AB50-ASA2-AA16,34,107(7) Cost sharing maximum. A health benefit plan offered on the individual 8or small employer market may not require an enrollee under the plan to pay more in 9cost sharing than the maximum amount calculated under 42 USC 18022 (c), 10including the annual indexing of the limits. AB50-ASA2-AA16,34,1311(8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means 12the proportion, expressed as a percentage, of premium revenues spent by a health 13benefit plan on clinical services and quality improvement. AB50-ASA2-AA16,34,1514(b) A health benefit plan on the individual or small employer market shall 15have a medical loss ratio of at least 80 percent. AB50-ASA2-AA16,34,1716(c) A group health benefit plan other than one described under par. (b) shall 17have a medical loss ratio of at least 85 percent. AB50-ASA2-AA16,34,2118(9) Actuarial values of plan tiers. Any health benefit plan offered on the 19individual or small employer market shall provide a level of coverage that is 20designed to provide benefits that are actuarially equivalent to at least 60 percent of 21the full actuarial value of the benefits provided under the plan. AB50-ASA2-AA16,4022Section 40. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and 23amended to read: AB50-ASA2-AA16,35,7
1632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group 2health benefit plan may, with respect to a participant or beneficiary under the plan, 3not impose a preexisting condition exclusion only if the exclusion relates to a 4condition, whether physical or mental, regardless of the cause of the condition, for 5which medical advice, diagnosis, care or treatment was recommended or received 6within the 6-month period ending on the participant’s or beneficiary’s enrollment 7date under the plan on a participant or beneficiary under the plan. AB50-ASA2-AA16,35,1310632.746 (2) (a) An insurer offering a group health benefit plan may not treat 11impose a preexisting condition exclusion based on genetic information as a 12preexisting condition under sub. (1) without a diagnosis of a condition related to the 13information. AB50-ASA2-AA16,4314Section 43. 632.746 (2) (c), (d) and (e) of the statutes are repealed. AB50-ASA2-AA16,4516Section 45. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d). AB50-ASA2-AA16,4617Section 46. 632.746 (3) (d) 2. and 3. of the statutes are repealed. AB50-ASA2-AA16,4819Section 48. 632.746 (8) (a) (intro.) of the statutes is amended to read: AB50-ASA2-AA16,35,2320632.746 (8) (a) (intro.) A health maintenance organization that offers a group 21health benefit plan and that does not impose any preexisting condition exclusion 22under sub. (1) with respect to a particular coverage option may impose an affiliation 23period for that coverage option, but only if all of the following apply: AB50-ASA2-AA16,36,82632.748 (2) An insurer offering a group health benefit plan may not require 3any individual, as a condition of enrollment or continued enrollment under the 4plan, to pay, on the basis of any health status-related factor with respect to the 5individual or a dependent of the individual, a premium or contribution or a 6deductible, copayment, or coinsurance amount that is greater than the premium or 7contribution or deductible, copayment, or coinsurance amount, respectively, for a 8an otherwise similarly situated individual enrolled under the plan. AB50-ASA2-AA16,509Section 50. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to 10read: AB50-ASA2-AA16,36,1811632.76 (2) (a) No claim for loss incurred or disability commencing after 2 12years from the date of issue of the policy may be reduced or denied on the ground 13that a disease or physical condition existed prior to the effective date of coverage, 14unless the condition was excluded from coverage by name or specific description by 15a provision effective on the date of loss. This paragraph does not apply to a group 16health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746, a 17disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health 18plan, as defined in s. 632.85 (1) (c). AB50-ASA2-AA16,37,219(ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability 20commencing after 12 months from the date of issue of under an individual disability 21insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the 22ground that a disease or physical condition existed prior to the effective date of
