Chapter Ins 8

Ins 8.68(10)(a) (a) An insurer offering individual or group health benefit plans or coverage under a trust or association health benefit plan in this state shall investigate and determine whether the plans are subject to this subchapter and ch. 635, Stats. An insurer shall obtain the following information from applicants for individual and group health benefit plans at the time of application:

Ins 8.68(10)(a)1. 1. Whether or not any portion of the premium will be paid by or on behalf of a small employer, either directly or through wage adjustments or other means of reimbursement;

Ins 8.68(10)(a)2. 2. Whether or not any portion of the premium will be collected by or with the cooperation of a small employer; and

Ins 8.68(10)(a)3. 3. Whether or not the prospective policyholder, certificate holder or any prospective insured individual intends to treat the health benefit plan as part of a plan or program under Section 162, Section 125 or Section 106 of the United States internal revenue code.

Ins 8.68(10)(b) (b) If a small employer insurer fails to comply with par. (a), the small employer insurer is deemed to be on notice of any information that could reasonably have been obtained if the small employer insurer had complied with par. (a).

Ins 8.68(10)(c) (c) An insurer is not relieved from complying with ch. 635, Stats., and there is no presumption that ch. 635, Stats., does not apply merely because the insurer has complied with the minimum obligation to investigate the status of applicants imposed under this subsection.

Ins 8.68(11) (11) No small employer insurer may permit an insurance intermediary to advise, and no insurance intermediary may advise, a small employer whether the insurer may accept the small employer’s application for coverage under a health benefit plan based on claims experience or health conditions of the group except after submittal of an application and review by the insurer.

Ins 8.68(12) (12) A small employer insurer shall annually file information with the commissioner related to health benefit plans issued by the small employer insurer to small employers in this state in the form prescribed by the commissioner.

Ins 8.68 Note Note: Copies of forms referred to in this section may be obtained without charge from the Office of the Commissioner of Insurance by sending a written request to P. O. Box 7873, Madison, Wisconsin 53707-7873.

Ins 8.68 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94; correction in (10) (a) made under 13.93 (2m) (b) 7., Register, March, 2000, No. 531; corrections in (3) (b) and (c) (intro.) made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562; CR 17-015: r. (3) (b), (c), am. (4) Register December 2017 No. 744, eff. 1-1-18.

Ins 8.69 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.

Ins 8.69(1) (1) No small employer insurer may have a basic market share ratio which is significantly less than the basic market share ratio for all small employer insurers unless the insurer establishes by clear and convincing evidence that the reason the basic market share ratio is significantly less is because:

Ins 8.69(1)(a) (a) Of a specific practice or condition that is beyond the control of the insurer; or

Ins 8.69(1)(b) (b) The insurer uses risk characteristics to underwrite applications for policies to a substantially lesser extent than most other small employer insurers.

Ins 8.69(2) (2) No small employer insurer may have a market share ratio which is significantly less than the market share ratio for all small employer insurers unless the small employer insurer establishes by clear and convincing evidence that the reason the market share ratio is significantly less is because:

Ins 8.69(2)(a) (a) Of a specific practice or condition that is beyond the control of the insurer; or

Ins 8.69(2)(b) (b) The insurer uses risk characteristics to underwrite applications for policies to a substantially lesser extent than most other small employer insurers.

Ins 8.69(3) (3) For the purpose of this section:

Ins 8.69(3)(a) (a) A small employer insurer’s basic market share ratio is presumed to be significantly less than the basic market share ratio for all small employer insurers if the small employer insurer’s basic market share ratio is less than a number equal to q-2. For the purpose of this paragraph:

Ins 8.69(3)(a)1. 1. ‘m’ is the number of basic health benefit plans the small employer insurer has in force; and

Ins 8.69(3)(a)2. 2. ‘q’ is the basic market share ratio for all small employer insurers.

Ins 8.69(3)(b) (b) A small employer insurer’s market share ratio is presumed to be significantly less than the market share ratio for all small employer insurers if the small employer insurer’s market share ratio is less than a number equal to p-2. For the purpose of this paragraph:

Ins 8.69(3)(b)1. 1. ‘n’ is the number of policies the small employer insurer has in force; and

Ins 8.69(3)(b)2. 2. ‘p’ is the market share ratio for all small employer insurers.

