Amendment SSA1-AB68

AB68-SSA1,1339,18 (8) Continuity of care. (a) In this subsection:

AB68-SSA1,1339,19 1. “Continuing care patient” means an individual who is any of the following:

AB68-SSA1,1339,21 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

AB68-SSA1,1339,23 b. Undergoing a course of institutional or inpatient care from a provider or facility.

AB68-SSA1,1339,25 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

AB68-SSA1,1340,2 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

AB68-SSA1,1340,4 e. Terminally ill and receiving treatment for the illness from a provider or facility.

AB68-SSA1,1340,5 2. “Serious and complex condition” means any of the following:

AB68-SSA1,1340,8 a. In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.

AB68-SSA1,1340,11 b. In the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital and requires specialized medical care over a prolonged period of time.

AB68-SSA1,1340,17 (b) If an enrollee is a continuing care patient and is obtaining items or services from a participating provider or facility and the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the participating provider or facility is terminated or the coverage of benefits that include the items or services provided by the participating provider or facility are terminated by the plan, the plan shall do all of the following:

AB68-SSA1,1340,20 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-SSA1,1340,22 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB68-SSA1,1341,4 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-SSA1,1341,8 (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-SSA1,2963 Section 2963. 609.713 of the statutes is created to read:

AB68-SSA1,1341,11 609.713 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB68-SSA1,2964 Section 2964. 609.719 of the statutes is created to read:

AB68-SSA1,1341,14 609.719 Telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

AB68-SSA1,2965 Section 2965 . 609.83 of the statutes is amended to read:

AB68-SSA1,1341,18 609.83 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, 632.862, and 632.895 (16t) and (16v).

AB68-SSA1,2966 Section 2966 . 609.83 of the statutes, as affected by 2021 Wisconsin Act .... (this act), section 2965, is amended to read:

AB68-SSA1,1341,23 609.83 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, 632.862, and 632.895 (6) (b), (16t), and (16v).

AB68-SSA1,2967 Section 2967. 609.847 of the statutes is created to read:

AB68-SSA1,1342,3 609.847 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-SSA1,2968 Section 2968. 625.12 (1) (a) of the statutes is amended to read:

AB68-SSA1,1342,6 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB68-SSA1,2969 Section 2969. 625.12 (1) (e) of the statutes is amended to read:

AB68-SSA1,1342,9 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB68-SSA1,2970 Section 2970. 625.12 (2) of the statutes is amended to read:

AB68-SSA1,1342,19 625.12 (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-SSA1,2971 Section 2971. 625.15 (1) of the statutes is amended to read:

AB68-SSA1,1343,3 625.15 (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-SSA1,2972 Section 2972 . 628.34 (3) (a) of the statutes is amended to read:

AB68-SSA1,1343,12 628.34 (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-SSA1,2973 Section 2973 . 628.34 (3) (a) of the statutes, as affected by 2021 Wisconsin Act .... (this act), is amended to read:

AB68-SSA1,1343,22 628.34 (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-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.