Chapter Ins 8

Ins 8.74 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.75 Ins 8.75 Limitations and restrictions.

Ins 8.75(1) (1) Preexisting conditions. Section 635.17 (1), Stats., applies to a plan subject to this subchapter.

Ins 8.75 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.746, Stats.

Ins 8.75(2) (2) Annual maximum. The annual calendar year maximum benefit for a plan is $30,000 per insured individual. Charges for a hospitalization which extends from one calendar year to another shall be subject to the calendar year maximum for the year in which each charge was incurred and only one $100 copayment shall apply to the confinement.

Ins 8.75(3) (3) Limitation on coverage for mental health and substance abuse treatment. The annual calendar year benefit payable for treatment of a covered person for nervous and mental disorders and alcoholism and other drug abuse is $1,400. A plan may not apply the cost of outpatient prescription drugs used in the treatment of nervous and mental disorders or alcoholism or other drug abuse toward the annual limit specified in this subsection.

Ins 8.75 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.76 Ins 8.76 Policy terms; exclusions; limitations.

Ins 8.76(1) (1) Except as otherwise provided in this subchapter, a plan’s policy terms shall be defined consistently with the definitions in the small employer insurer’s other small group health benefit plans.

Ins 8.76(2) (2) A plan may exclude from coverage or limit coverage for specified conditions and services other than those required under s. Ins 8.72 but may exclude or limit only those conditions and services which are generally excluded from coverage or limited under the small employer insurer’s other small group health benefit plans.

Ins 8.76(3) (3) A plan may apply the same limitations on provider choice, coverage and geographical service area that apply under the small employer insurer’s other small group health benefit plans.

Ins 8.76 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.77 Ins 8.77 Copayments; coinsurance.

Ins 8.77(1) (1) Definitions. In this section:

Ins 8.77(1)(a) (a) “Primary care provider” means any of the following:

Ins 8.77(1)(a)1. 1. If the plan is an indemnity plan, a preferred provider organization or health maintenance organization that does not require the insured to designate a primary provider, the physician who normally provides care to the insured, if the physician is any of the following:

Ins 8.77(1)(a)1.a. a. A physician who is not certified by any specialty board.

Ins 8.77(1)(a)1.b. b. A physician certified by the American board of family practice.

Ins 8.77(1)(a)1.c. c. A physician certified by the American board of internal medicine.

Ins 8.77(1)(a)1.d. d. A physician certified by the American board of obstetrics and gynecology.

Ins 8.77(1)(a)1.e. e. A physician certified by the American board of pediatrics.

Ins 8.77(1)(a)2. 2. If the plan is a health maintenance organization that requires an insured to designate a primary provider, the physician designated.

Ins 8.77(1)(b) (b) “Specialist” means any physician other than a primary care provider.

Ins 8.77(2) (2) Copayments.

Ins 8.77(2)(a) (a) Except as provided in par. (b), sub. (4) and s. Ins 8.79, a copayment in the specified amount applies each time an insured receives any of the following:

Ins 8.77(2)(a)1. 1. Professional services from a primary care provider or from a specialist who is consulted with a referral from a primary care provider when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01 (2), Stats.: $25.

Ins 8.77(2)(a)2. 2. Professional services from a specialist when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01 (2), Stats., when the specialist is consulted without a referral from a primary care provider: $35.

Ins 8.77(2)(a)3. 3. Professional services from a chiropractor: $11.

Ins 8.77(2)(a)4. 4. Ambulance service, unless immediately admitted to the hospital: $75.

Ins 8.77(2)(a)5. 5. Treatment in a hospital emergency room, unless immediately admitted to the hospital: $75.

Ins 8.77(2)(a)6. 6. Inpatient hospitalization: $100.

Ins 8.77(2)(a)7. 7. Prescription drugs, proprietary: $20 or the cost of the prescription, whichever is less.

Ins 8.77(2)(a)8. 8. Prescription drugs, generic: $10, or the cost of the prescription, whichever is less.

Ins 8.77(2)(b) (b) The copayments specified in par. (a) 1. and 2. do not apply to professional services in connection with prenatal care or well baby care from birth to 24 months.

Ins 8.77(3) (3) Coinsurance. Except as provided in sub. (4) and s. Ins 8.79, for each insured individual, a plan shall pay the following portions of the amount by which covered charges in a calendar year exceed the copayments:

Ins 8.77(3)(a) (a) For all charges other than for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems:

Ins 8.77(3)(a)1. 1. 80% of the first $5,000 of charges until the plan has paid $4,000.

Ins 8.77(3)(a)2. 2. 95% of the remainder of charges until the plan limit under s. Ins 8.75 (2) has been met.

Ins 8.77(3)(b) (b) For the treatment of nervous or mental disorders or alcoholism or other drug abuse problems, 80% of the charges until the plan has paid $1,400 or the plan limit under s. Ins 8.75 (2) has been met.

Ins 8.77(4) (4) Exception for health maintenance organizations. A plan offered by a health maintenance organization that requires participants to use only specified health care providers may elect to offer either copayments or coinsurance if the amount for which a participant is responsible is the actuarial equivalent of the copayments and coinsurance required under subs. (2) and (3). Upon request, a health maintenance organization shall provide the office of the commissioner of insurance with sufficient documentation to support its determination of actuarial equivalence.

Ins 8.77(5) (5) Deductibles and other cost-sharing prohibited. A plan shall not include an annual deductible or any copayment or coinsurance requirement other than those specified in this section, except as provided in s. Ins 8.79.

Ins 8.77 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.78 Ins 8.78 Participation; enrollment.

Ins 8.78(1) (1) Participation.

