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AB68-ASA2-AA2,80,1111 8. Disability.
AB68-ASA2-AA2,80,1812 (b) An insurer offering an individual health benefit plan or a self-insured
13health plan may not require any individual, as a condition of enrollment or continued
14enrollment under the plan, to pay, on the basis of any health status-related factor
15under par. (a) with respect to the individual or a dependent of the individual, a
16premium or contribution or a deductible, copayment, or coinsurance amount that is
17greater than the premium or contribution or deductible, copayment, or coinsurance
18amount respectively for a similarly situated individual enrolled under the plan.
AB68-ASA2-AA2,80,2219 (c) Nothing in this subsection prevents an insurer offering an individual health
20benefit plan or a self-insured health plan from establishing premium discounts or
21rebates or modifying otherwise applicable cost sharing in return for adherence to
22programs of health promotion and disease prevention.
AB68-ASA2-AA2,80,25 23(4) Premium rate variation. A health benefit plan offered on the individual or
24small employer market or a self-insured health plan may vary premium rates for a
25specific plan based only on the following considerations:
AB68-ASA2-AA2,81,1
1(a) Whether the policy or plan covers an individual or a family.
AB68-ASA2-AA2,81,22 (b) Rating area in the state, as established by the commissioner.
AB68-ASA2-AA2,81,53 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over
4the age groups and the age bands shall be consistent with recommendations of the
5National Association of Insurance Commissioners.
AB68-ASA2-AA2,81,66 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
AB68-ASA2-AA2,81,11 7(5) Statewide risk pool. An insurer offering a health benefit plan may not
8segregate enrollees into risk pools other than a single statewide risk pool for the
9individual market and a single statewide risk pool for the small employer market or
10a single statewide risk pool that combines the individual and small employer
11markets.
AB68-ASA2-AA2,81,13 12(6) Annual and lifetime limits. An individual or group health benefit plan or
13a self-insured health plan may not establish any of the following:
AB68-ASA2-AA2,81,1514 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
15of an enrollee under the plan.
AB68-ASA2-AA2,81,1716 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent
17of an enrollee under the plan.
AB68-ASA2-AA2,81,21 18(7) Cost sharing maximum. A health benefit plan offered on the individual or
19small employer market may not require an enrollee under the plan to pay more in
20cost sharing than the maximum amount calculated under 42 USC 18022 (c),
21including the annual indexing of the limits.
AB68-ASA2-AA2,81,24 22(8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the
23proportion, expressed as a percentage, of premium revenues spent by a health
24benefit plan on clinical services and quality improvement.
AB68-ASA2-AA2,82,2
1(b) A health benefit plan on the individual or small employer market shall have
2a medical loss ratio of at least 80 percent.
AB68-ASA2-AA2,82,43 (c) A group health benefit plan other than one described under par. (b) shall
4have a medical loss ratio of at least 85 percent.
AB68-ASA2-AA2,82,8 5(9) Actuarial values of plan tiers. Any health benefit plan offered on the
6individual or small employer market shall provide a level of coverage that is designed
7to provide benefits that are actuarially equivalent to at least 60 percent of the full
8actuarial value of the benefits provided under the plan.
AB68-ASA2-AA2,412p 9Section 412p. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and
10amended to read:
AB68-ASA2-AA2,82,1711 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health
12benefit plan may, with respect to a participant or beneficiary under the plan, not
13impose a preexisting condition exclusion only if the exclusion relates to a condition,
14whether physical or mental, regardless of the cause of the condition, for which
15medical advice, diagnosis, care or treatment was recommended or received within
16the 6-month period ending on the participant's or beneficiary's enrollment date
17under the plan
on a participant or beneficiary under the plan.
AB68-ASA2-AA2,412q 18Section 412q. 632.746 (1) (b) of the statutes is repealed.
AB68-ASA2-AA2,412r 19Section 412r. 632.746 (2) (a) of the statutes is amended to read:
AB68-ASA2-AA2,82,2320 632.746 (2) (a) An insurer offering a group health benefit plan may not treat
21impose a preexisting condition exclusion based on genetic information as a
22preexisting condition under sub. (1) without a diagnosis of a condition related to the
23information
.
