Amendment AA16-ASA2-AB50

AB50-ASA2-AA16,24 Section 24. 632.895 (6) (b) of the statutes is created to read:

AB50-ASA2-AA16,24,23 632.895 (6) (b) 1. In this paragraph:

AB50-ASA2-AA16,25,3 a. “Cost sharing” means the total of any deductible, copayment, or coinsurance amounts imposed on a person covered under a disability insurance policy or self-insured health plan.

AB50-ASA2-AA16,25,4 b. “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50-ASA2-AA16,25,7 2. Every disability insurance policy and self-insured health plan that covers insulin and imposes cost sharing on prescription drugs may not impose cost sharing on insulin in an amount that exceeds $35 for a one-month supply of insulin.

AB50-ASA2-AA16,25,11 3. Nothing in this paragraph prohibits a disability insurance policy or self- insured health plan from imposing cost sharing on insulin in an amount less than the amount specified under subd. 2. Nothing in this paragraph requires a disability insurance policy or self-insured health plan to impose any cost sharing on insulin.

AB50-ASA2-AA16,9423 Section 9423. Effective dates; Insurance.

AB50-ASA2-AA16,25,16 (1) Cost-sharing cap on insulin. The treatment of ss. 609.83 and 632.895 (6) (title), the renumbering and amendment of s. 632.895 (6), and the creation of s. 632.895 (6) (b) take effect on the first day of the 4th month beginning after publication.”.

AB50-ASA2-AA16,25,17 17. At the appropriate places, insert all of the following:

AB50-ASA2-AA16,25,18 “Section 25. 40.51 (8) of the statutes is amended to read:

AB50-ASA2-AA16,25,23 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.722, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.

AB50-ASA2-AA16,26 Section 26. 40.51 (8m) of the statutes is amended to read:

AB50-ASA2-AA16,26,5 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.722, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.885, 632.89, and 632.895 (11) to (17).

AB50-ASA2-AA16,27 Section 27. 66.0137 (4) of the statutes is amended to read:

AB50-ASA2-AA16,26,13 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

AB50-ASA2-AA16,28 Section 28. 120.13 (2) (g) of the statutes is amended to read:

AB50-ASA2-AA16,26,18 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

AB50-ASA2-AA16,29 Section 29. 185.983 (1) (intro.) of the statutes is amended to read:

AB50-ASA2-AA16,27,3 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (2) to (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association shall:

AB50-ASA2-AA16,30 Section 30. 609.83 of the statutes is amended to read:

AB50-ASA2-AA16,27,8 609.83 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).

AB50-ASA2-AA16,31 Section 31. 632.862 of the statutes is created to read:

AB50-ASA2-AA16,27,11 632.862 Application of prescription drug payments. (1) Definitions. In this section:

AB50-ASA2-AA16,27,12 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

AB50-ASA2-AA16,27,13 (b) “Brand name drug” means any of the following:

AB50-ASA2-AA16,27,15 1. A prescription drug that contains a brand name and that has no generic equivalent.

AB50-ASA2-AA16,27,20 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or self-insured health plan or authorization from a physician to obtain the prescription drug under the disability insurance policy or self-insured health plan.

AB50-ASA2-AA16,27,21 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB50-ASA2-AA16,27,22 (d) “Prescription drug” has the meaning given in s. 450.01 (20).

AB50-ASA2-AA16,28,2 (e) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

AB50-ASA2-AA16,28,8 (2) Application of discounts. A disability insurance policy that offers a prescription drug benefit or a self-insured health plan shall apply to any calculation of an out-of-pocket maximum amount and to any deductible of the disability insurance policy or self-insured health plan for an enrollee the amount that any discount provided by the manufacturer of a brand name drug reduces the cost sharing amount charged to the enrollee for that brand name drug.

AB50-ASA2-AA16,9323 Section 9323. Initial applicability; Insurance.

AB50-ASA2-AA16,28,10 (1) Application of manufacturer discounts.

AB50-ASA2-AA16,28,16 (a) For policies and plans containing provisions inconsistent with the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862, the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862 first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

AB50-ASA2-AA16,28,23 (b) For policies or plans that are affected by a collective bargaining agreement containing provisions inconsistent with the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862, the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862 first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is newly established, extended, modified, or renewed, whichever is later.

AB50-ASA2-AA16,9423 Section 9423. Effective dates; Insurance.

