Amendment SSA1-AB68

AB68-SSA1,2974 Section 2974. 628.495 of the statutes is created to read:

AB68-SSA1,1344,3 628.495 Pharmacy benefit management broker and consultant licenses. (1) Definition. In this section, “pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB68-SSA1,1344,6 (2) License required. No person may serve as a pharmacy benefit management broker or consultant or any other person who procures the services of a pharmacy benefit manager on behalf of a client without a license.

AB68-SSA1,1344,9 (3) Rules. The commissioner may promulgate rules to establish criteria and procedures for initial licensure and renewal of licensure and to implement licensure under this section.

AB68-SSA1,2975 Section 2975 . 632.35 of the statutes is amended to read:

AB68-SSA1,1344,15 632.35 Prohibited rejection, cancellation and nonrenewal. No insurer may cancel or refuse to issue or renew an automobile insurance policy wholly or partially because of one or more of the following characteristics of any person: age, sex, residence, race, color, creed, religion, national origin, ancestry, marital status or, occupation, or status as a holder or nonholder of a license under s. 343.03 (3r).

AB68-SSA1,2976 Section 2976. 632.728 of the statutes is created to read:

AB68-SSA1,1344,18 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB68-SSA1,1344,20 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB68-SSA1,1344,21 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB68-SSA1,1344,22 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68-SSA1,1345,3 (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-SSA1,1345,6 (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-SSA1,1345,11 (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-SSA1,1345,12 1. Health status.

AB68-SSA1,1345,13 2. Medical condition, including both physical and mental illnesses.

AB68-SSA1,1345,14 3. Claims experience.

AB68-SSA1,1345,15 4. Receipt of health care.

AB68-SSA1,1345,16 5. Medical history.

AB68-SSA1,1345,17 6. Genetic information.

AB68-SSA1,1345,19 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68-SSA1,1345,20 8. Disability.

AB68-SSA1,1346,2 (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-SSA1,1346,6 (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-SSA1,1346,9 (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-SSA1,1346,10 (a) Whether the policy or plan covers an individual or a family.

AB68-SSA1,1346,11 (b) Rating area in the state, as established by the commissioner.

AB68-SSA1,1346,14 (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-SSA1,1346,15 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68-SSA1,1346,20 (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-SSA1,1346,22 (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-SSA1,1346,24 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-SSA1,1347,2 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-SSA1,1347,6 (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-SSA1,1347,9 (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-SSA1,1347,11 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB68-SSA1,1347,13 (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-SSA1,1347,17 (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-SSA1,2977 Section 2977. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB68-SSA1,1348,2 632.746 (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-SSA1,2978 Section 2978. 632.746 (1) (b) of the statutes is repealed.

AB68-SSA1,2979 Section 2979. 632.746 (2) (a) of the statutes is amended to read:

AB68-SSA1,1348,8 632.746 (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-SSA1,2980 Section 2980. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB68-SSA1,2981 Section 2981. 632.746 (3) (a) of the statutes is repealed.

AB68-SSA1,2982 Section 2982 . 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB68-SSA1,2983 Section 2983 . 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB68-SSA1,2984 Section 2984 . 632.746 (5) of the statutes is repealed.

AB68-SSA1,2985 Section 2985. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB68-SSA1,1348,18 632.746 (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-SSA1,2986 Section 2986 . 632.748 (2) of the statutes is amended to read:

AB68-SSA1,1349,2 632.748 (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-SSA1,2987 Section 2987. 632.7495 (4) (b) of the statutes is amended to read:

AB68-SSA1,1349,4 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

AB68-SSA1,2988 Section 2988. 632.7495 (4) (c) of the statutes is amended to read:

AB68-SSA1,1349,10 632.7495 (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-SSA1,2989 Section 2989 . 632.7496 of the statutes is created to read:

AB68-SSA1,1349,14 632.7496 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-SSA1,1349,17 (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-SSA1,1349,22 (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-SSA1,1349,23 1. Health status.

AB68-SSA1,1349,24 2. Medical condition, including both physical and mental illnesses.

AB68-SSA1,1349,25 3. Claims experience.

AB68-SSA1,1350,1 4. Receipt of health care.

AB68-SSA1,1350,2 5. Medical history.

AB68-SSA1,1350,3 6. Genetic information.

AB68-SSA1,1350,5 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68-SSA1,1350,6 8. Disability.

AB68-SSA1,1350,13 (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.

AB68-SSA1,1350,15 (4) Premium rate variation. A short-term, limited duration plan may vary premium rates for a specific plan based only on the following considerations:

AB68-SSA1,1350,16 (a) Whether the policy or plan covers an individual or a family.

AB68-SSA1,1350,17 (b) Rating area in the state, as established by the commissioner.

AB68-SSA1,1350,20 (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-SSA1,1350,21 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68-SSA1,1350,23 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

AB68-SSA1,1350,25 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-SSA1,1351,2 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan for the initial or cumulative duration of the plan.

AB68-SSA1,2990 Section 2990. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB68-SSA1,1351,12 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c).

AB68-SSA1,1351,18 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB68-SSA1,1351,25 2. Except as provided in subd. 3., an An individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition that was present before the date of enrollment for the coverage, whether physical or mental, regardless of the cause of the condition, for which and regardless of whether medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB68-SSA1,2991 Section 2991. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB68-SSA1,1352,4 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term, limited duration policy subject to s. 632.7495 (4) and (5):

AB68-SSA1,2992 Section 2992. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

AB68-SSA1,1352,11 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB68-SSA1,2993 Section 2993. 632.795 (4) (a) of the statutes is amended to read:

AB68-SSA1,1352,24 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods , or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.

AB68-SSA1,2994 Section 2994. 632.796 of the statutes is created to read:

AB68-SSA1,1353,2 632.796 Drug cost report. (1) Definition. In this section, “disability insurance policy” has the meaning given in s. 632.895 (1) (a).