SB45-SSA2-SA4,141,442. Medical condition, including both physical and mental illnesses. SB45-SSA2-SA4,141,553. Claims experience. SB45-SSA2-SA4,141,664. Receipt of health care. SB45-SSA2-SA4,141,775. Medical history. SB45-SSA2-SA4,141,886. Genetic information. SB45-SSA2-SA4,141,1097. Evidence of insurability, including conditions arising out of acts of domestic 10violence. SB45-SSA2-SA4,141,1912(b) An insurer offering an individual health benefit plan or a self-insured 13health plan may not require any individual, as a condition of enrollment or 14continued enrollment under the plan, to pay, on the basis of any health status-15related factor under par. (a) with respect to the individual or a dependent of the 16individual, a premium or contribution or a deductible, copayment, or coinsurance 17amount that is greater than the premium or contribution or deductible, copayment, 18or coinsurance amount, respectively, for an otherwise similarly situated individual 19enrolled under the plan. SB45-SSA2-SA4,141,2320(c) Nothing in this subsection prevents an insurer offering an individual 21health benefit plan or a self-insured health plan from establishing premium 22discounts or rebates or modifying otherwise applicable cost sharing in return for 23adherence to programs of health promotion and disease prevention. SB45-SSA2-SA4,142,3
1(4) Premium rate variation. A health benefit plan offered on the individual 2or small employer market or a self-insured health plan may vary premium rates for 3a specific plan based only on the following considerations: SB45-SSA2-SA4,142,44(a) Whether the policy or plan covers an individual or a family. SB45-SSA2-SA4,142,55(b) Rating area in the state, as established by the commissioner. SB45-SSA2-SA4,142,86(c) Age, except that the rate may not vary by more than 3 to 1 for adults over 7the age groups and the age bands shall be consistent with recommendations of the 8National Association of Insurance Commissioners. SB45-SSA2-SA4,142,99(d) Tobacco use, except that the rate may not vary by more than 1.5 to 1. SB45-SSA2-SA4,142,1410(5) Statewide risk pool. An insurer offering a health benefit plan may not 11segregate enrollees into risk pools other than a single statewide risk pool for the 12individual market and a single statewide risk pool for the small employer market or 13a single statewide risk pool that combines the individual and small employer 14markets. SB45-SSA2-SA4,142,1615(6) Annual and lifetime limits. An individual or group health benefit plan 16or a self-insured health plan may not establish any of the following: SB45-SSA2-SA4,142,1817(a) Lifetime limits on the dollar value of benefits for an enrollee or a 18dependent of an enrollee under the plan. SB45-SSA2-SA4,142,2019(b) Annual limits on the dollar value of benefits for an enrollee or a dependent 20of an enrollee under the plan. SB45-SSA2-SA4,143,221(7) Cost sharing maximum. A health benefit plan offered on the individual 22or small employer market may not require an enrollee under the plan to pay more in
1cost sharing than the maximum amount calculated under 42 USC 18022 (c), 2including the annual indexing of the limits. SB45-SSA2-SA4,143,53(8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means 4the proportion, expressed as a percentage, of premium revenues spent by a health 5benefit plan on clinical services and quality improvement. SB45-SSA2-SA4,143,76(b) A health benefit plan on the individual or small employer market shall 7have a medical loss ratio of at least 80 percent. SB45-SSA2-SA4,143,98(c) A group health benefit plan other than one described under par. (b) shall 9have a medical loss ratio of at least 85 percent. SB45-SSA2-SA4,143,1310(9) Actuarial values of plan tiers. Any health benefit plan offered on the 11individual or small employer market shall provide a level of coverage that is 12designed to provide benefits that are actuarially equivalent to at least 60 percent of 13the full actuarial value of the benefits provided under the plan. SB45-SSA2-SA4,22114Section 221. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and 15amended to read: SB45-SSA2-SA4,143,2216632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group 17health benefit plan may, with respect to a participant or beneficiary under the plan, 18not impose a preexisting condition exclusion only if the exclusion relates to a 19condition, whether physical or mental, regardless of the cause of the condition, for 20which medical advice, diagnosis, care or treatment was recommended or received 21within the 6-month period ending on the participant’s or beneficiary’s enrollment 22date under the plan on a participant or beneficiary under the plan. SB45-SSA2-SA4,144,52632.746 (2) (a) An insurer offering a group health benefit plan may not treat 3impose a preexisting condition exclusion based on genetic information as a 4preexisting condition under sub. (1) without a diagnosis of a condition related to the 5information. SB45-SSA2-SA4,2246Section 224. 632.746 (2) (c), (d) and (e) of the statutes are repealed. SB45-SSA2-SA4,2268Section 226. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d). SB45-SSA2-SA4,2279Section 227. 