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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.
AB68-SSA1,2987 3Section 2987. 632.7495 (4) (b) of the statutes is amended to read:
AB68-SSA1,1349,44 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.
AB68-SSA1,2988 5Section 2988. 632.7495 (4) (c) of the statutes is amended to read:
AB68-SSA1,1349,106 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of
7the insurer's coverage of the insured by individual health benefit plan coverage not
8required to be renewed under this subsection does not exceed 18 6 months. For
9purposes of this paragraph, coverage periods are consecutive if there are no more
10than 63 days between the coverage periods.
AB68-SSA1,2989 11Section 2989 . 632.7496 of the statutes is created to read:
AB68-SSA1,1349,14 12632.7496 Coverage requirements for short-term plans. (1) Definition.
13In this section, “short-term, limited duration plan” means an individual health
14benefit plan described in s. 632.7495 (4) that an insurer is not required to renew.
AB68-SSA1,1349,17 15(2) Guaranteed issue. Every short-term, limited duration plan shall accept
16every individual in this state who applies for coverage whether or not any individual
17has a preexisting condition.
AB68-SSA1,1349,22 18(3) Prohibiting discrimination based on health status. (a) A short-term,
19limited duration plan may not establish rules for the eligibility of any individual to
20enroll, or for the continued eligibility of any individual to remain enrolled, under the
21plan based on any of the following health status-related factors in relation to the
22individual or a dependent of the individual:
AB68-SSA1,1349,2323 1. Health status.
AB68-SSA1,1349,2424 2. Medical condition, including both physical and mental illnesses.
AB68-SSA1,1349,2525 3. Claims experience.
AB68-SSA1,1350,1
14. Receipt of health care.
AB68-SSA1,1350,22 5. Medical history.
AB68-SSA1,1350,33 6. Genetic information.
AB68-SSA1,1350,54 7. Evidence of insurability, including conditions arising out of acts of domestic
5violence.
AB68-SSA1,1350,66 8. Disability.
AB68-SSA1,1350,137 (b) A short-term, limited duration plan may not require any individual, as a
8condition of enrollment or continued enrollment under the plan, to pay, on the basis
9of any health status-related factor under par. (a) with respect to the individual or a
10dependent of the individual, a premium or contribution or a deductible, copayment,
11or coinsurance amount that is greater than the premium or contribution or
12deductible, copayment, or coinsurance amount respectively for a similarly situated
13individual enrolled under the plan.
AB68-SSA1,1350,15 14(4) Premium rate variation. A short-term, limited duration plan may vary
15premium rates for a specific plan based only on the following considerations:
AB68-SSA1,1350,1616 (a) Whether the policy or plan covers an individual or a family.
AB68-SSA1,1350,1717 (b) Rating area in the state, as established by the commissioner.
AB68-SSA1,1350,2018 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over
19the age groups and the age bands shall be consistent with recommendations of the
20National Association of Insurance Commissioners.
AB68-SSA1,1350,2121 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
AB68-SSA1,1350,23 22(5) Annual and lifetime limits. A short-term, limited duration plan may not
23establish any of the following:
AB68-SSA1,1350,2524 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
25of an enrollee under the plan.
AB68-SSA1,1351,2
1(b) Limits on the dollar value of benefits for an enrollee or a dependent of an
2enrollee under the plan for the initial or cumulative duration of the plan.
AB68-SSA1,2990 3Section 2990. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to
4read:
AB68-SSA1,1351,125 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years
6from the date of issue of the policy may be reduced or denied on the ground that a
7disease or physical condition existed prior to the effective date of coverage, unless the
8condition was excluded from coverage by name or specific description by a provision
9effective on the date of loss. This paragraph does not apply to a group health benefit
10plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance
11policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s.
12632.85 (1) (c)
.
AB68-SSA1,1351,1813 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability
14commencing after 12 months from the date of issue of under an individual disability
15insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the
16ground that a disease or physical condition existed prior to the effective date of
17coverage, unless the condition was excluded from coverage by name or specific
18description by a provision effective on the date of the loss
.
AB68-SSA1,1351,2519 2. Except as provided in subd. 3., an An individual disability insurance policy,
20as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495
21(4) and (5), may not define a preexisting condition more restrictively than a condition
22that was present before the date of enrollment for the coverage, whether physical or
23mental, regardless of the cause of the condition, for which and regardless of whether
24medical advice, diagnosis, care, or treatment was recommended or received within
2512 months before the effective date of coverage
.
AB68-SSA1,2991
1Section 2991. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:
AB68-SSA1,1352,42 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under
3s. 632.7495 (5), all of the following apply to an individual disability insurance policy
4that is a short-term, limited duration policy subject to s. 632.7495 (4) and (5):
AB68-SSA1,2992 5Section 2992. 632.76 (2) (ac) 3. b. of the statutes is amended to read:
AB68-SSA1,1352,116 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a
7may not impose any preexisting condition exclusion may be imposed by the
8aggregate of the insured's consecutive periods of coverage under the insurer's
9individual disability insurance policies that are short-term policies subject to s.
10632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive
11if there are no more than 63 days between the coverage periods
.
AB68-SSA1,2993 12Section 2993. 632.795 (4) (a) of the statutes is amended to read:
AB68-SSA1,1352,2413 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.
AB68-SSA1,2994 25Section 2994. 632.796 of the statutes is created to read:
AB68-SSA1,1353,2
1632.796 Drug cost report. (1) Definition. In this section, “disability
2insurance policy” has the meaning given in s. 632.895 (1) (a).
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