AB68-ASA2-AA2,412s 24Section 412s. 632.746 (2) (c), (d) and (e) of the statutes are repealed.
AB68-ASA2-AA2,412t 25Section 412t. 632.746 (3) (a) of the statutes is repealed.
AB68-ASA2-AA2,412u
1Section 412u. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).
AB68-ASA2-AA2,412v 2Section 412v. 632.746 (3) (d) 2. and 3. of the statutes are repealed.
AB68-ASA2-AA2,412w 3Section 412w. 632.746 (5) of the statutes is repealed.
AB68-ASA2-AA2,412x 4Section 412x. 632.746 (8) (a) (intro.) of the statutes is amended to read:
AB68-ASA2-AA2,83,85 632.746 (8) (a) (intro.) A health maintenance organization that offers a group
6health benefit plan and that does not impose any preexisting condition exclusion
7under sub. (1)
with respect to a particular coverage option may impose an affiliation
8period for that coverage option, but only if all of the following apply:
AB68-ASA2-AA2,412y 9Section 412y. 632.748 (2) of the statutes is amended to read:
AB68-ASA2-AA2,83,1610 632.748 (2) An insurer offering a group health benefit plan may not require any
11individual, as a condition of enrollment or continued enrollment under the plan, to
12pay, on the basis of any health status-related factor with respect to the individual
13or a dependent of the individual, a premium or contribution or a deductible,
14copayment, or coinsurance amount
that is greater than the premium or contribution
15or deductible, copayment, or coinsurance amount respectively for a similarly
16situated individual enrolled under the plan.
AB68-ASA2-AA2,412yc 17Section 412yc. 632.7495 (4) (b) of the statutes is amended to read:
AB68-ASA2-AA2,83,1818 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.
AB68-ASA2-AA2,412ye 19Section 412ye. 632.7495 (4) (c) of the statutes is amended to read:
AB68-ASA2-AA2,83,2420 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of
21the insurer's coverage of the insured by individual health benefit plan coverage not
22required to be renewed under this subsection does not exceed 18 6 months. For
23purposes of this paragraph, coverage periods are consecutive if there are no more
24than 63 days between the coverage periods.
AB68-ASA2-AA2,412yg 25Section 412yg. 632.7496 of the statutes is created to read:
AB68-ASA2-AA2,84,3
1632.7496 Coverage requirements for short-term plans. (1) Definition.
2In this section, “short-term, limited duration plan” means an individual health
3benefit plan described in s. 632.7495 (4) that an insurer is not required to renew.
AB68-ASA2-AA2,84,6 4(2) Guaranteed issue. Every short-term, limited duration plan shall accept
5every individual in this state who applies for coverage whether or not any individual
6has a preexisting condition.
AB68-ASA2-AA2,84,11 7(3) Prohibiting discrimination based on health status. (a) A short-term,
8limited duration plan may not establish rules for the eligibility of any individual to
9enroll, or for the continued eligibility of any individual to remain enrolled, under the
10plan based on any of the following health status-related factors in relation to the
11individual or a dependent of the individual:
AB68-ASA2-AA2,84,1212 1. Health status.
AB68-ASA2-AA2,84,1313 2. Medical condition, including both physical and mental illnesses.
AB68-ASA2-AA2,84,1414 3. Claims experience.
AB68-ASA2-AA2,84,1515 4. Receipt of health care.
AB68-ASA2-AA2,84,1616 5. Medical history.
AB68-ASA2-AA2,84,1717 6. Genetic information.
AB68-ASA2-AA2,84,1918 7. Evidence of insurability, including conditions arising out of acts of domestic
19violence.
AB68-ASA2-AA2,84,2020 8. Disability.