Ins 8.69(4) (4) A small employer insurer shall submit an application for an exemption under s. 635.26 (3) (a), Stats., in the form prescribed by the commissioner. Any application for an exemption under s. 635.26 (3) (a), Stats., shall include the small employer insurer’s basic market share ratio and market share ratio and shall address whether the small employer insurer has ratios which are, or are likely to be, significantly higher than the ratios for all small employer insurers and the reasons why the small employer insurer ratios are, or are likely to be, significantly higher than the ratio for all small employer insurers.

Ins 8.69 Note Note: 1997 Wis. Act 27 repealed s. 635.26, Stats. See s. 635.19 (6), Stats.

Ins 8.69(5) (5) Each small employer insurer shall file, in the form prescribed by the commissioner:

Ins 8.69(5)(a) (a) Within 45 days after the end of each quarter calendar year in calendar years 1993, 1994 and 1995:

Ins 8.69(5)(a)1. 1. The number of risk characteristic basic health benefit plans it has in force at the end of the previous quarter calendar year;

Ins 8.69(5)(a)2. 2. The number of risk characteristic basic health benefit plans it issued in the previous quarter calendar year;

Ins 8.69(5)(a)3. 3. The number of basic health benefit plans it has in force at the end of the previous quarter calendar year;

Ins 8.69(5)(a)4. 4. The number of basic health benefit plans it issued in the previous quarter calendar year;

Ins 8.69(5)(a)5. 5. The total number of policies it has in force at the end of the previous quarter calendar year;

Ins 8.69(5)(a)6. 6. The total number of policies it issued in the previous quarter calendar year;

Ins 8.69(5)(a)7. 7. Its basic market share ratio for the previous quarter calendar year;

Ins 8.69(5)(a)8. 8. Its market share ratio for the previous quarter calendar year;

Ins 8.69(5)(a)9. 9. The total number of applications for any policy which the small employer insurer received in the previous quarter calendar year, regardless of whether, or what type of, a policy was issued, and which the small employer insurer:

Ins 8.69(5)(a)9.a. a. Rejected, or would have rejected, for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan; or

Ins 8.69(5)(a)9.b. b. Assigned, or would have assigned, a rate for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan, which exceeds the new business premium rate for the policy by 15% or more; and

Ins 8.69(5)(a)10. 10. The total number of applications for any policy which the small employer insurer received in the previous quarter calendar year, regardless of whether, or what type of, a policy was issued.

Ins 8.69(5)(b) (b) By March 1 of each year:

Ins 8.69(5)(b)1. 1. The number of risk characteristic basic health benefit plans it had in force at the end of the previous calendar year;

Ins 8.69(5)(b)2. 2. The number of risk characteristic basic health benefit plans it issued in the previous calendar year;

Ins 8.69(5)(b)3. 3. The number of basic health benefit plans it had in force at the end of the previous calendar year;

Ins 8.69(5)(b)4. 4. The number of basic health benefit plans it issued in the previous calendar year;

Ins 8.69(5)(b)5. 5. The total number of policies it had in force at the end of the previous calendar year;

Ins 8.69(5)(b)6. 6. The total number of policies it issued in the previous calendar year;

Ins 8.69(5)(b)7. 7. Its basic market share ratio for the previous calendar year;

Ins 8.69(5)(b)8. 8. Its market share ratio for the previous calendar year;

Ins 8.69(5)(b)9. 9. The total number of applications for any policy which the small employer insurer received in the previous calendar year, regardless of whether, or what type of, a policy was issued, and which the small employer insurer:

Ins 8.69(5)(b)9.a. a. Rejected, or would have rejected, for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan; or

Ins 8.69(5)(b)9.b. b. Assigned, or would have assigned, a rate for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan, which exceeds the new business premium rate for the policy by 15% or more; and

Ins 8.69(5)(b)10. 10. The total number of applications for any policy which the small employer insurer received in the previous calendar year, regardless of whether, or what type of, a policy was issued.

