Chapter Ins 8

Chapter Ins 8

EMPLOYEE WELFARE FUNDS; EMPLOYEE BENEFIT PLAN ADMINISTRATORS;
SMALL EMPLOYER HEALTH INSURANCE

Subchapter I — Employee Welfare Funds

Ins 8.11   County and school district self-insured employee health care benefits: excess or stop-loss insurance requirements.

Subchapter II — Employee Benefit Plan Administrators

Ins 8.20   Purpose.

Ins 8.22   Definitions.

Ins 8.24   Exemptions.

Ins 8.26   Licensing.

Ins 8.28   Performance bond requirements.

Ins 8.30   Notification to office.

Ins 8.32   Audit.

Subchapter III — Small Employer Health Insurance

Ins 8.40   Purpose.

Ins 8.42   Definitions.

Ins 8.44   Applicability; exclusion.

Ins 8.46   Required policy provisions.

Ins 8.48   Solicitation; disclosure requirements.

Ins 8.49   Uniform employee application form.

Ins 8.50   Underwriting restriction.

Ins 8.52   Regulation of rates and rate changes.

Ins 8.54   Guaranteed renewability; cancellation and renewal restrictions.

Ins 8.56   Certification of compliance; additional information required.

Ins 8.59   Small employer insurers shall offer an initial enrollment period to all members of small employer groups; riders and discriminatory coverage are prohibited.

Ins 8.60   A small employer insurer may accept an employee’s or dependent’s waiver of coverage during an initial enrollment period only under limited conditions.

Ins 8.61   Small employer insurers shall offer coverage to new entrants.

Ins 8.62   Small employer insurers shall offer an open enrollment for individuals excluded prior to enactment or application of the small employer health insurance law.

Ins 8.63   Small employer insurers shall offer coverage to late enrollees.

Ins 8.64   Small employer insurers may not participate with a small employer to coerce, or discriminate among, eligible employees or dependents.

Ins 8.65   A small employer insurer shall require small employers to provide documentation to establish that waivers of coverage are voluntary and permitted.

Ins 8.66   Qualifying coverage for portability and late enrollees; transition.

Ins 8.67   Restrictive riders prohibited.

Ins 8.68   Fair marketing standards.

Ins 8.69   Minimum standards for market share of basic health benefit plans in force; exemption from guarantee issuance of the basic health benefit plan.

Subchapter IV — Basic Health Benefit Plan For Small Employers

Ins 8.70   Purpose.

Ins 8.71   Definitions.

Ins 8.72   Basic benefits.

Ins 8.73   Health insurance mandates.

Ins 8.74   Policy title; term.

Ins 8.75   Limitations and restrictions.

Ins 8.76   Policy terms; exclusions; limitations.

Ins 8.77   Copayments; coinsurance.

Ins 8.78   Participation; enrollment.

Ins 8.79   Managed care options.

Ins 8.80   Rating.

Ins 8.81   Form approval and marketing.

Ch. Ins 8 Note Note: Sections Ins 8.20 to 8.32 were created as emergency rules effective October, 1, 1991. Sections Ins 8.40 to 8.56 were created as emergency rules effective February 12, 1992.

subch. I of ch. Ins 8 Subchapter I — Employee Welfare Funds

Ins 8.11 Ins 8.11 County and school district self-insured employee health care benefits: excess or stop-loss insurance requirements.

Ins 8.11(1) (1) Purpose. This section interprets ss. 59.52 (11) (c) and 120.13 (2) (c), Stats., for the purpose of prescribing detailed requirements for excess or stop-loss insurance for self-insured employee health care benefit plans provided by counties or school districts.

Ins 8.11(2) (2) Scope. This section applies to any county or school district that alone or together with one or more counties or one or more school districts provides employee health care benefits on a self-insured basis to less than 1,000 covered employees.

Ins 8.11(3) (3) Definitions. In this section:

Ins 8.11(3)(a) (a) “Aggregate claims” means total actual claim amounts incurred under the employee health care benefit plan during a benefit period.

Ins 8.11(3)(b) (b) “Aggregate deductible” means the aggregate amount of liability specified in the excess or stop-loss insurance contract at or below which the county or school district remains liable for payments for eligible claims.

Ins 8.11(3)(c) (c) “Benefit period” means a twelve-month accounting or reporting period of the employee health care benefit plan.

Ins 8.11(3)(d) (d) “Coinsurance” means a fixed percentage of each claim established in the employee health care benefit plan which the county or school district is obligated to pay for each person covered in the plan.