenewal. No insurer
12may cancel or refuse to issue or renew an automobile insurance policy wholly or
13partially because of one or more of the following characteristics of any person: age,
14sex, residence, race, color, creed, religion, national origin, ancestry, marital status or,
15occupation, or status as a holder or nonholder of a license under s. 343.03 (3r).
AB68-SSA1,2976 16Section 2976. 632.728 of the statutes is created to read:
AB68-SSA1,1344,18 17632.728 Coverage of persons with preexisting conditions; guaranteed
18issue; benefit limits.
(1) Definitions. In this section:
AB68-SSA1,1344,2019 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar
20charges.
AB68-SSA1,1344,2121 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).
AB68-SSA1,1344,2222 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
AB68-SSA1,1345,3 23(2) Guaranteed issue. (a) Every individual health benefit plan shall accept
24every individual in this state who, and every group health benefit plan shall accept
25every employer in this state that, applies for coverage, regardless of sexual

1orientation, gender identity, or whether or not any employee or individual has a
2preexisting condition. A health benefit plan may restrict enrollment in coverage
3described in this paragraph to open or special enrollment periods.
AB68-SSA1,1345,64 (b) The commissioner shall establish a statewide open enrollment period of no
5shorter than 30 days for every individual health benefit plan to allow individuals,
6including individuals who do not have coverage, to enroll in coverage.
AB68-SSA1,1345,11 7(3) Prohibiting discrimination based on health status. (a) An individual
8health benefit plan or a self-insured health plan may not establish rules for the
9eligibility of any individual to enroll, or for the continued eligibility of any individual
10to remain enrolled, under the plan based on any of the following health
11status-related factors in relation to the individual or a dependent of the individual:
AB68-SSA1,1345,1212 1. Health status.
AB68-SSA1,1345,1313 2. Medical condition, including both physical and mental illnesses.
AB68-SSA1,1345,1414 3. Claims experience.
AB68-SSA1,1345,1515 4. Receipt of health care.
AB68-SSA1,1345,1616 5. Medical history.
AB68-SSA1,1345,1717 6. Genetic information.
AB68-SSA1,1345,1918 7. Evidence of insurability, including conditions arising out of acts of domestic
19violence.
AB68-SSA1,1345,2020 8. Disability.
AB68-SSA1,1346,221 (b) An insurer offering an individual health benefit plan or a self-insured
22health plan may not require any individual, as a condition of enrollment or continued
23enrollment under the plan, to pay, on the basis of any health status-related factor
24under par. (a) with respect to the individual or a dependent of the individual, a
25premium or contribution or a deductible, copayment, or coinsurance amount that is

1greater than the premium or contribution or deductible, copayment, or coinsurance
2amount respectively for a similarly situated individual enrolled under the plan.
AB68-SSA1,1346,63 (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.
AB68-SSA1,1346,9 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:
AB68-SSA1,1346,1010 (a) Whether the policy or plan covers an individual or a family.
AB68-SSA1,1346,1111 (b) Rating area in the state, as established by the commissioner.
AB68-SSA1,1346,1412 (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.
AB68-SSA1,1346,1515 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
AB68-SSA1,1346,20 16(5) Statewide risk pool. An insurer offering a health benefit plan may not
17segregate enrollees into risk pools other than a single statewide risk pool for the
18individual market and a single statewide risk pool for the small employer market or
19a single statewide risk pool that combines the individual and small employer
20markets.
AB68-SSA1,1346,22 21(6) Annual and lifetime limits. An individual or group health benefit plan or
22a self-insured health plan may not establish any of the following:
AB68-SSA1,1346,2423 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
24of an enrollee under the plan.
AB68-SSA1,1347,2
1(b) Annual limits on the dollar value of benefits for an enrollee or a dependent
2of an enrollee under the plan.
AB68-SSA1,1347,6 3(7) Cost sharing maximum. A health benefit plan offered on the individual or
4small employer market may not require an enrollee under the plan to pay more in
5cost sharing than the maximum amount calculated under 42 USC 18022 (c),
6including the annual indexing of the limits.
AB68-SSA1,1347,9 7(8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the
8proportion, expressed as a percentage, of premium revenues spent by a health
9benefit plan on clinical services and quality improvement.
AB68-SSA1,1347,1110 (b) A health benefit plan on the individual or small employer market shall have
11a medical loss ratio of at least 80 percent.
AB68-SSA1,1347,1312 (c) A group health benefit plan other than one described under par. (b) shall
13have a medical loss ratio of at least 85 percent.
AB68-SSA1,1347,17 14(9) Actuarial values of plan tiers. Any health benefit plan offered on the
15individual or small employer market shall provide a level of coverage that is designed
16to provide benefits that are actuarially equivalent to at least 60 percent of the full
17actuarial value of the benefits provided under the plan.
AB68-SSA1,2977 18Section 2977. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and
19amended to read:
AB68-SSA1,1348,220 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health
21benefit plan may, with respect to a participant or beneficiary under the plan, not
22impose a preexisting condition exclusion only if the exclusion relates to a condition,
23whether physical or mental, regardless of the cause of the condition, for which
24medical advice, diagnosis, care or treatment was recommended or received within

1the 6-month period ending on the participant's or beneficiary's enrollment date
2under the plan
on a participant or beneficiary under the plan.
AB68-SSA1,2978 3Section 2978. 632.746 (1) (b) of the statutes is repealed.
AB68-SSA1,2979 4Section 2979. 632.746 (2) (a) of the statutes is amended to read:
AB68-SSA1,1348,85 632.746 (2) (a) An insurer offering a group health benefit plan may not treat
6impose a preexisting condition exclusion based on genetic information as a
7preexisting condition under sub. (1) without a diagnosis of a condition related to the
8information
.
AB68-SSA1,2980 9Section 2980. 632.746 (2) (c), (d) and (e) of the statutes are repealed.
AB68-SSA1,2981 10Section 2981. 632.746 (3) (a) of the statutes is repealed.
AB68-SSA1,2982 11Section 2982 . 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).
AB68-SSA1,2983 12Section 2983 . 632.746 (3) (d) 2. and 3. of the statutes are repealed.
AB68-SSA1,2984 13Section 2984 . 632.746 (5) of the statutes is repealed.
AB68-SSA1,2985 14Section 2985. 632.746 (8) (a) (intro.) of the statutes is amended to read:
AB68-SSA1,1348,1815 632.746 (8) (a) (intro.) A health maintenance organization that offers a group
16health benefit plan and that does not impose any preexisting condition exclusion
17under sub. (1)
with respect to a particular coverage option may impose an affiliation
18period for that coverage option, but only if all of the following apply:
AB68-SSA1,2986 19Section 2986 . 632.748 (2) of the statutes is amended to read:
AB68-SSA1,1349,220 632.748 (2) An insurer offering a group health benefit plan may not require any
21individual, as a condition of enrollment or continued enrollment under the plan, to
22pay, on the basis of any health status-related factor with respect to the individual
23or a dependent of the individual, a premium or contribution or a deductible,
24copayment, or coinsurance amount
that is greater than the premium or contribution

1or deductible, copayment, or coinsurance amount respectively for a similarly
2situated individual enrolled under the plan.
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