AB43: Bill Text

AB43,,8613 611.11 (4) (a) In this subsection, “municipality” has the meaning given in s. 345.05 (1) (c), but also includes any transit authority created under s. 66.1039.

AB43,3061 Section 3061. 625.12 (1) (a) of the statutes is amended to read:

AB43,,8615 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB43,3062 Section 3062. 625.12 (1) (e) of the statutes is amended to read:

AB43,,8617 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB43,3063 Section 3063. 625.12 (2) of the statutes is amended to read:

AB43,,8619 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB43,3064 Section 3064. 625.15 (1) of the statutes is amended to read:

AB43,,8621 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB43,3065 Section 3065. 628.34 (3) (a) of the statutes is amended to read:

AB43,,8623 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

****Note: This is reconciled s. 628.34 (3) (a). This Section has been affected by drafts with the following LRB numbers: -1153/P1 and -1154/P1.

AB43,3066 Section 3066. 628.495 of the statutes is created to read:

AB43,,8625 628.495 Pharmacy benefit management broker and consultant licenses. (1) Definition. In this section, “pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB43,,8626 (2) License required. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmacy benefit management broker or consultant or any other individual who procures the services of a pharmacy benefit manager on behalf of a client without being licensed by the commissioner under this section.

AB43,,8627 (3) Rules. The commissioner may promulgate rules to establish criteria and procedures for initial licensure and renewal of licensure and to implement licensure under this section.

AB43,3067 Section 3067. 632.35 of the statutes is amended to read:

AB43,,8629 632.35 Prohibited rejection, cancellation and nonrenewal. No insurer may cancel or refuse to issue or renew an automobile insurance policy wholly or partially because of one or more of the following characteristics of any person: age, sex, residence, race, color, creed, religion, national origin, ancestry, marital status or, occupation, or status as a holder or nonholder of a license under s. 343.03 (3r).

AB43,3068 Section 3068. 632.728 of the statutes is created to read:

AB43,,8631 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB43,,8632 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB43,,8633 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB43,,8634 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB43,,8635 (2) Guaranteed issue. (a) Every individual health benefit plan shall accept every individual in this state who, and every group health benefit plan shall accept every employer in this state that, applies for coverage, regardless of sexual orientation, gender identity, or whether or not any employee or individual has a preexisting condition. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

AB43,,8636 (b) The commissioner shall establish a statewide open enrollment period of no shorter than 30 days for every individual health benefit plan to allow individuals, including individuals who do not have coverage, to enroll in coverage.

AB43,,8637 (3) Prohibiting discrimination based on health status. (a) An individual health benefit plan or a self-insured health 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:

AB43,,8638 1. Health status.

AB43,,8639 2. Medical condition, including both physical and mental illnesses.

AB43,,8640 3. Claims experience.

AB43,,8641 4. Receipt of health care.

AB43,,8642 5. Medical history.

AB43,,8643 6. Genetic information.

AB43,,8644 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB43,,8645 8. Disability.

AB43,,8646 (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.

AB43,,8647 (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.

AB43,,8648 (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:

AB43,,8649 (a) Whether the policy or plan covers an individual or a family.

AB43,,8650 (b) Rating area in the state, as established by the commissioner.

AB43,,8651 (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.

AB43,,8652 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB43,,8653 (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.

AB43,,8654 (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:

AB43,,8655 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB43,,8656 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB43,,8657 (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.

AB43,,8658 (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.

AB43,,8659 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB43,,8660 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB43,,8661 (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.

AB43,3069 Section 3069. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB43,,8663 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.

AB43,3070 Section 3070. 632.746 (1) (b) of the statutes is repealed.

AB43,3071 Section 3071. 632.746 (2) (a) of the statutes is amended to read:

AB43,,8666 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.

AB43,3072 Section 3072. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB43,3073 Section 3073. 632.746 (3) (a) of the statutes is repealed.

AB43,3074 Section 3074. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB43,3075 Section 3075. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB43,3076 Section 3076. 632.746 (5) of the statutes is repealed.

AB43,3077 Section 3077. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB43,,8673 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:

AB43,3078 Section 3078. 632.748 (2) of the statutes is amended to read:

AB43,,8675 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.

AB43,3079 Section 3079. 632.7495 (4) (b) of the statutes is amended to read:

AB43,,8677 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

AB43,3080 Section 3080. 632.7495 (4) (c) of the statutes is amended to read:

AB43,,8679 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.

AB43,3081 Section 3081. 632.7496 of the statutes is created to read:

AB43,,8681 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).

AB43,,8682 (2) Guaranteed issue. An insurer that offers a short-term, limited duration plan shall accept every individual in this state who applies for coverage regardless of whether the individual has a preexisting condition.

AB43,,8683 (3) Prohibiting discrimination based on health status. (a) An insurer that offers 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 a short-term, limited duration plan based on any of the following health status-related factors with respect to the individual or a dependent of the individual:

AB43,,8684 1. Health status.

AB43,,8685 2. Medical condition, including both physical and mental illnesses.

AB43,,8686 3. Claims experience.

AB43,,8687 4. Receipt of health care.

AB43,,8688 5. Medical history.

AB43,,8689 6. Genetic information.

AB43,,8690 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB43,,8691 8. Disability.

AB43,,8692 (b) An insurer that offers a short-term, limited duration plan may not require any individual, as a condition of enrollment or continued enrollment under the short-term, limited duration plan, to pay, on the basis of any health status-related factor described 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 short-term, limited duration plan.

AB43,,8693 (4) Premium rate variation. An insurer that offers a short-term, limited duration plan may vary premium rates for a specific short-term, limited duration plan based only on the following considerations:

AB43,,8694 (a) Whether the short-term, limited duration plan covers an individual or a family.

AB43,,8695 (b) Rating area in the state, as established by the commissioner.

AB43,,8696 (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.

AB43,,8697 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB43,,8698 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

AB43,,8699 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan.

AB43,,8700 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan for a term of coverage or for the aggregate duration of the short-term, limited duration plan.