AB50: Bill Text

AB50,1437,13 628.495 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).

AB50,1437,18 (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 and no individual may act to procure the services of a pharmacy benefit manager on behalf of a client without being licensed by the commissioner under this section.

AB50,1437,21 (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.

AB50,2921 Section 2921. 632.35 of the statutes is amended to read:

AB50,1438,3 632.35 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).

AB50,2922 Section 2922. 632.728 of the statutes is created to read:

AB50,1438,6 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB50,1438,8 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB50,1438,9 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB50,1438,10 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50,1438,17 (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.

AB50,1438,21 (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.

AB50,1439,3 (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:

AB50,1439,4 1. Health status.

AB50,1439,5 2. Medical condition, including both physical and mental illnesses.

AB50,1439,6 3. Claims experience.

AB50,1439,7 4. Receipt of health care.

AB50,1439,8 5. Medical history.

AB50,1439,9 6. Genetic information.

AB50,1439,11 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB50,1439,12 8. Disability.

AB50,1439,20 (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.

AB50,1440,2 (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.

AB50,1440,5 (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:

AB50,1440,6 (a) Whether the policy or plan covers an individual or a family.

AB50,1440,7 (b) Rating area in the state, as established by the commissioner.

AB50,1440,10 (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.

AB50,1440,11 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB50,1440,16 (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.

AB50,1440,18 (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:

AB50,1440,20 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB50,1440,22 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB50,1441,3 (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.

AB50,1441,6 (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.

AB50,1441,8 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB50,1441,10 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB50,1441,14 (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.

AB50,2923 Section 2923. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB50,1441,23 632.746 (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.

AB50,2924 Section 2924. 632.746 (1) (b) of the statutes is repealed.

AB50,2925 Section 2925. 632.746 (2) (a) of the statutes is amended to read:

AB50,1442,6 632.746 (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.

AB50,2926 Section 2926. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB50,2927 Section 2927. 632.746 (3) (a) of the statutes is repealed.

AB50,2928 Section 2928. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB50,2929 Section 2929. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB50,2930 Section 2930. 632.746 (5) of the statutes is repealed.

AB50,2931 Section 2931. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB50,1442,16 632.746 (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:

AB50,2932 Section 2932. 632.748 (2) of the statutes is amended to read:

AB50,1443,2 632.748 (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.

AB50,2933 Section 2933. 632.7495 (4) (b) of the statutes is amended to read:

AB50,1443,4 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

AB50,2934 Section 2934. 632.7495 (4) (c) of the statutes is amended to read:

AB50,1443,10 632.7495 (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.

AB50,2935 Section 2935. 632.7496 of the statutes is created to read:

AB50,1443,14 632.7496 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).

AB50,1443,17 (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.

AB50,1443,23 (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:

AB50,1444,1 1. Health status.

AB50,1444,2 2. Medical condition, including both physical and mental illnesses.

AB50,1444,3 3. Claims experience.

AB50,1444,4 4. Receipt of health care.

AB50,1444,5 5. Medical history.

AB50,1444,6 6. Genetic information.

AB50,1444,8 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB50,1444,9 8. Disability.

AB50,1444,17 (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.

AB50,1444,20 (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:

AB50,1444,22 (a) Whether the short-term, limited duration plan covers an individual or a family.

AB50,1444,23 (b) Rating area in the state, as established by the commissioner.

AB50,1445,3 (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.

AB50,1445,4 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB50,1445,6 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

AB50,1445,8 (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.

AB50,1445,11 (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.

AB50,2936 Section 2936. 632.7498 of the statutes is created to read:

AB50,1445,14 632.7498 Special enrollment period for pregnancy. (1) Definitions. In this section:

AB50,1445,15 (a) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB50,1445,16 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50,1446,2 (2) Special enrollment period. A health benefit plan or self-insured health plan shall allow a pregnant individual who is eligible for coverage under the plan, and any individual who is eligible for coverage under the plan because of a relationship to the pregnant individual, to enroll for coverage at any time during the pregnancy. The coverage shall begin no later than the first day of the first calendar month in which the pregnant individual receives medical verification of the pregnancy, except that a pregnant individual may direct coverage to begin on the first day of any month occurring during the pregnancy.

AB50,1446,6 (3) Notice. An insurer offering group health insurance coverage in this state shall provide notice of the special enrollment period under sub. (2) at or before the time an individual is initially offered the opportunity to enroll for coverage under the plan.

AB50,2937 Section 2937. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB50,1446,16 632.76 (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).

AB50,1446,22 (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.

AB50,1447,6 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 limited duration plan 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.

AB50,2938 Section 2938. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB50,1447,10 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy, limited duration plan subject to s. 632.7495 (4) and (5):

AB50,2939 Section 2939. 632.76 (2) (ac) 3. b. of the statutes is amended to read: