AB50-ASA2-AA16,27,1110632.862 Application of prescription drug payments. (1) Definitions. 11In this section: AB50-ASA2-AA16,27,1212(a) “Brand name” has the meaning given in s. 450.12 (1) (a). AB50-ASA2-AA16,27,1313(b) “Brand name drug” means any of the following: AB50-ASA2-AA16,27,15141. A prescription drug that contains a brand name and that has no generic 15equivalent. AB50-ASA2-AA16,27,20162. A prescription drug that contains a brand name and has a generic 17equivalent but for which the enrollee has received prior authorization from the 18insurer offering the disability insurance policy or self-insured health plan or 19authorization from a physician to obtain the prescription drug under the disability 20insurance policy or self-insured health plan. AB50-ASA2-AA16,27,2121(c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a). AB50-ASA2-AA16,27,2222(d) “Prescription drug” has the meaning given in s. 450.01 (20). AB50-ASA2-AA16,28,2
1(e) “Self-insured health plan” means a self-insured health plan of the state or 2a county, city, village, town, or school district. AB50-ASA2-AA16,28,83(2) Application of discounts. A disability insurance policy that offers a 4prescription drug benefit or a self-insured health plan shall apply to any calculation 5of an out-of-pocket maximum amount and to any deductible of the disability 6insurance policy or self-insured health plan for an enrollee the amount that any 7discount provided by the manufacturer of a brand name drug reduces the cost 8sharing amount charged to the enrollee for that brand name drug. AB50-ASA2-AA16,28,1010(1) Application of manufacturer discounts. AB50-ASA2-AA16,28,1611(a) For policies and plans containing provisions inconsistent with the 12treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 13609.83, and 632.862, the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) 14(g), 185.983 (1) (intro.), 609.83, and 632.862 first applies to policy or plan years 15beginning on January 1 of the year following the year in which this paragraph takes 16effect, except as provided in par. (b). AB50-ASA2-AA16,28,2317(b) For policies or plans that are affected by a collective bargaining agreement 18containing provisions inconsistent with the treatment of ss. 40.51 (8) and (8m), 1966.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862, the treatment of 20ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 21632.862 first applies to policy or plan years beginning on the effective date of this 22paragraph or on the day on which the collective bargaining agreement is newly 23established, extended, modified, or renewed, whichever is later. AB50-ASA2-AA16,29,52(1) Application of manufacturer discounts. The treatment of ss. 40.51 (8) 3and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862 and 4Section 9323 (1) take effect on the first day of the 4th month beginning after 5publication.”. AB50-ASA2-AA16,29,138(1) Board on aging and long-term care medigap helpline. In the 9schedule under s. 20.005 (3) for the appropriation to the board on aging and long-10term care under s. 20.432 (1) (kb), the dollar amount for fiscal year 2025-26 is 11increased by $100,600 and the dollar amount for fiscal year 2026-27 is increased by 12$122,000 to support telephone counseling services provided under s. 16.009 (2) (j) 13for individuals seeing information on medicare supplemental insurance policies.”. AB50-ASA2-AA16,29,1816609.712 Essential health benefits; preventive services. Defined 17network plans and preferred provider plans are subject to s. 632.895 (13m) and 18(14m). AB50-ASA2-AA16,29,2220609.847 Preexisting condition discrimination and certain benefit 21limits prohibited. Limited service health organizations, preferred provider 22plans, and defined network plans are subject to s. 632.728. AB50-ASA2-AA16,30,2
1625.12 (1) (a) Past and prospective loss and expense experience within and 2outside of this state, except as provided in s. 632.728. AB50-ASA2-AA16,30,54625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, 5including the judgment of technical personnel. AB50-ASA2-AA16,30,157625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, 8risks may be classified in any reasonable way for the establishment of rates and 9minimum premiums, except that no classifications may be based on race, color, 10creed or national origin, and classifications in automobile insurance may not be 11based on physical condition or developmental disability as defined in s. 51.01 (5). 12Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified 13for individual risks in accordance with rating plans or schedules that establish 14reasonable standards for measuring probable variations in hazards, expenses, or 15both. Rates may also be modified for individual risks under s. 625.13 (2). AB50-ASA2-AA16,31,217625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may 18itself establish rates and supplementary rate information for one or more market 19segments based on the factors in s. 625.12 and, if the rates are for motor vehicle 20liability insurance, subject to s. 632.365, or the insurer may use rates and 21supplementary rate information prepared by a rate service organization, with 22average expense factors determined by the rate service organization or with such
