Register December 2020 No. 780
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 8.28 Performance bond requirements.
Ins 8.30 Notification to office.
Subchapter III — Small Employer Health Insurance
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 8.73 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 8.81 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.
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)(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.
Ins 8.11(3)(e)
(e) “Covered employees" means employees participating in an employee health care benefit plan.
Ins 8.11(3)(f)
(f) “Employees eligible to participate" means employees who are eligible to be covered employees under the terms of the employee health care benefit plan.
Ins 8.11(3)(g)
(g) “Employee health care benefit plan" means a self-insured plan established by one county or school district or jointly by 2 or more counties or 2 or more school districts to provide health care benefits to employees eligible to participate in the plan.
Ins 8.11(3)(h)
(h) “Expected claims" means the most accurate actuarial estimate of aggregate claims during a benefit period.
Ins 8.11(3)(i)
(i) “Incurred" means to have provided or furnished a service or item to an employee or dependent covered under an employee health care benefit plan for which a charge for a covered expense is made.
Ins 8.11(3)(j)
(j) “Maximums" means the largest total amount of claims per person established by the employee health care benefit plan which the county or school district is obligated to pay.
Ins 8.11(3)(k)
(k) “Paid basis" means the application of a claim payment to the aggregate deductible for the benefit period in which the payment is actually made, regardless of when the claim is incurred.
