Amendment AA2-ASA2-AB68

AB68-ASA2-AA2,75,24 1. Notify each enrollee of the termination of the contract or benefits and of the right for the enrollee to elect to continue transitional care from the provider or facility under this subsection.

AB68-ASA2-AA2,76,2 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB68-ASA2-AA2,76,9 3. Allow the enrollee to elect to continue to have the benefits provided under the plan under the same terms and conditions as would have applied to the item or service if the termination had not occurred for the course of treatment related to the enrollee's status as a continuing care patient beginning on the date on which the notice under subd. 1. is provided and ending 90 days after the date on which the notice under subd. 1. is provided or the date on which the enrollee is no longer a continuing care patient, whichever is earlier.

AB68-ASA2-AA2,76,13 (9) Rule making. The commissioner may promulgate any rules necessary to implement this section, including specifying the independent dispute resolution process. The commissioner may promulgate rules to modify the list of those items and services for which a provider may not balance bill under sub. (5) (c).

AB68-ASA2-AA2,412c Section 412c. 609.713 of the statutes is created to read:

AB68-ASA2-AA2,76,16 609.713 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB68-ASA2-AA2,412d Section 412d. 609.719 of the statutes is created to read:

AB68-ASA2-AA2,76,19 609.719 Telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

AB68-ASA2-AA2,412e Section 412e. 609.83 of the statutes, as affected by 2021 Wisconsin Act 9, is amended to read:

AB68-ASA2-AA2,76,24 609.83 Coverage of drugs and devices ; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and (16v).

AB68-ASA2-AA2,412f Section 412f. 609.83 of the statutes, as affected by 2021 Wisconsin Act .... (this act), section 412e, is amended to read:

AB68-ASA2-AA2,77,6 609.83 Coverage of drugs and devices; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), (16t), and (16v).

AB68-ASA2-AA2,412g Section 412g. 609.847 of the statutes is created to read:

AB68-ASA2-AA2,77,10 609.847 Preexisting condition discrimination and certain benefit limits prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.

AB68-ASA2-AA2,412h Section 412h. 625.12 (1) (a) of the statutes is amended to read:

AB68-ASA2-AA2,77,13 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB68-ASA2-AA2,412i Section 412i. 625.12 (1) (e) of the statutes is amended to read:

AB68-ASA2-AA2,77,16 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB68-ASA2-AA2,412j Section 412j. 625.12 (2) of the statutes is amended to read:

AB68-ASA2-AA2,78,2 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB68-ASA2-AA2,412k Section 412k. 625.15 (1) of the statutes is amended to read:

AB68-ASA2-AA2,78,11 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB68-ASA2-AA2,412L Section 412L. 628.34 (3) (a) of the statutes is amended to read:

AB68-ASA2-AA2,78,20 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.729, 632.746 and, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB68-ASA2-AA2,412m Section 412m. 628.34 (3) (a) of the statutes, as affected by 2021 Wisconsin Act .... (this act), section 412L, is amended to read:

AB68-ASA2-AA2,79,5 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB68-ASA2-AA2,412n Section 412n. 632.728 of the statutes is created to read:

AB68-ASA2-AA2,79,8 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB68-ASA2-AA2,79,10 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB68-ASA2-AA2,79,11 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB68-ASA2-AA2,79,12 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68-ASA2-AA2,79,18 (2) Guaranteed issue. (a) Every individual health benefit plan shall accept every individual in this state who, and every group health benefit plan shall accept every employer in this state that, applies for coverage, regardless of sexual orientation, gender identity, or whether or not any employee or individual has a preexisting condition. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

AB68-ASA2-AA2,79,21 (b) The commissioner shall establish a statewide open enrollment period of no shorter than 30 days for every individual health benefit plan to allow individuals, including individuals who do not have coverage, to enroll in coverage.

AB68-ASA2-AA2,80,2 (3) Prohibiting discrimination based on health status. (a) An individual health benefit plan or a self-insured health plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB68-ASA2-AA2,80,3 1. Health status.

AB68-ASA2-AA2,80,4 2. Medical condition, including both physical and mental illnesses.

AB68-ASA2-AA2,80,5 3. Claims experience.

AB68-ASA2-AA2,80,6 4. Receipt of health care.

AB68-ASA2-AA2,80,7 5. Medical history.

AB68-ASA2-AA2,80,8 6. Genetic information.

AB68-ASA2-AA2,80,10 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68-ASA2-AA2,80,11 8. Disability.

AB68-ASA2-AA2,80,18 (b) An insurer offering an individual health benefit plan or a self-insured health plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor under par. (a) with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.

AB68-ASA2-AA2,80,22 (c) Nothing in this subsection prevents an insurer offering an individual health benefit plan or a self-insured health plan from establishing premium discounts or rebates or modifying otherwise applicable cost sharing in return for adherence to programs of health promotion and disease prevention.