1modification for its own expense and loss experience as the credibility of that 2experience allows. AB50-ASA2-AA16,31,114628.34 (3) (a) No insurer may unfairly discriminate among policyholders by 5charging different premiums or by offering different terms of coverage except on the 6basis of classifications related to the nature and the degree of the risk covered or the 7expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746, and 632.748. 8Rates are not unfairly discriminatory if they are averaged broadly among persons 9insured under a group, blanket or franchise policy, and terms are not unfairly 10discriminatory merely because they are more favorable than in a similar individual 11policy. AB50-ASA2-AA16,31,1413632.728 Coverage of persons with preexisting conditions; guaranteed 14issue; benefit limits. (1) Definitions. In this section: AB50-ASA2-AA16,31,1615(a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar 16charges. AB50-ASA2-AA16,31,1717(b) “Health benefit plan” has the meaning given in s. 632.745 (11). AB50-ASA2-AA16,31,1818(c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). AB50-ASA2-AA16,32,219(2) Guaranteed issue. (a) Every individual health benefit plan shall accept 20every individual in this state who, and every group health benefit plan shall accept 21every employer in this state that, applies for coverage, regardless of the sexual 22orientation, the gender identity, or any preexisting condition of any individual or 23employee who will be covered by the plan. A health benefit plan may restrict
1enrollment in coverage described in this paragraph to open or special enrollment 2periods. AB50-ASA2-AA16,32,63(b) The commissioner shall establish a statewide open enrollment period that 4is no shorter than 30 days, during which every individual health benefit plan shall 5allow individuals, including individuals who do not have coverage, to enroll in 6coverage. AB50-ASA2-AA16,32,117(3) Prohibiting discrimination based on health status. (a) An 8individual health benefit plan or a self-insured health plan may not establish rules 9for the eligibility of any individual to enroll, or for the continued eligibility of any 10individual to 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: AB50-ASA2-AA16,32,13132. Medical condition, including both physical and mental illnesses. AB50-ASA2-AA16,32,14143. Claims experience. AB50-ASA2-AA16,32,15154. Receipt of health care. AB50-ASA2-AA16,32,16165. Medical history. AB50-ASA2-AA16,32,17176. Genetic information. AB50-ASA2-AA16,32,19187. Evidence of insurability, including conditions arising out of acts of domestic 19violence. AB50-ASA2-AA16,33,521(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 23continued enrollment under the plan, to pay, on the basis of any health status-
1related factor under par. (a) with respect to the individual or a dependent of the 2individual, a premium or contribution or a deductible, copayment, or coinsurance 3amount that is greater than the premium or contribution or deductible, copayment, 4or coinsurance amount, respectively, for an otherwise similarly situated individual 5enrolled under the plan. AB50-ASA2-AA16,33,96(c) Nothing in this subsection prevents an insurer offering an individual 7health benefit plan or a self-insured health plan from establishing premium 8discounts or rebates or modifying otherwise applicable cost sharing in return for 9adherence to programs of health promotion and disease prevention. AB50-ASA2-AA16,33,1210(4) Premium rate variation. A health benefit plan offered on the individual 11or small employer market or a self-insured health plan may vary premium rates for 12a specific plan based only on the following considerations: AB50-ASA2-AA16,33,1313(a) Whether the policy or plan covers an individual or a family. AB50-ASA2-AA16,33,1414(b) Rating area in the state, as established by the commissioner. AB50-ASA2-AA16,33,1715(c) Age, except that the rate may not vary by more than 3 to 1 for adults over 16the age groups and the age bands shall be consistent with recommendations of the 17National Association of Insurance Commissioners. AB50-ASA2-AA16,33,1818(d) Tobacco use, except that the rate may not vary by more than 1.5 to 1. AB50-ASA2-AA16,33,2319(5) Statewide risk pool. An insurer offering a health benefit plan may not 20segregate enrollees into risk pools other than a single statewide risk pool for the 21individual market and a single statewide risk pool for the small employer market or 22a single statewide risk pool that combines the individual and small employer 23markets. AB50-ASA2-AA16,34,2
1(6) Annual and lifetime limits. An individual or group health benefit plan 2or a self-insured health plan may not establish any of the following: AB50-ASA2-AA16,34,43(a) Lifetime limits on the dollar value of benefits for an enrollee or a 4dependent of an enrollee under the plan. AB50-ASA2-AA16,34,65(b) Annual limits on the dollar value of benefits for an enrollee or a dependent 6of an enrollee under the plan. AB50-ASA2-AA16,34,107(7) Cost sharing maximum. A health benefit plan offered on the individual 8or small employer market may not require an enrollee under the plan to pay more in 9cost sharing than the maximum amount calculated under 42 USC 18022 (c), 10including the annual indexing of the limits. AB50-ASA2-AA16,34,1311(8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means 12the proportion, expressed as a percentage, of premium revenues spent by a health 13benefit plan on clinical services and quality improvement. AB50-ASA2-AA16,34,1514(b) A health benefit plan on the individual or small employer market shall 15have a medical loss ratio of at least 80 percent. AB50-ASA2-AA16,34,1716(c) A group health benefit plan other than one described under par. (b) shall 17have a medical loss ratio of at least 85 percent. AB50-ASA2-AA16,34,2118(9) Actuarial values of plan tiers. Any health benefit plan offered on the 19individual or small employer market shall provide a level of coverage that is 20designed to provide benefits that are actuarially equivalent to at least 60 percent of 21the full actuarial value of the benefits provided under the plan. AB50-ASA2-AA16,4022Section 40. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and 23amended to read: AB50-ASA2-AA16,35,7
