Amendment AA16-ASA2-AB50

AB50-ASA2-AA16,31,14 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB50-ASA2-AA16,31,16 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB50-ASA2-AA16,31,17 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB50-ASA2-AA16,31,18 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50-ASA2-AA16,32,2 (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 the sexual orientation, the gender identity, or any preexisting condition of any individual or employee who will be covered by the plan. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

AB50-ASA2-AA16,32,6 (b) The commissioner shall establish a statewide open enrollment period that is no shorter than 30 days, during which every individual health benefit plan shall allow individuals, including individuals who do not have coverage, to enroll in coverage.

AB50-ASA2-AA16,32,11 (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:

AB50-ASA2-AA16,32,12 1. Health status.

AB50-ASA2-AA16,32,13 2. Medical condition, including both physical and mental illnesses.

AB50-ASA2-AA16,32,14 3. Claims experience.

AB50-ASA2-AA16,32,15 4. Receipt of health care.

AB50-ASA2-AA16,32,16 5. Medical history.

AB50-ASA2-AA16,32,17 6. Genetic information.

AB50-ASA2-AA16,32,19 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB50-ASA2-AA16,32,20 8. Disability.

AB50-ASA2-AA16,33,5 (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 an otherwise similarly situated individual enrolled under the plan.

AB50-ASA2-AA16,33,9 (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.

AB50-ASA2-AA16,33,12 (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:

AB50-ASA2-AA16,33,13 (a) Whether the policy or plan covers an individual or a family.

AB50-ASA2-AA16,33,14 (b) Rating area in the state, as established by the commissioner.

AB50-ASA2-AA16,33,17 (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.

AB50-ASA2-AA16,33,18 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB50-ASA2-AA16,33,23 (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.

AB50-ASA2-AA16,34,2 (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:

AB50-ASA2-AA16,34,4 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB50-ASA2-AA16,34,6 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB50-ASA2-AA16,34,10 (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.

AB50-ASA2-AA16,34,13 (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.

AB50-ASA2-AA16,34,15 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB50-ASA2-AA16,34,17 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB50-ASA2-AA16,34,21 (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.

AB50-ASA2-AA16,40 Section 40. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB50-ASA2-AA16,35,7 632.746 (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.

AB50-ASA2-AA16,41 Section 41. 632.746 (1) (b) of the statutes is repealed.

AB50-ASA2-AA16,42 Section 42. 632.746 (2) (a) of the statutes is amended to read:

AB50-ASA2-AA16,35,13 632.746 (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.

AB50-ASA2-AA16,43 Section 43. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB50-ASA2-AA16,44 Section 44. 632.746 (3) (a) of the statutes is repealed.

AB50-ASA2-AA16,45 Section 45. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB50-ASA2-AA16,46 Section 46. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB50-ASA2-AA16,47 Section 47. 632.746 (5) of the statutes is repealed.

AB50-ASA2-AA16,48 Section 48. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB50-ASA2-AA16,35,23 632.746 (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:

AB50-ASA2-AA16,49 Section 49. 632.748 (2) of the statutes is amended to read:

AB50-ASA2-AA16,36,8 632.748 (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 an otherwise similarly situated individual enrolled under the plan.

AB50-ASA2-AA16,50 Section 50. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB50-ASA2-AA16,36,18 632.76 (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).

AB50-ASA2-AA16,37,2 (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.

AB50-ASA2-AA16,37,9 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.

AB50-ASA2-AA16,51 Section 51. 632.795 (4) (a) of the statutes is amended to read:

AB50-ASA2-AA16,37,22 632.795 (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.

AB50-ASA2-AA16,52 Section 52. 632.895 (8) (d) of the statutes is amended to read:

AB50-ASA2-AA16,38,7 632.895 (8) (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c), and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy. Coverage under this subsection may not be subject to any deductibles, copayments, or coinsurance.

AB50-ASA2-AA16,53 Section 53. 632.895 (13m) of the statutes is created to read:

AB50-ASA2-AA16,38,10 632.895 (13m) Preventive services. (a) In this section, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50-ASA2-AA16,38,13 (b) Every disability insurance policy, except any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12., and every self-insured health plan shall provide coverage for all of the following preventive services:

AB50-ASA2-AA16,38,14 1. Mammography in accordance with sub. (8).

AB50-ASA2-AA16,38,16 2. Genetic breast cancer screening and counseling and preventive medication for adult women at high risk for breast cancer.