632.746 (3) (d) 2. and 3. of the statutes are repealed. SB45-SSA2-SA4,22911Section 229. 632.746 (8) (a) (intro.) of the statutes is amended to read: SB45-SSA2-SA4,144,1512632.746 (8) (a) (intro.) A health maintenance organization that offers a group 13health benefit plan and that does not impose any preexisting condition exclusion 14under sub. (1) with respect to a particular coverage option may impose an affiliation 15period for that coverage option, but only if all of the following apply: SB45-SSA2-SA4,144,2317632.748 (2) An insurer offering a group health benefit plan may not require 18any individual, as a condition of enrollment or continued enrollment under the 19plan, to pay, on the basis of any health status-related factor with respect to the 20individual or a dependent of the individual, a premium or contribution or a 21deductible, copayment, or coinsurance amount that is greater than the premium or 22contribution or deductible, copayment, or coinsurance amount, respectively, for a 23an otherwise similarly situated individual enrolled under the plan. SB45-SSA2-SA4,145,22632.7495 (4) (b) The coverage has a term of not more than 12 3 months. SB45-SSA2-SA4,145,84632.7495 (4) (c) The coverage term aggregated with all consecutive periods of 5the insurer’s coverage of the insured by individual health benefit plan coverage not 6required to be renewed under this subsection does not exceed 18 6 months. For 7purposes of this paragraph, coverage periods are consecutive if there are no more 8than 63 days between the coverage periods. SB45-SSA2-SA4,145,1210632.7496 Coverage requirements for short-term plans. (1) Definition. 11In this section, “short-term, limited duration plan” means an individual health 12benefit plan described in s. 632.7495 (4). SB45-SSA2-SA4,145,1513(2) Guaranteed issue. An insurer that offers a short-term, limited duration 14plan shall accept every individual in this state who applies for coverage regardless 15of whether the individual has a preexisting condition. SB45-SSA2-SA4,145,2116(3) Prohibiting discrimination based on health status. (a) An insurer 17that offers a short-term, limited duration plan may not establish rules for the 18eligibility of any individual to enroll, or for the continued eligibility of any 19individual to remain enrolled, under a short-term, limited duration plan based on 20any of the following health status-related factors with respect to the individual or a 21dependent of the individual: SB45-SSA2-SA4,145,23232. Medical condition, including both physical and mental illnesses. SB45-SSA2-SA4,146,1
13. Claims experience. SB45-SSA2-SA4,146,224. Receipt of health care. SB45-SSA2-SA4,146,335. Medical history. SB45-SSA2-SA4,146,446. Genetic information. SB45-SSA2-SA4,146,657. Evidence of insurability, including conditions arising out of acts of domestic 6violence. SB45-SSA2-SA4,146,158(b) An insurer that offers a short-term, limited duration plan may not require 9any individual, as a condition of enrollment or continued enrollment under the 10short-term, limited duration plan, to pay, on the basis of any health status-related 11factor described under par. (a) with respect to the individual or a dependent of the 12individual, a premium or contribution or a deductible, copayment, or coinsurance 13amount that is greater than the premium or contribution or deductible, copayment, 14or coinsurance amount respectively for a similarly situated individual enrolled 15under the short-term, limited duration plan. SB45-SSA2-SA4,146,1816(4) Premium rate variation. An insurer that offers a short-term, limited 17duration plan may vary premium rates for a specific short-term, limited duration 18plan based only on the following considerations: SB45-SSA2-SA4,146,2019(a) Whether the short-term, limited duration plan covers an individual or a 20family. SB45-SSA2-SA4,146,2121(b) Rating area in the state, as established by the commissioner. SB45-SSA2-SA4,147,222(c) Age, except that the rate may not vary by more than 3 to 1 for adults over
1the age groups and the age bands shall be consistent with recommendations of the 2National Association of Insurance Commissioners. SB45-SSA2-SA4,147,33(d) Tobacco use, except that the rate may not vary by more than 1.5 to 1. SB45-SSA2-SA4,147,54(5) Annual and lifetime limits. A short-term, limited duration plan may 5not establish any of the following: SB45-SSA2-SA4,147,76(a) Lifetime limits on the dollar value of benefits for an enrollee or a 7dependent of an enrollee under the short-term, limited duration plan. SB45-SSA2-SA4,147,108(b) Limits on the dollar value of benefits for an enrollee or a dependent of an 9enrollee under the short-term, limited duration plan for a term of coverage or for 10the aggregate duration of the short-term, limited duration plan. SB45-SSA2-SA4,147,1312632.7498 Special enrollment period for pregnancy. (1) Definitions. In 13this section: SB45-SSA2-SA4,147,1414(a) “Health benefit plan” has the meaning given in s. 632.745 (11). SB45-SSA2-SA4,147,1515(b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). SB45-SSA2-SA4,147,2316(2) Special enrollment period. A health benefit plan or self-insured health 17plan shall allow a pregnant individual who is eligible for coverage under the plan, 18and any individual who is eligible for coverage under the plan because of a 19relationship to the pregnant individual, to enroll for coverage at any time during the 20pregnancy. The coverage shall begin no later than the first day of the first calendar 21month in which the pregnant individual receives medical verification of the 22pregnancy, except that a pregnant individual may direct coverage to begin on the 23first day of any month occurring during the pregnancy. SB45-SSA2-SA4,148,4
