Amendment SA4-SSA2-SB45

SB45-SSA2-SA4,142,4 (a) Whether the policy or plan covers an individual or a family.

SB45-SSA2-SA4,142,5 (b) Rating area in the state, as established by the commissioner.

SB45-SSA2-SA4,142,8 (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.

SB45-SSA2-SA4,142,9 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB45-SSA2-SA4,142,14 (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.

SB45-SSA2-SA4,142,16 (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:

SB45-SSA2-SA4,142,18 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB45-SSA2-SA4,142,20 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB45-SSA2-SA4,143,2 (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.

SB45-SSA2-SA4,143,5 (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.

SB45-SSA2-SA4,143,7 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

SB45-SSA2-SA4,143,9 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

SB45-SSA2-SA4,143,13 (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.

SB45-SSA2-SA4,221 Section 221. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

SB45-SSA2-SA4,143,22 632.746 (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.

SB45-SSA2-SA4,222 Section 222. 632.746 (1) (b) of the statutes is repealed.

SB45-SSA2-SA4,223 Section 223. 632.746 (2) (a) of the statutes is amended to read:

SB45-SSA2-SA4,144,5 632.746 (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.

SB45-SSA2-SA4,224 Section 224. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

SB45-SSA2-SA4,225 Section 225. 632.746 (3) (a) of the statutes is repealed.

SB45-SSA2-SA4,226 Section 226. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

SB45-SSA2-SA4,227 Section 227. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

SB45-SSA2-SA4,228 Section 228. 632.746 (5) of the statutes is repealed.

SB45-SSA2-SA4,229 Section 229. 632.746 (8) (a) (intro.) of the statutes is amended to read:

SB45-SSA2-SA4,144,15 632.746 (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:

SB45-SSA2-SA4,230 Section 230. 632.748 (2) of the statutes is amended to read:

SB45-SSA2-SA4,144,23 632.748 (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 an otherwise similarly situated individual enrolled under the plan.

SB45-SSA2-SA4,231 Section 231. 632.7495 (4) (b) of the statutes is amended to read:

SB45-SSA2-SA4,145,2 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

SB45-SSA2-SA4,232 Section 232. 632.7495 (4) (c) of the statutes is amended to read:

SB45-SSA2-SA4,145,8 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer’s coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 6 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.

SB45-SSA2-SA4,233 Section 233. 632.7496 of the statutes is created to read:

SB45-SSA2-SA4,145,12 632.7496 Coverage requirements for short-term plans. (1) Definition. In this section, “short-term, limited duration plan” means an individual health benefit plan described in s. 632.7495 (4).

SB45-SSA2-SA4,145,15 (2) Guaranteed issue. An insurer that offers a short-term, limited duration plan shall accept every individual in this state who applies for coverage regardless of whether the individual has a preexisting condition.

SB45-SSA2-SA4,145,21 (3) Prohibiting discrimination based on health status. (a) An insurer that offers a short-term, limited duration 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 a short-term, limited duration plan based on any of the following health status-related factors with respect to the individual or a dependent of the individual:

SB45-SSA2-SA4,145,22 1. Health status.

SB45-SSA2-SA4,145,23 2. Medical condition, including both physical and mental illnesses.

SB45-SSA2-SA4,146,1 3. Claims experience.

SB45-SSA2-SA4,146,2 4. Receipt of health care.

SB45-SSA2-SA4,146,3 5. Medical history.

SB45-SSA2-SA4,146,4 6. Genetic information.

SB45-SSA2-SA4,146,6 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

SB45-SSA2-SA4,146,7 8. Disability.

SB45-SSA2-SA4,146,15 (b) An insurer that offers a short-term, limited duration plan may not require any individual, as a condition of enrollment or continued enrollment under the short-term, limited duration plan, to pay, on the basis of any health status-related factor described 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 short-term, limited duration plan.

SB45-SSA2-SA4,146,18 (4) Premium rate variation. An insurer that offers a short-term, limited duration plan may vary premium rates for a specific short-term, limited duration plan based only on the following considerations:

SB45-SSA2-SA4,146,20 (a) Whether the short-term, limited duration plan covers an individual or a family.

SB45-SSA2-SA4,146,21 (b) Rating area in the state, as established by the commissioner.

SB45-SSA2-SA4,147,2 (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.

SB45-SSA2-SA4,147,3 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB45-SSA2-SA4,147,5 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

SB45-SSA2-SA4,147,7 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan.

SB45-SSA2-SA4,147,10 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan for a term of coverage or for the aggregate duration of the short-term, limited duration plan.

