AB50-ASA2-AA8,26,13766.0137 (4) Self-insured health plans. If a city, including a 1st class city, 8or a village provides health care benefits under its home rule power, or if a town 9provides health care benefits, to its officers and employees on a self-insured basis, 10the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 11632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 12632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4) to (6), 632.885, 632.89, 13632.895 (9) to (17), 632.896, and 767.513 (4). AB50-ASA2-AA8,2114Section 21. 120.13 (2) (g) of the statutes is amended to read: AB50-ASA2-AA8,26,1815120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 1649.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and 17(b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 18632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4). AB50-ASA2-AA8,2219Section 22. 185.983 (1) (intro.) of the statutes is amended to read: AB50-ASA2-AA8,27,320185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a 21cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 22646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 23601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 24631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795,
1632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (2) to (6), 2632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 3620, 630, 635, 645, and 646, but the sponsoring association shall: AB50-ASA2-AA8,27,85609.83 Coverage of drugs and devices; application of payments. 6Limited service health organizations, preferred provider plans, and defined 7network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and 8(16v). AB50-ASA2-AA8,27,1110632.862 Application of prescription drug payments. (1) Definitions. 11In this section: AB50-ASA2-AA8,27,1212(a) “Brand name” has the meaning given in s. 450.12 (1) (a). AB50-ASA2-AA8,27,1313(b) “Brand name drug” means any of the following: AB50-ASA2-AA8,27,15141. A prescription drug that contains a brand name and that has no generic 15equivalent. AB50-ASA2-AA8,27,20162. A prescription drug that contains a brand name and has a generic 17equivalent but for which the enrollee has received prior authorization from the 18insurer offering the disability insurance policy or self-insured health plan or 19authorization from a physician to obtain the prescription drug under the disability 20insurance policy or self-insured health plan. AB50-ASA2-AA8,27,2121(c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a). AB50-ASA2-AA8,27,2222(d) “Prescription drug” has the meaning given in s. 450.01 (20). AB50-ASA2-AA8,28,2
1(e) “Self-insured health plan” means a self-insured health plan of the state or 2a county, city, village, town, or school district. AB50-ASA2-AA8,28,83(2) Application of discounts. A disability insurance policy that offers a 4prescription drug benefit or a self-insured health plan shall apply to any calculation 5of an out-of-pocket maximum amount and to any deductible of the disability 6insurance policy or self-insured health plan for an enrollee the amount that any 7discount provided by the manufacturer of a brand name drug reduces the cost 8sharing amount charged to the enrollee for that brand name drug. AB50-ASA2-AA8,28,1010(1) Application of manufacturer discounts. AB50-ASA2-AA8,28,1611(a) For policies and plans containing provisions inconsistent with the 12treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 13609.83, and 632.862, the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) 14(g), 185.983 (1) (intro.), 609.83, and 632.862 first applies to policy or plan years 15beginning on January 1 of the year following the year in which this paragraph takes 16effect, except as provided in par. (b). AB50-ASA2-AA8,28,2317(b) For policies or plans that are affected by a collective bargaining agreement 18containing provisions inconsistent with the treatment of ss. 40.51 (8) and (8m), 1966.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862, the treatment of 20ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 21632.862 first applies to policy or plan years beginning on the effective date of this 22paragraph or on the day on which the collective bargaining agreement is newly 23established, extended, modified, or renewed, whichever is later. AB50-ASA2-AA8,29,52(1) Application of manufacturer discounts. The treatment of ss. 40.51 (8) 3and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.83, and 632.862 and 4Section 9323 (1) take effect on the first day of the 4th month beginning after 5publication.”. AB50-ASA2-AA8,29,147“Section 25. 20.005 (3) (schedule) of the statutes: at the appropriate place, 8insert the following amounts for the purposes indicated: AB50-ASA2-AA8,2615Section 26. 20.115 (4) (aq) of the statutes is created to read: AB50-ASA2-AA8,29,181620.115 (4) (aq) Food security and Wisconsin products grants. As a continuing 17appropriation, the amounts in the schedule for food security and Wisconsin 18products grants under s. 93.62. AB50-ASA2-AA8,30,22093.62 Food security and Wisconsin products grant program. The 21department may award grants from the appropriation under s. 20.115 (4) (aq) to 22nonprofit food banks, nonprofit food pantries, and other nonprofit organizations
1that provide food assistance for the purpose of purchasing food products that are 2made or grown in this state.”. AB50-ASA2-AA8,30,75609.712 Essential health benefits; preventive services. Defined 6network plans and preferred provider plans are subject to s. 632.895 (13m) and 7(14m). AB50-ASA2-AA8,30,119609.847 Preexisting condition discrimination and certain benefit 10limits prohibited. Limited service health organizations, preferred provider 11plans, and defined network plans are subject to s. 632.728. AB50-ASA2-AA8,3012Section 30. 625.12 (1) (a) of the statutes is amended to read: AB50-ASA2-AA8,30,1413625.12 (1) (a) Past and prospective loss and expense experience within and 14outside of this state, except as provided in s. 632.728. AB50-ASA2-AA8,3115Section 31. 625.12 (1) (e) of the statutes is amended to read: AB50-ASA2-AA8,30,1716625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, 17including the judgment of technical personnel. AB50-ASA2-AA8,31,419625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, 20risks may be classified in any reasonable way for the establishment of rates and 21minimum premiums, except that no classifications may be based on race, color, 22creed or national origin, and classifications in automobile insurance may not be 23based on physical condition or developmental disability as defined in s. 51.01 (5).
1Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified 2for individual risks in accordance with rating plans or schedules that establish 3reasonable standards for measuring probable variations in hazards, expenses, or 4both. Rates may also be modified for individual risks under s. 625.13 (2). AB50-ASA2-AA8,31,136625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may 7itself establish rates and supplementary rate information for one or more market 8segments based on the factors in s. 625.12 and, if the rates are for motor vehicle 9liability insurance, subject to s. 632.365, or the insurer may use rates and 10supplementary rate information prepared by a rate service organization, with 11average expense factors determined by the rate service organization or with such 12modification for its own expense and loss experience as the credibility of that 13experience allows. AB50-ASA2-AA8,3414Section 34. 628.34 (3) (a) of the statutes is amended to read: AB50-ASA2-AA8,31,2215628.34 (3) (a) No insurer may unfairly discriminate among policyholders by 16charging different premiums or by offering different terms of coverage except on the 17basis of classifications related to the nature and the degree of the risk covered or the 18expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746, and 632.748. 19Rates are not unfairly discriminatory if they are averaged broadly among persons 20insured under a group, blanket or franchise policy, and terms are not unfairly 21discriminatory merely because they are more favorable than in a similar individual 22policy. AB50-ASA2-AA8,32,2
1632.728 Coverage of persons with preexisting conditions; guaranteed 2issue; benefit limits. (1) Definitions. In this section: AB50-ASA2-AA8,32,43(a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar 4charges. AB50-ASA2-AA8,32,55(b) “Health benefit plan” has the meaning given in s. 632.745 (11). AB50-ASA2-AA8,32,66(c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). AB50-ASA2-AA8,32,137(2) Guaranteed issue. (a) Every individual health benefit plan shall accept 8every individual in this state who, and every group health benefit plan shall accept 9every employer in this state that, applies for coverage, regardless of the sexual 10orientation, the gender identity, or any preexisting condition of any individual or 11employee who will be covered by the plan. A health benefit plan may restrict 12enrollment in coverage described in this paragraph to open or special enrollment 13periods. AB50-ASA2-AA8,32,1714(b) The commissioner shall establish a statewide open enrollment period that 15is no shorter than 30 days, during which every individual health benefit plan shall 16allow individuals, including individuals who do not have coverage, to enroll in 17coverage. AB50-ASA2-AA8,32,2218(3) Prohibiting discrimination based on health status. (a) An 19individual health benefit plan or a self-insured health plan may not establish rules 20for the eligibility of any individual to enroll, or for the continued eligibility of any 21individual to remain enrolled, under the plan based on any of the following health 22status-related factors in relation to the individual or a dependent of the individual: AB50-ASA2-AA8,32,23231. Health status. AB50-ASA2-AA8,33,1
12. Medical condition, including both physical and mental illnesses. AB50-ASA2-AA8,33,223. Claims experience. AB50-ASA2-AA8,33,334. Receipt of health care. AB50-ASA2-AA8,33,445. Medical history. AB50-ASA2-AA8,33,556. Genetic information. AB50-ASA2-AA8,33,767. Evidence of insurability, including conditions arising out of acts of domestic 7violence. AB50-ASA2-AA8,33,169(b) An insurer offering an individual health benefit plan or a self-insured 10health plan may not require any individual, as a condition of enrollment or 11continued enrollment under the plan, to pay, on the basis of any health status-12related factor under par. (a) with respect to the individual or a dependent of the 13individual, a premium or contribution or a deductible, copayment, or coinsurance 14amount that is greater than the premium or contribution or deductible, copayment, 15or coinsurance amount, respectively, for an otherwise similarly situated individual 16enrolled under the plan. AB50-ASA2-AA8,33,2017(c) Nothing in this subsection prevents an insurer offering an individual 18health benefit plan or a self-insured health plan from establishing premium 19discounts or rebates or modifying otherwise applicable cost sharing in return for 20adherence to programs of health promotion and disease prevention. AB50-ASA2-AA8,33,2321(4) Premium rate variation. A health benefit plan offered on the individual 22or small employer market or a self-insured health plan may vary premium rates for 23a specific plan based only on the following considerations: AB50-ASA2-AA8,34,1