AB68-ASA2-AA2,85,221 (b) A short-term, limited duration plan may not require any individual, as a
22condition of enrollment or continued enrollment under the plan, to pay, on the basis
23of any health status-related factor under par. (a) with respect to the individual or a
24dependent of the individual, a premium or contribution or a deductible, copayment,
25or coinsurance amount that is greater than the premium or contribution or

1deductible, copayment, or coinsurance amount respectively for a similarly situated
2individual enrolled under the plan.
AB68-ASA2-AA2,85,4 3(4) Premium rate variation. A short-term, limited duration plan may vary
4premium rates for a specific plan based only on the following considerations:
AB68-ASA2-AA2,85,55 (a) Whether the policy or plan covers an individual or a family.
AB68-ASA2-AA2,85,66 (b) Rating area in the state, as established by the commissioner.
AB68-ASA2-AA2,85,97 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over
8the age groups and the age bands shall be consistent with recommendations of the
9National Association of Insurance Commissioners.
AB68-ASA2-AA2,85,1010 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
AB68-ASA2-AA2,85,12 11(5) Annual and lifetime limits. A short-term, limited duration plan may not
12establish any of the following:
AB68-ASA2-AA2,85,1413 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
14of an enrollee under the plan.
AB68-ASA2-AA2,85,1615 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an
16enrollee under the plan for the initial or cumulative duration of the plan.
AB68-ASA2-AA2,412yj 17Section 412yj. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to
18read:
AB68-ASA2-AA2,86,219 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years
20from the date of issue of the policy may be reduced or denied on the ground that a
21disease or physical condition existed prior to the effective date of coverage, unless the
22condition was excluded from coverage by name or specific description by a provision
23effective on the date of loss. This paragraph does not apply to a group health benefit
24plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance

1policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s.
2632.85 (1) (c)
.
AB68-ASA2-AA2,86,83 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability
4commencing after 12 months from the date of issue of under an individual disability
5insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the
6ground that a disease or physical condition existed prior to the effective date of
7coverage, unless the condition was excluded from coverage by name or specific
8description by a provision effective on the date of the loss
.
AB68-ASA2-AA2,86,159 2. Except as provided in subd. 3., an An individual disability insurance policy,
10as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495
11(4) and (5), may not define a preexisting condition more restrictively than a condition
12that was present before the date of enrollment for the coverage, whether physical or
13mental, regardless of the cause of the condition, for which and regardless of whether
14medical advice, diagnosis, care, or treatment was recommended or received within
1512 months before the effective date of coverage
.
AB68-ASA2-AA2,412ym 16Section 412ym. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:
AB68-ASA2-AA2,86,1917 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under
18s. 632.7495 (5), all of the following apply to an individual disability insurance policy
19that is a short-term, limited duration policy subject to s. 632.7495 (4) and (5):
AB68-ASA2-AA2,412yp 20Section 412yp. 632.76 (2) (ac) 3. b. of the statutes is amended to read:
AB68-ASA2-AA2,87,221 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a
22may not impose any preexisting condition exclusion may be imposed by the
23aggregate of the insured's consecutive periods of coverage under the insurer's
24individual disability insurance policies that are short-term policies subject to s.

1632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive
2if there are no more than 63 days between the coverage periods
.
AB68-ASA2-AA2,412ys 3Section 412ys. 632.795 (4) (a) of the statutes is amended to read:
AB68-ASA2-AA2,87,154 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the
5same policy form and for the same premium as it originally offered in the most recent
6enrollment period, subject only to the medical underwriting used in that enrollment
7period. Unless otherwise prescribed by rule, the insurer may apply deductibles,
8preexisting condition limitations, waiting periods , or other limits only to the extent
9that they would have been applicable had coverage been extended at the time of the
10most recent enrollment period and with credit for the satisfaction or partial
11satisfaction of similar provisions under the liquidated insurer's policy or plan. The
12insurer may exclude coverage of claims that are payable by a solvent insurer under
13insolvency coverage required by the commissioner or by the insurance regulator of
14another jurisdiction. Coverage shall be effective on the date that the liquidated
15insurer's coverage terminates.