Ins 8.69(6) (6) A small employer insurer shall obtain sufficient information to comply with sub. (5) and shall maintain the information and the documentation required under sub. (5) for 3 years or until the issued policy, if any, terminates, whichever is later.

Ins 8.69(7) (7) A small employer insurer shall establish procedures for determining whether a basic health benefit plan is a risk characteristic basic health benefit plan and shall document the basis for each such determination.

Ins 8.69 Note Note: Copies of forms referred to in this section may be obtained without charge from the Office of the Commissioner of Insurance by sending a written request to P. O. Box 7873, Madison, Wisconsin 53707-7873.

Ins 8.69 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94.

subch. IV of ch. Ins 8 Subchapter IV — Basic Health Benefit Plan For Small Employers

Ins 8.70 Ins 8.70 Purpose. This subchapter implements ch. 635, Stats., by establishing the basic health benefit plan that small employer insurers shall actively market and offer to small employers.

Ins 8.70 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93; correction in (intro.) made under 13.93 (2m) (b) 7., Stats., Register, March, 2000, No. 531.

Ins 8.71 Ins 8.71 Definitions.

Ins 8.71(1) (1) The definitions in s. 635.02, Stats., apply to this subchapter.

Ins 8.71(2) (2) In this subchapter, “health care provider” means any of the following:

Ins 8.71(2)(a) (a) A medical or osteopathic physician, podiatrist, physical therapist or physician’s assistant licensed or certified under ch. 448, Stats.

Ins 8.71(2)(b) (b) A psychologist licensed under ch. 445, Stats.

Ins 8.71(2)(c) (c) A chiropractor licensed under ch. 446, Stats.

Ins 8.71(2)(d) (d) A nurse midwife certified under s. 441.15, Stats.

Ins 8.71(2)(e) (e) A nurse practitioner licensed under ch. 441, Stats.

Ins 8.71(2)(f) (f) A nurse licensed under ch. 441, Stats., who is certified as a nurse anesthetist by the American association of nurse anesthetists.

Ins 8.71(2)(g) (g) A dentist licensed under ch. 447, Stats.

Ins 8.71 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register April 2004 No. 580.

Ins 8.72 Ins 8.72 Basic benefits. Subject to the limitations and restrictions under s. Ins 8.75 and copayments and coinsurance under s. Ins 8.77, each plan shall provide coverage for all of the following, if medically necessary:

Ins 8.72(1) (1) Professional services by a health care provider acting within the scope and limitations of his or her license or certificate or a person acting under the direction of a health care provider, including all of the following:

Ins 8.72(1)(a) (a) Office, outpatient, inpatient and emergency room visits including treatment rendered during those visits.

Ins 8.72(1)(b) (b) Surgical services including postoperative care following inpatient or outpatient surgery.

Ins 8.72(1)(c) (c) Services of an assistant surgeon if necessary to perform surgery.

Ins 8.72(1)(d) (d) Anesthesia services.

Ins 8.72(2) (2) Hospital care, including all of the following:

Ins 8.72(2)(a) (a) Semi-private room, board and ancillary services and supplies that are generally provided to hospital inpatients.

Ins 8.72(2)(b) (b) Confinement in an intensive care or coronary care unit of a hospital.

Ins 8.72(2)(c) (c) Outpatient medical care and treatment.

Ins 8.72(2)(d) (d) Medical care and treatment provided in a hospital emergency room.

Ins 8.72(3) (3) Medical care and treatment provided in an ambulatory surgery center, as defined in 42 CFR 416.2.

Ins 8.72(4) (4) Outpatient x-ray, laboratory and other diagnostic tests.

Ins 8.72(5) (5) Confinement in a skilled nursing home licensed under subch. I of ch. 50, Stats.

Ins 8.72(6) (6) Services provided by a home health agency licensed under s. 50.49, Stats.

Ins 8.72(7) (7) Care provided by a hospice licensed under subch. VI of ch. 50, Stats.

Ins 8.72(8) (8) Local ground licensed ambulance services.

Ins 8.72(9) (9) Physical therapy.