AB50-ASA2-AA16,29,5 (1) Application of manufacturer discounts. The treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862 and Section 9323 (1) take effect on the first day of the 4th month beginning after publication.”.

AB50-ASA2-AA16,29,6 18. At the appropriate places, insert all of the following:

AB50-ASA2-AA16,29,7 “Section 9216. Fiscal changes; Administration.

AB50-ASA2-AA16,29,13 (1) Board on aging and long-term care medigap helpline. In the schedule under s. 20.005 (3) for the appropriation to the board on aging and long- term care under s. 20.432 (1) (kb), the dollar amount for fiscal year 2025-26 is increased by $100,600 and the dollar amount for fiscal year 2026-27 is increased by $122,000 to support telephone counseling services provided under s. 16.009 (2) (j) for individuals seeing information on medicare supplemental insurance policies.”.

AB50-ASA2-AA16,29,14 19. At the appropriate places, insert all of the following:

AB50-ASA2-AA16,29,15 “Section 32. 609.712 of the statutes is created to read:

AB50-ASA2-AA16,29,18 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB50-ASA2-AA16,33 Section 33. 609.847 of the statutes is created to read:

AB50-ASA2-AA16,29,22 609.847 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.

AB50-ASA2-AA16,34 Section 34. 625.12 (1) (a) of the statutes is amended to read:

AB50-ASA2-AA16,30,2 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB50-ASA2-AA16,35 Section 35. 625.12 (1) (e) of the statutes is amended to read:

AB50-ASA2-AA16,30,5 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB50-ASA2-AA16,36 Section 36. 625.12 (2) of the statutes is amended to read:

AB50-ASA2-AA16,30,15 625.12 (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).

AB50-ASA2-AA16,37 Section 37. 625.15 (1) of the statutes is amended to read:

AB50-ASA2-AA16,31,2 625.15 (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.

AB50-ASA2-AA16,38 Section 38. 628.34 (3) (a) of the statutes is amended to read:

AB50-ASA2-AA16,31,11 628.34 (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, and 632.748. 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.

AB50-ASA2-AA16,39 Section 39. 632.728 of the statutes is created to read:

AB50-ASA2-AA16,31,14 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB50-ASA2-AA16,31,16 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB50-ASA2-AA16,31,17 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB50-ASA2-AA16,31,18 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50-ASA2-AA16,32,2 (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 the sexual orientation, the gender identity, or any preexisting condition of any individual or employee who will be covered by the plan. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

AB50-ASA2-AA16,32,6 (b) The commissioner shall establish a statewide open enrollment period that is no shorter than 30 days, during which every individual health benefit plan shall allow individuals, including individuals who do not have coverage, to enroll in coverage.

AB50-ASA2-AA16,32,11 (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:

AB50-ASA2-AA16,32,12 1. Health status.

AB50-ASA2-AA16,32,13 2. Medical condition, including both physical and mental illnesses.

AB50-ASA2-AA16,32,14 3. Claims experience.

AB50-ASA2-AA16,32,15 4. Receipt of health care.

AB50-ASA2-AA16,32,16 5. Medical history.

AB50-ASA2-AA16,32,17 6. Genetic information.

AB50-ASA2-AA16,32,19 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB50-ASA2-AA16,32,20 8. Disability.

AB50-ASA2-AA16,33,5 (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 an otherwise similarly situated individual enrolled under the plan.

AB50-ASA2-AA16,33,9 (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.

AB50-ASA2-AA16,33,12 (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:

AB50-ASA2-AA16,33,13 (a) Whether the policy or plan covers an individual or a family.

AB50-ASA2-AA16,33,14 (b) Rating area in the state, as established by the commissioner.

AB50-ASA2-AA16,33,17 (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.

AB50-ASA2-AA16,33,18 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB50-ASA2-AA16,33,23 (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.

AB50-ASA2-AA16,34,2 (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:

AB50-ASA2-AA16,34,4 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB50-ASA2-AA16,34,6 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB50-ASA2-AA16,34,10 (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.

AB50-ASA2-AA16,34,13 (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.

AB50-ASA2-AA16,34,15 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB50-ASA2-AA16,34,17 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB50-ASA2-AA16,34,21 (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.

AB50-ASA2-AA16,40 Section 40. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB50-ASA2-AA16,35,7 632.746 (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.