1(3) Notice. An insurer offering group health insurance coverage in this state 2shall provide notice of the special enrollment period under sub. (2) at or before the 3time an individual is initially offered the opportunity to enroll for coverage under 4the plan. SB45-SSA2-SA4,2355Section 235. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to 6read: SB45-SSA2-SA4,148,147632.76 (2) (a) No claim for loss incurred or disability commencing after 2 8years from the date of issue of the policy may be reduced or denied on the ground 9that a disease or physical condition existed prior to the effective date of coverage, 10unless the condition was excluded from coverage by name or specific description by 11a provision effective on the date of loss. This paragraph does not apply to a group 12health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746, a 13disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health 14plan, as defined in s. 632.85 (1) (c). SB45-SSA2-SA4,148,2015(ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability 16commencing after 12 months from the date of issue of under an individual disability 17insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the 18ground that a disease or physical condition existed prior to the effective date of 19coverage, unless the condition was excluded from coverage by name or specific 20description by a provision effective on the date of the loss. SB45-SSA2-SA4,149,4212. Except as provided in subd. 3., an An individual disability insurance policy, 22as defined in s. 632.895 (1) (a), other than a short-term policy limited duration plan 23subject to s. 632.7495 (4) and (5), may not define a preexisting condition more
1restrictively than a condition that was present before the date of enrollment for the 2coverage, whether physical or mental, regardless of the cause of the condition, for 3which and regardless of whether medical advice, diagnosis, care, or treatment was 4recommended or received within 12 months before the effective date of coverage. SB45-SSA2-SA4,2365Section 236. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read: SB45-SSA2-SA4,149,86632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 7632.7495 (5), all of the following apply to an individual disability insurance policy 8that is a short-term policy, limited duration plan subject to s. 632.7495 (4) and (5): SB45-SSA2-SA4,2379Section 237. 632.76 (2) (ac) 3. b. of the statutes is amended to read: SB45-SSA2-SA4,149,1510632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a 11may not impose any preexisting condition exclusion may be imposed by the 12aggregate of the insured’s consecutive periods of coverage under the insurer’s 13individual disability insurance policies that are short-term policies subject to s. 14632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are 15consecutive if there are no more than 63 days between the coverage periods. SB45-SSA2-SA4,150,517632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the 18same policy form and for the same premium as it originally offered in the most 19recent enrollment period, subject only to the medical underwriting used in that 20enrollment period. Unless otherwise prescribed by rule, the insurer may apply 21deductibles, preexisting condition limitations, waiting periods, or other limits only 22to the extent that they would have been applicable had coverage been extended at 23the time of the most recent enrollment period and with credit for the satisfaction or
1partial satisfaction of similar provisions under the liquidated insurer’s policy or 2plan. The insurer may exclude coverage of claims that are payable by a solvent 3insurer under insolvency coverage required by the commissioner or by the 4insurance regulator of another jurisdiction. Coverage shall be effective on the date 5that the liquidated insurer’s coverage terminates. SB45-SSA2-SA4,150,87632.848 Exemption from prior authorization requirements. (1) In this 8section: SB45-SSA2-SA4,150,119(a) “Evaluation period” means the period of time established by the 10commissioner by rule that is used to evaluate whether a health care provider 11qualifies for an exemption from obtaining prior authorizations under sub. (2). SB45-SSA2-SA4,150,1212(b) “Health benefit plan” has the meaning given in s. 632.745 (11). SB45-SSA2-SA4,150,1313(c) “Health care item or service” includes all of the following: SB45-SSA2-SA4,150,14141. Prescription drugs. SB45-SSA2-SA4,150,15152. Laboratory testing. SB45-SSA2-SA4,150,16163. Medical equipment. SB45-SSA2-SA4,150,17174. Medical supplies. SB45-SSA2-SA4,150,1818(d) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).
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