AB50-ASA2-AA16,38,18 3. Papanicolaou test for cancer screening for women 21 years of age or older with an intact cervix.

AB50-ASA2-AA16,38,20 4. Human papillomavirus testing for women who have attained the age of 30 years but have not attained the age of 66 years.

AB50-ASA2-AA16,38,21 5. Colorectal cancer screening in accordance with sub. (16m).

AB50-ASA2-AA16,39,2 6. Annual tomography for lung cancer screening for adults who have attained the age of 55 years but have not attained the age of 80 years and who have health histories demonstrating a risk for lung cancer.

AB50-ASA2-AA16,39,4 7. Skin cancer screening for individuals who have attained the age of 10 years but have not attained the age of 22 years.

AB50-ASA2-AA16,39,6 8. Counseling for skin cancer prevention for adults who have attained the age of 18 years but have not attained the age of 25 years.

AB50-ASA2-AA16,39,8 9. Abdominal aortic aneurysm screening for men who have attained the age of 65 years but have not attained the age of 75 years and who have ever smoked.

AB50-ASA2-AA16,39,11 10. Hypertension screening for adults and blood pressure testing for adults, for children under the age of 3 years who are at high risk for hypertension, and for children 3 years of age or older.

AB50-ASA2-AA16,39,13 11. Lipid disorder screening for minors 2 years of age or older, adults 20 years of age or older at high risk for lipid disorders, and all men 35 years of age or older.

AB50-ASA2-AA16,39,16 12. Aspirin therapy for cardiovascular health for adults who have attained the age of 55 years but have not attained the age of 80 years and for men who have attained the age of 45 years but have not attained the age of 55 years.

AB50-ASA2-AA16,39,18 13. Behavioral counseling for cardiovascular health for adults who are overweight or obese and who have risk factors for cardiovascular disease.

AB50-ASA2-AA16,39,19 14. Type II diabetes screening for adults with elevated blood pressure.

AB50-ASA2-AA16,39,21 15. Depression screening for minors 11 years of age or older and for adults when follow-up supports are available.

AB50-ASA2-AA16,39,23 16. Hepatitis B screening for minors at high risk for infection and adults at high risk for infection.

AB50-ASA2-AA16,40,2 17. Hepatitis C screening for adults at high risk for infection and onetime hepatitis C screening for adults born in any year from 1945 to 1965.

AB50-ASA2-AA16,40,6 18. Obesity screening and management for all minors and adults with a body mass index indicating obesity, counseling and behavioral interventions for obese minors who are 6 years of age or older, and referral for intervention for obesity for adults with a body mass index of 30 kilograms per square meter or higher.

AB50-ASA2-AA16,40,8 19. Osteoporosis screening for all women 65 years of age or older and for women at high risk for osteoporosis under the age of 65 years.

AB50-ASA2-AA16,40,9 20. Immunizations in accordance with sub. (14).

AB50-ASA2-AA16,40,12 21. Anemia screening for individuals 6 months of age or older and iron supplements for individuals at high risk for anemia who have attained the age of 6 months but have not attained the age of 12 months.

AB50-ASA2-AA16,40,14 22. Fluoride varnish for prevention of tooth decay for minors at the age of eruption of their primary teeth.

AB50-ASA2-AA16,40,16 23. Fluoride supplements for prevention of tooth decay for minors 6 months of age or older who do not have fluoride in their water source.

AB50-ASA2-AA16,40,17 24. Gonorrhea prophylaxis treatment for newborns.

AB50-ASA2-AA16,40,18 25. Health history and physical exams for prenatal visits and for minors.

AB50-ASA2-AA16,40,20 26. Length and weight measurements for newborns and height and weight measurements for minors.

AB50-ASA2-AA16,40,22 27. Head circumference and weight-for-length measurements for newborns and minors who have not attained the age of 3 years.

AB50-ASA2-AA16,40,23 28. Body mass index for minors 2 years of age or older.

AB50-ASA2-AA16,41,2 29. Blood pressure measurements for minors 3 years of age or older and a blood pressure risk assessment at birth.

AB50-ASA2-AA16,41,4 30. Risk assessment and referral for oral health issues for minors who have attained the age of 6 months but have not attained the age of 7 years.

AB50-ASA2-AA16,41,6 31. Blood screening for newborns and minors who have not attained the age of 2 months.

AB50-ASA2-AA16,41,7 32. Screening for critical congenital health defects for newborns.

AB50-ASA2-AA16,41,8 33. Lead screenings in accordance with sub. (10).