1(a) Whether the policy or plan covers an individual or a family. AB50-ASA2-AA8,34,22(b) Rating area in the state, as established by the commissioner. AB50-ASA2-AA8,34,53(c) Age, except that the rate may not vary by more than 3 to 1 for adults over 4the age groups and the age bands shall be consistent with recommendations of the 5National Association of Insurance Commissioners. AB50-ASA2-AA8,34,66(d) Tobacco use, except that the rate may not vary by more than 1.5 to 1. AB50-ASA2-AA8,34,117(5) Statewide risk pool. An insurer offering a health benefit plan may not 8segregate enrollees into risk pools other than a single statewide risk pool for the 9individual market and a single statewide risk pool for the small employer market or 10a single statewide risk pool that combines the individual and small employer 11markets. AB50-ASA2-AA8,34,1312(6) Annual and lifetime limits. An individual or group health benefit plan 13or a self-insured health plan may not establish any of the following: AB50-ASA2-AA8,34,1514(a) Lifetime limits on the dollar value of benefits for an enrollee or a 15dependent of an enrollee under the plan. AB50-ASA2-AA8,34,1716(b) Annual limits on the dollar value of benefits for an enrollee or a dependent 17of an enrollee under the plan. AB50-ASA2-AA8,34,2118(7) Cost sharing maximum. A health benefit plan offered on the individual 19or small employer market may not require an enrollee under the plan to pay more in 20cost sharing than the maximum amount calculated under 42 USC 18022 (c), 21including the annual indexing of the limits. AB50-ASA2-AA8,35,222(8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means
1the proportion, expressed as a percentage, of premium revenues spent by a health 2benefit plan on clinical services and quality improvement. AB50-ASA2-AA8,35,43(b) A health benefit plan on the individual or small employer market shall 4have a medical loss ratio of at least 80 percent. AB50-ASA2-AA8,35,65(c) A group health benefit plan other than one described under par. (b) shall 6have a medical loss ratio of at least 85 percent. AB50-ASA2-AA8,35,107(9) Actuarial values of plan tiers. Any health benefit plan offered on the 8individual or small employer market shall provide a level of coverage that is 9designed to provide benefits that are actuarially equivalent to at least 60 percent of 10the full actuarial value of the benefits provided under the plan. AB50-ASA2-AA8,3611Section 36. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and 12amended to read: AB50-ASA2-AA8,35,1913632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group 14health benefit plan may, with respect to a participant or beneficiary under the plan, 15not impose a preexisting condition exclusion only if the exclusion relates to a 16condition, whether physical or mental, regardless of the cause of the condition, for 17which medical advice, diagnosis, care or treatment was recommended or received 18within the 6-month period ending on the participant’s or beneficiary’s enrollment 19date under the plan on a participant or beneficiary under the plan. AB50-ASA2-AA8,3821Section 38. 632.746 (2) (a) of the statutes is amended to read: AB50-ASA2-AA8,36,222632.746 (2) (a) An insurer offering a group health benefit plan may not treat 23impose a preexisting condition exclusion based on genetic information as a
1preexisting condition under sub. (1) without a diagnosis of a condition related to the 2information. AB50-ASA2-AA8,393Section 39. 632.746 (2) (c), (d) and (e) of the statutes are repealed. AB50-ASA2-AA8,415Section 41. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d). AB50-ASA2-AA8,426Section 42. 632.746 (3) (d) 2. and 3. of the statutes are repealed. AB50-ASA2-AA8,448Section 44. 632.746 (8) (a) (intro.) of the statutes is amended to read: AB50-ASA2-AA8,36,129632.746 (8) (a) (intro.) A health maintenance organization that offers a group 10health benefit plan and that does not impose any preexisting condition exclusion 11under sub. (1) with respect to a particular coverage option may impose an affiliation 12period for that coverage option, but only if all of the following apply:
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