AB68-ASA2-AA2,80,25 (4) Premium rate variation. A health benefit plan offered on the individual or small employer market or a self-insured health plan may vary premium rates for a specific plan based only on the following considerations:

AB68-ASA2-AA2,81,1 (a) Whether the policy or plan covers an individual or a family.

AB68-ASA2-AA2,81,2 (b) Rating area in the state, as established by the commissioner.

AB68-ASA2-AA2,81,5 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over the age groups and the age bands shall be consistent with recommendations of the National Association of Insurance Commissioners.

AB68-ASA2-AA2,81,6 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68-ASA2-AA2,81,11 (5) Statewide risk pool. An insurer offering a health benefit plan may not segregate enrollees into risk pools other than a single statewide risk pool for the individual market and a single statewide risk pool for the small employer market or a single statewide risk pool that combines the individual and small employer markets.

AB68-ASA2-AA2,81,13 (6) Annual and lifetime limits. An individual or group health benefit plan or a self-insured health plan may not establish any of the following:

AB68-ASA2-AA2,81,15 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-ASA2-AA2,81,17 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-ASA2-AA2,81,21 (7) Cost sharing maximum. A health benefit plan offered on the individual or small employer market may not require an enrollee under the plan to pay more in cost sharing than the maximum amount calculated under 42 USC 18022 (c), including the annual indexing of the limits.

AB68-ASA2-AA2,81,24 (8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the proportion, expressed as a percentage, of premium revenues spent by a health benefit plan on clinical services and quality improvement.

AB68-ASA2-AA2,82,2 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB68-ASA2-AA2,82,4 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB68-ASA2-AA2,82,8 (9) Actuarial values of plan tiers. Any health benefit plan offered on the individual or small employer market shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to at least 60 percent of the full actuarial value of the benefits provided under the plan.

AB68-ASA2-AA2,412p Section 412p. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB68-ASA2-AA2,82,17 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant's or beneficiary's enrollment date under the plan on a participant or beneficiary under the plan.

AB68-ASA2-AA2,412q Section 412q. 632.746 (1) (b) of the statutes is repealed.

AB68-ASA2-AA2,412r Section 412r. 632.746 (2) (a) of the statutes is amended to read:

AB68-ASA2-AA2,82,23 632.746 (2) (a) An insurer offering a group health benefit plan may not treat impose a preexisting condition exclusion based on genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

AB68-ASA2-AA2,412s Section 412s. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB68-ASA2-AA2,412t Section 412t. 632.746 (3) (a) of the statutes is repealed.

AB68-ASA2-AA2,412u Section 412u. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB68-ASA2-AA2,412v Section 412v. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB68-ASA2-AA2,412w Section 412w. 632.746 (5) of the statutes is repealed.

AB68-ASA2-AA2,412x Section 412x. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB68-ASA2-AA2,83,8 632.746 (8) (a) (intro.) A health maintenance organization that offers a group health benefit plan and that does not impose any preexisting condition exclusion under sub. (1) with respect to a particular coverage option may impose an affiliation period for that coverage option, but only if all of the following apply:

AB68-ASA2-AA2,412y Section 412y. 632.748 (2) of the statutes is amended to read:

AB68-ASA2-AA2,83,16 632.748 (2) An insurer offering a group health benefit plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.

AB68-ASA2-AA2,412yc Section 412yc. 632.7495 (4) (b) of the statutes is amended to read:

AB68-ASA2-AA2,83,18 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

AB68-ASA2-AA2,412ye Section 412ye. 632.7495 (4) (c) of the statutes is amended to read:

AB68-ASA2-AA2,83,24 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 6 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB68-ASA2-AA2,412yg Section 412yg. 632.7496 of the statutes is created to read:

AB68-ASA2-AA2,84,3 632.7496 Coverage requirements for short-term plans. (1) Definition. In this section, “short-term, limited duration plan” means an individual health benefit plan described in s. 632.7495 (4) that an insurer is not required to renew.

AB68-ASA2-AA2,84,6 (2) Guaranteed issue. Every short-term, limited duration plan shall accept every individual in this state who applies for coverage whether or not any individual has a preexisting condition.

AB68-ASA2-AA2,84,11 (3) Prohibiting discrimination based on health status. (a) A short-term, limited duration plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB68-ASA2-AA2,84,12 1. Health status.

AB68-ASA2-AA2,84,13 2. Medical condition, including both physical and mental illnesses.

AB68-ASA2-AA2,84,14 3. Claims experience.

AB68-ASA2-AA2,84,15 4. Receipt of health care.

AB68-ASA2-AA2,84,16 5. Medical history.

AB68-ASA2-AA2,84,17 6. Genetic information.

AB68-ASA2-AA2,84,19 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68-ASA2-AA2,84,20 8. Disability.

AB68-ASA2-AA2,85,2 (b) A short-term, limited duration plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor under par. (a) with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.