1coverage, unless the condition was excluded from coverage by name or specific 2description by a provision effective on the date of the loss. AB50-ASA2-AA16,37,932. Except as provided in subd. 3., an An individual disability insurance policy, 4as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 5(4) and (5), may not define a preexisting condition more restrictively than a 6condition that was present before the date of enrollment for the coverage, whether 7physical or mental, regardless of the cause of the condition, for which and 8regardless of whether medical advice, diagnosis, care, or treatment was 9recommended or received within 12 months before the effective date of coverage. AB50-ASA2-AA16,37,2211632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the 12same policy form and for the same premium as it originally offered in the most 13recent enrollment period, subject only to the medical underwriting used in that 14enrollment period. Unless otherwise prescribed by rule, the insurer may apply 15deductibles, preexisting condition limitations, waiting periods, or other limits only 16to the extent that they would have been applicable had coverage been extended at 17the time of the most recent enrollment period and with credit for the satisfaction or 18partial satisfaction of similar provisions under the liquidated insurer’s policy or 19plan. The insurer may exclude coverage of claims that are payable by a solvent 20insurer under insolvency coverage required by the commissioner or by the 21insurance regulator of another jurisdiction. Coverage shall be effective on the date 22that the liquidated insurer’s coverage terminates. AB50-ASA2-AA16,38,7
1632.895 (8) (d) Coverage is required under this subsection despite whether 2the woman shows any symptoms of breast cancer. Except as provided in pars. (b), 3(c), and (e), coverage under this subsection may only be subject to exclusions and 4limitations, including deductibles, copayments and restrictions on excessive 5charges, that are applied to other radiological examinations covered under the 6disability insurance policy. Coverage under this subsection may not be subject to 7any deductibles, copayments, or coinsurance. AB50-ASA2-AA16,38,109632.895 (13m) Preventive services. (a) In this section, “self-insured health 10plan” has the meaning given in s. 632.85 (1) (c). AB50-ASA2-AA16,38,1311(b) Every disability insurance policy, except any disability insurance policy 12that is described in s. 632.745 (11) (b) 1. to 12., and every self-insured health plan 13shall provide coverage for all of the following preventive services: AB50-ASA2-AA16,38,14141. Mammography in accordance with sub. (8). AB50-ASA2-AA16,38,16152. Genetic breast cancer screening and counseling and preventive medication 16for adult women at high risk for breast cancer. AB50-ASA2-AA16,38,18173. Papanicolaou test for cancer screening for women 21 years of age or older 18with an intact cervix. AB50-ASA2-AA16,38,20194. Human papillomavirus testing for women who have attained the age of 30 20years but have not attained the age of 66 years. AB50-ASA2-AA16,38,21215. Colorectal cancer screening in accordance with sub. (16m). AB50-ASA2-AA16,39,2226. Annual tomography for lung cancer screening for adults who have attained
1the age of 55 years but have not attained the age of 80 years and who have health 2histories demonstrating a risk for lung cancer. AB50-ASA2-AA16,39,437. Skin cancer screening for individuals who have attained the age of 10 years 4but have not attained the age of 22 years. AB50-ASA2-AA16,39,658. Counseling for skin cancer prevention for adults who have attained the age 6of 18 years but have not attained the age of 25 years. AB50-ASA2-AA16,39,879. Abdominal aortic aneurysm screening for men who have attained the age of 865 years but have not attained the age of 75 years and who have ever smoked. AB50-ASA2-AA16,39,11910. Hypertension screening for adults and blood pressure testing for adults, 10for children under the age of 3 years who are at high risk for hypertension, and for 11children 3 years of age or older. AB50-ASA2-AA16,39,131211. Lipid disorder screening for minors 2 years of age or older, adults 20 years 13of age or older at high risk for lipid disorders, and all men 35 years of age or older. AB50-ASA2-AA16,39,161412. Aspirin therapy for cardiovascular health for adults who have attained the 15age of 55 years but have not attained the age of 80 years and for men who have 16attained the age of 45 years but have not attained the age of 55 years. AB50-ASA2-AA16,39,181713. Behavioral counseling for cardiovascular health for adults who are 18overweight or obese and who have risk factors for cardiovascular disease. AB50-ASA2-AA16,39,191914. Type II diabetes screening for adults with elevated blood pressure. AB50-ASA2-AA16,39,212015. Depression screening for minors 11 years of age or older and for adults 21when follow-up supports are available. AB50-ASA2-AA16,39,232216. Hepatitis B screening for minors at high risk for infection and adults at 23high risk for infection. AB50-ASA2-AA16,40,2
117. Hepatitis C screening for adults at high risk for infection and onetime 2hepatitis C screening for adults born in any year from 1945 to 1965. AB50-ASA2-AA16,40,6318. Obesity screening and management for all minors and adults with a body 4mass index indicating obesity, counseling and behavioral interventions for obese 5minors who are 6 years of age or older, and referral for intervention for obesity for 6adults with a body mass index of 30 kilograms per square meter or higher. AB50-ASA2-AA16,40,8719. Osteoporosis screening for all women 65 years of age or older and for 8women at high risk for osteoporosis under the age of 65 years. AB50-ASA2-AA16,40,9920. Immunizations in accordance with sub. (14). AB50-ASA2-AA16,40,121021. Anemia screening for individuals 6 months of age or older and iron 11supplements for individuals at high