1632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group 2health benefit plan may, with respect to a participant or beneficiary under the plan, 3not impose a preexisting condition exclusion only if the exclusion relates to a 4condition, whether physical or mental, regardless of the cause of the condition, for 5which medical advice, diagnosis, care or treatment was recommended or received 6within the 6-month period ending on the participant’s or beneficiary’s enrollment 7date under the plan on a participant or beneficiary under the plan. AB50-ASA2-AA16,35,1310632.746 (2) (a) An insurer offering a group health benefit plan may not treat 11impose a preexisting condition exclusion based on genetic information as a 12preexisting condition under sub. (1) without a diagnosis of a condition related to the 13information. AB50-ASA2-AA16,4314Section 43. 632.746 (2) (c), (d) and (e) of the statutes are repealed. AB50-ASA2-AA16,4516Section 45. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d). AB50-ASA2-AA16,4617Section 46. 632.746 (3) (d) 2. and 3. of the statutes are repealed. AB50-ASA2-AA16,4819Section 48. 632.746 (8) (a) (intro.) of the statutes is amended to read: AB50-ASA2-AA16,35,2320632.746 (8) (a) (intro.) A health maintenance organization that offers a group 21health benefit plan and that does not impose any preexisting condition exclusion 22under sub. (1) with respect to a particular coverage option may impose an affiliation 23period for that coverage option, but only if all of the following apply: AB50-ASA2-AA16,36,82632.748 (2) An insurer offering a group health benefit plan may not require 3any individual, as a condition of enrollment or continued enrollment under the 4plan, to pay, on the basis of any health status-related factor with respect to the 5individual or a dependent of the individual, a premium or contribution or a 6deductible, copayment, or coinsurance amount that is greater than the premium or 7contribution or deductible, copayment, or coinsurance amount, respectively, for a 8an otherwise similarly situated individual enrolled under the plan. AB50-ASA2-AA16,509Section 50. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to 10read: AB50-ASA2-AA16,36,1811632.76 (2) (a) No claim for loss incurred or disability commencing after 2 12years from the date of issue of the policy may be reduced or denied on the ground 13that a disease or physical condition existed prior to the effective date of coverage, 14unless the condition was excluded from coverage by name or specific description by 15a provision effective on the date of loss. This paragraph does not apply to a group 16health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746, a 17disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health 18plan, as defined in s. 632.85 (1) (c). AB50-ASA2-AA16,37,219(ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability 20commencing after 12 months from the date of issue of under an individual disability 21insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the 22ground that a disease or physical condition existed prior to the effective date of
1coverage, unless the condition was excluded from coverage by name or specific 2description by a provision effective on the date of the loss. AB50-ASA2-AA16,37,932. Except as provided in subd. 3., an An individual disability insurance policy, 4as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 5(4) and (5), may not define a preexisting condition more restrictively than a 6condition that was present before the date of enrollment for the coverage, whether 7physical or mental, regardless of the cause of the condition, for which and 8regardless of whether medical advice, diagnosis, care, or treatment was 9recommended or received within 12 months before the effective date of coverage. AB50-ASA2-AA16,37,2211632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the 12same policy form and for the same premium as it originally offered in the most 13recent enrollment period, subject only to the medical underwriting used in that 14enrollment period. Unless otherwise prescribed by rule, the insurer may apply 15deductibles, preexisting condition limitations, waiting periods, or other limits only 16to the extent that they would have been applicable had coverage been extended at 17the time of the most recent enrollment period and with credit for the satisfaction or 18partial satisfaction of similar provisions under the liquidated insurer’s policy or 19plan. The insurer may exclude coverage of claims that are payable by a solvent 20insurer under insolvency coverage required by the commissioner or by the 21insurance regulator of another jurisdiction. Coverage shall be effective on the date 22that the liquidated insurer’s coverage terminates. AB50-ASA2-AA16,38,7
1632.895 (8) (d) Coverage is required under this subsection despite whether 2the woman shows any symptoms of breast cancer. Except as provided in pars. (b), 3(c), and (e), coverage under this subsection may only be subject to exclusions and 4limitations, including deductibles, copayments and restrictions on excessive 5charges, that are applied to other radiological examinations covered under the 6disability insurance policy. Coverage under this subsection may not be subject to 7any deductibles, copayments, or coinsurance. AB50-ASA2-AA16,38,109632.895 (13m) Preventive services. (a) In this section, “self-insured health 10plan” has the meaning given in s. 632.85 (1) (c).
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