AB68-ASA2-AA2,412yu 16Section 412yu. 632.796 of the statutes is created to read:
AB68-ASA2-AA2,87,18 17632.796 Drug cost report. (1) Definition. In this section, “disability
18insurance policy” has the meaning given in s. 632.895 (1) (a).
AB68-ASA2-AA2,87,24 19(2) Report required. Annually, at the time the insurer files its rate request
20with the commissioner, each insurer that offers a disability insurance policy that
21covers prescription drugs shall submit to the commissioner a report that identifies
22the 25 prescription drugs that are the highest cost to the insurer and the 25
23prescription drugs that have the highest cost increases over the 12 months before the
24submission of the report.
AB68-ASA2-AA2,412yw 25Section 412yw. 632.862 of the statutes is created to read:
AB68-ASA2-AA2,88,2
1632.862 Application of prescription drug payments. (1) Definitions. In
2this section:
AB68-ASA2-AA2,88,33 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).
AB68-ASA2-AA2,88,44 (b) “Brand name drug” means any of the following:
AB68-ASA2-AA2,88,65 1. A prescription drug that contains a brand name and that has no generic
6equivalent.
AB68-ASA2-AA2,88,107 2. A prescription drug that contains a brand name and has a generic equivalent
8but for which the enrollee has received prior authorization from the insurer offering
9the disability insurance policy or the self-insured health plan or authorization from
10a physician to obtain the prescription drug under the policy or plan.
AB68-ASA2-AA2,88,1111 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
AB68-ASA2-AA2,88,1212 (d) “Prescription drug” has the meaning given in s. 450.01 (20)
AB68-ASA2-AA2,88,1313 (e) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
AB68-ASA2-AA2,88,19 14(2) Application of discounts. A disability insurance policy that offers a
15prescription drug benefit or a self-insured health plan shall apply to any calculation
16of an out-of-pocket maximum and to any deductible of the policy or plan for an
17enrollee the amount that any discount provided by the manufacturer of a brand
18name drug reduces the cost sharing amount charged to an enrollee for that brand
19name drug.
AB68-ASA2-AA2,412yz 20Section 412yz. 632.8655 of the statutes is created to read:
AB68-ASA2-AA2,88,22 21632.8655 Prescription drug cost reporting. (1) Definitions. In this
22section:
AB68-ASA2-AA2,88,2423 (a) “Brand-name drug” means a prescription drug approved under 21 USC 355
24(b) or 42 USC 262.
AB68-ASA2-AA2,89,2
1(b) “Covered hospital” means an entity described in 42 USC 256b (a) (4) (L) to
2(N) that participates in the federal drug pricing program under 42 USC 256b.
AB68-ASA2-AA2,89,33 (c) “Generic drug” means a prescription drug approved under 21 USC 355 (j).
AB68-ASA2-AA2,89,74 (d) “Margin” means, for a covered hospital, the difference between the net cost
5of a brand-name drug or generic drug covered under the federal drug pricing
6program under 42 USC 256b and the net payment by the covered hospital for that
7brand-name drug or generic drug.
AB68-ASA2-AA2,89,98 (e) “Net payment” means the amount paid for a brand-name drug or generic
9drug after all discounts and rebates have been applied.
AB68-ASA2-AA2,89,14 10(2) Hospital margin spending. By March 1 annually, each covered hospital
11operating in this state shall report to the commissioner the per unit margin for each
12drug covered under the federal drug pricing program under 42 USC 256b dispensed
13in the previous year multiplied by the number of units dispensed at that margin and
14how the margin revenue was used.
AB68-ASA2-AA2,89,20 15(3) Public reporting. The commissioner shall publicly post covered hospital
16documentation of how each hospital spends the margin revenue. The commissioner
17shall analyze data collected under this section and publish annually a report
18including an analysis on hospital-specific margins and how that revenue is spent or
19allocated on a hospital-specific basis. The commissioner shall keep any trade secret
20or proprietary information confidential.
AB68-ASA2-AA2,412z 21Section 412z. 632.8665 of the statutes is created to read:
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