risk for anemia who have attained the age of 6 12months but have not attained the age of 12 months. AB50-ASA2-AA16,40,141322. Fluoride varnish for prevention of tooth decay for minors at the age of 14eruption of their primary teeth. AB50-ASA2-AA16,40,161523. Fluoride supplements for prevention of tooth decay for minors 6 months of 16age or older who do not have fluoride in their water source. AB50-ASA2-AA16,40,171724. Gonorrhea prophylaxis treatment for newborns. AB50-ASA2-AA16,40,181825. Health history and physical exams for prenatal visits and for minors. AB50-ASA2-AA16,40,201926. Length and weight measurements for newborns and height and weight 20measurements for minors. AB50-ASA2-AA16,40,222127. Head circumference and weight-for-length measurements for newborns 22and minors who have not attained the age of 3 years. AB50-ASA2-AA16,40,232328. Body mass index for minors 2 years of age or older. AB50-ASA2-AA16,41,2
129. Blood pressure measurements for minors 3 years of age or older and a 2blood pressure risk assessment at birth. AB50-ASA2-AA16,41,4330. Risk assessment and referral for oral health issues for minors who have 4attained the age of 6 months but have not attained the age of 7 years. AB50-ASA2-AA16,41,6531. Blood screening for newborns and minors who have not attained the age of 62 months. AB50-ASA2-AA16,41,7732. Screening for critical congenital health defects for newborns. AB50-ASA2-AA16,41,8833. Lead screenings in accordance with sub. (10). AB50-ASA2-AA16,41,10934. Metabolic and hemoglobin screening and screening for phenylketonuria, 10sickle cell anemia, and congenital hypothyroidism for minors including newborns. AB50-ASA2-AA16,41,121135. Tuberculin skin test based on risk assessment for minors one month of age 12or older. AB50-ASA2-AA16,41,141336. Tobacco counseling and cessation interventions for individuals who are 5 14years of age or older. AB50-ASA2-AA16,41,161537. Vision and hearing screening and assessment for minors including 16newborns. AB50-ASA2-AA16,41,181738. Sexually transmitted infection and human immunodeficiency virus 18counseling for sexually active minors. AB50-ASA2-AA16,41,211939. Risk assessment for sexually transmitted infection for minors who are 10 20years of age or older and screening for sexually transmitted infection for minors 21who are 16 years of age or older. AB50-ASA2-AA16,41,232240. Alcohol misuse screening and counseling for minors 11 years of age or 23older. AB50-ASA2-AA16,42,2
141. Autism screening for minors who have attained the age of 18 months but 2have not attained the age of 25 months. AB50-ASA2-AA16,42,3342. Developmental screening and surveillance for minors including newborns. AB50-ASA2-AA16,42,4443. Psychosocial and behavioral assessment for minors including newborns. AB50-ASA2-AA16,42,6544. Alcohol misuse screening and counseling for pregnant adults and a risk 6assessment for all adults. AB50-ASA2-AA16,42,8745. Fall prevention and counseling and preventive medication for fall 8prevention for community-dwelling adults 65 years of age or older. AB50-ASA2-AA16,42,9946. Screening and counseling for intimate partner violence for adult women. AB50-ASA2-AA16,42,121047. Well-woman visits for women who have attained the age of 18 years but 11have not attained the age of 65 years and well-woman visits for recommended 12preventive services, preconception care, and prenatal care. AB50-ASA2-AA16,42,141348. Counseling on, consultations with a trained provider on, and equipment 14rental for breastfeeding for pregnant and lactating women. AB50-ASA2-AA16,42,151549. Folic acid supplement for adult women with reproductive capacity. AB50-ASA2-AA16,42,161650. Iron deficiency anemia screening for pregnant and lactating women. AB50-ASA2-AA16,42,181751. Preeclampsia preventive medicine for pregnant adult women at high risk 18for preeclampsia. AB50-ASA2-AA16,42,201952. Low-dose aspirin after 12 weeks of gestation for pregnant women at high 20risk for miscarriage, preeclampsia, or clotting disorders. AB50-ASA2-AA16,42,212153. Screenings for hepatitis B and bacteriuria for pregnant women. AB50-ASA2-AA16,43,22254. Screening for gonorrhea for pregnant and sexually active females 24 years
1of age or younger and females older than 24 years of age who are at risk for 2infection. AB50-ASA2-AA16,43,5355. Screening for chlamydia for pregnant and sexually active females 24 years 4of age and younger and females older than 24 years of age who are at risk for 5infection. AB50-ASA2-AA16,43,7656. Screening for syphilis for pregnant women and adults who are at high risk 7for infection. AB50-ASA2-AA16,43,10857. Human immunodeficiency virus screening for adults who have attained 9the age of 15 years but have not attained the age of 66 years and individuals at high 10risk of infection who are younger than 15 years of age or older than 65 years of age. AB50-ASA2-AA16,43,111158. All contraceptives and services in accordance with sub. (17). AB50-ASA2-AA16,43,131259. Any services not already specified under this paragraph having an A or B 13rating in current recommendations from the U.S. preventive services task force.
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