Ins 8.78(1)(a) (a) A small employer insurer shall offer a plan to any small employer meeting the definition of eligible employer in s. 635.20 (2), Stats., regardless of the number required for participation in other small group health benefit plans offered by the small employer insurer.

Ins 8.78 Note Note: 1997 Wis. Act 27 repealed s. 635.20.

Ins 8.78(1)(b) (b) In par. (c), the number of persons in a group means the number of eligible employees without other qualifying coverage, as defined in s. 635.02 (5m), Stats.

Ins 8.78 Note Note: 1995 Wis. Act 289 repealed s. 635.02 (5m).

Ins 8.78(1)(c) (c) A small employer insurer may impose participation requirements on a plan offered to a small employer, not to exceed the following:

Ins 8.78(1)(c)1. 1. For a group of more than 10 persons: 70% of the group.

Ins 8.78(1)(c)2. 2. For a group of 10 persons: 6 participants.

Ins 8.78(1)(c)3. 3. For a group of 8 or 9 persons: 5 participants.

Ins 8.78(1)(c)4. 4. For a group of 7 persons: 4 participants.

Ins 8.78(1)(c)5. 5. For a group of 5 or 6 persons: 3 participants.

Ins 8.78(1)(c)6. 6. For a group of 2 to 4 persons: 2 participants.

Ins 8.78(2) (2) Probationary period. A small employer may impose a waiting period of not more than 90 days from the date of hire before a new employee is eligible to enroll in the small employer’s plan.

Ins 8.78(3) (3) Enrollment.

Ins 8.78(3)(a) (a) A plan may require that new employees of a small employer and newly eligible dependents enroll in the plan within 30 days after becoming eligible to enroll.

Ins 8.78(3)(b) (b) An eligible employee or dependent whose coverage under another health insurance plan terminates for any reason may enroll in a small employer’s plan without medical underwriting within 30 days after termination of the other coverage.

Ins 8.78(3)(c) (c) Section Ins 8.63 (2) applies to an eligible employee or dependent who does not enroll in a small employer’s plan within the period specified in par. (a) or (b).

Ins 8.78(4) (4) Employer contribution exception.

Ins 8.78(4)(a) (a) A plan may limit coverage to eligible employees, as defined in s. 635.20 (1m), Stats., and their dependents.

Ins 8.78 Note Note: 1997 Wis. Act 27 repealed s. 635.20.

Ins 8.78(4)(b) (b) If a plan permits employees other than those defined as eligible employees in s. 635.20 (1m), Stats., to enroll, the small employer is not required to pay the employer contribution specified under s. 635.254 (1), Stats., for those employees. If the small employer elects not to contribute, the small employer shall withhold the entire amount of the premium from the earnings of each employee permitted to participate, as provided in s. 635.254 (2), Stats.

Ins 8.78 Note Note: 1997 Wis. Act 27 repealed ss. 635.20 and 635.254. See ss. 632.745 (5) and 635.19 (4), Stats.

Ins 8.78 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93; cr. (3) (c), Register, November, 1993, No. 455, eff. 2-1-94.

Ins 8.79 Ins 8.79 Managed care options. A small employer insurer that offers health benefit plans with one or more managed care options in the small employer market shall offer purchasers of a basic health benefit plan at least one managed care option. If the option offered is a preferred provider plan, as defined under s. 609.01 (4), Stats., the small employer insurer, in order to encourage the use of health care providers that participate in the plan, may increase any copayment specified in s. Ins 8.77 (2) or the percentage of an insured’s coinsurance under s. Ins 8.77 (3) if the insured uses a nonparticipating health care provider.

Ins 8.79 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.80 Ins 8.80 Rating.

Ins 8.80(1) (1) In establishing the new business premium rate for the plan, a small employer insurer shall take into account the experience of all of its small employer health benefit plans. The differences between the plan’s new business premium rate and the insurer’s new business premium rates for all other small employer health benefit plans shall be based solely on the differences in the plan designs and not on the actual or anticipated experience of those insured under the basic health benefit plan.

Ins 8.80(2) (2) 

Ins 8.80(2)(a) (a)

Ins 8.80(2)(a)1. 1. Except as provided in par. (b), the plan shall apply a higher rate to smokers than to nonsmokers. The rate applied to smokers shall be no higher than permitted under s. 111.35 (3), Stats. The small employer insurer shall provide the small employer with enough copies of the statements required under s. 111.35 (3) (a) 2. and (b) 2., Stats., for distribution to all plan participants.

Ins 8.80(2)(a)2. 2. For the purpose of complying with s. 635.05, Stats., and s. Ins 8.52, smoking status shall be treated as a case characteristic.

Ins 8.80(2)(b) (b) Paragraph (a) does not apply to a health maintenance organization federally qualified under title 13 of the public health service act.

Ins 8.80 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.81 Ins 8.81 Form approval and marketing.

Ins 8.81(1) (1) Except as provided in s. 635.26 (2m) to (4), Stats., each small employer insurer shall file its basic health benefit plan policy form with the commissioner of insurance under s. 631.20, Stats., before October 1, 1993.

Ins 8.81 Note Note: 1997 Wis. Act 27 repealed s. 635.26, Stats. See s. 635.19 (2), Stats.

Ins 8.81(2) (2) Except as provided in s. 635.26 (2m) to (4), Stats., no small employer insurer shall market any health benefit plan to small employers on and after December 1, 1993 unless its basic health benefit plan policy form has been filed with and approved by the commissioner of insurance under s. 631.20, Stats.

Ins 8.81 Note Note: 1997 Wis. Act 27 repealed s. 635.26, Stats. See 635.19 (2), Stats.

Ins 8.81 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.