SB45-SSA2-SA4,234 Section 234. 632.7498 of the statutes is created to read:

SB45-SSA2-SA4,147,13 632.7498 Special enrollment period for pregnancy. (1) Definitions. In this section:

SB45-SSA2-SA4,147,14 (a) “Health benefit plan” has the meaning given in s. 632.745 (11).

SB45-SSA2-SA4,147,15 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB45-SSA2-SA4,147,23 (2) Special enrollment period. A health benefit plan or self-insured health plan shall allow a pregnant individual who is eligible for coverage under the plan, and any individual who is eligible for coverage under the plan because of a relationship to the pregnant individual, to enroll for coverage at any time during the pregnancy. The coverage shall begin no later than the first day of the first calendar month in which the pregnant individual receives medical verification of the pregnancy, except that a pregnant individual may direct coverage to begin on the first day of any month occurring during the pregnancy.

SB45-SSA2-SA4,148,4 (3) Notice. An insurer offering group health insurance coverage in this state shall provide notice of the special enrollment period under sub. (2) at or before the time an individual is initially offered the opportunity to enroll for coverage under the plan.

SB45-SSA2-SA4,235 Section 235. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

SB45-SSA2-SA4,148,14 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746, a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c).

SB45-SSA2-SA4,148,20 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

SB45-SSA2-SA4,149,4 2. Except as provided in subd. 3., an An individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy limited duration plan subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition that was present before the date of enrollment for the coverage, whether physical or mental, regardless of the cause of the condition, for which and regardless of whether medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

SB45-SSA2-SA4,236 Section 236. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

SB45-SSA2-SA4,149,8 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy, limited duration plan subject to s. 632.7495 (4) and (5):

SB45-SSA2-SA4,237 Section 237. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

SB45-SSA2-SA4,149,15 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured’s consecutive periods of coverage under the insurer’s individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

SB45-SSA2-SA4,238 Section 238. 632.795 (4) (a) of the statutes is amended to read:

SB45-SSA2-SA4,150,5 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods, or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer’s policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer’s coverage terminates.

SB45-SSA2-SA4,239 Section 239. 632.848 of the statutes is created to read:

SB45-SSA2-SA4,150,8 632.848 Exemption from prior authorization requirements. (1) In this section:

SB45-SSA2-SA4,150,11 (a) “Evaluation period” means the period of time established by the commissioner by rule that is used to evaluate whether a health care provider qualifies for an exemption from obtaining prior authorizations under sub. (2).

SB45-SSA2-SA4,150,12 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

SB45-SSA2-SA4,150,13 (c) “Health care item or service” includes all of the following:

SB45-SSA2-SA4,150,14 1. Prescription drugs.

SB45-SSA2-SA4,150,15 2. Laboratory testing.

SB45-SSA2-SA4,150,16 3. Medical equipment.

SB45-SSA2-SA4,150,17 4. Medical supplies.

SB45-SSA2-SA4,150,18 (d) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).

SB45-SSA2-SA4,150,22 (e) “Prior authorization” means a determination by a health benefit plan, self- insured health plans, or person contracting with a health benefit plan or self- insured health plan that health care items or services proposed to be provided to a patient are medically necessary and appropriate.

SB45-SSA2-SA4,150,23 (f) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB45-SSA2-SA4,151,7 (2) The commissioner may by rule provide that any health benefit plan or self- insured health plan that uses a prior authorization process shall exempt health care providers from obtaining prior authorizations for a health care item or service for a period of time established by the commissioner if, in the most recent evaluation period, the health benefit plan or self-insured health plan has approved or would have approved not less than the proportion of prior authorization requests established under sub. (3) submitted by the health care provider for the health care item or service.

SB45-SSA2-SA4,151,11 (3) The commissioner shall specify the proportion of prior authorization requests submitted by a health care provider that have to be approved for the health care provider to qualify for an exemption from obtaining prior authorizations under sub. (2).

SB45-SSA2-SA4,151,14 (4) The commissioner may specify by rule the health care items or services that may be subject to the exemption from obtaining prior authorizations under sub. (2).

SB45-SSA2-SA4,151,17 (5) The commissioner may specify how health care providers may obtain an exemption from obtaining prior authorizations under sub. (2) including by providing a process for automatic evaluation.

SB45-SSA2-SA4,151,19 (6) The commissioner may promulgate further rules necessary to implement this section.

SB45-SSA2-SA4,240 Section 240. 632.851 of the statutes is created to read:

SB45-SSA2-SA4,151,22 632.851 Reimbursement of emergency ambulance services. (1) In this section:

SB45-SSA2-SA4,151,23 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

SB45-SSA2-SA4,152,3 (b) “Clean claim” means a claim that has no defect of impropriety, including a lack of required substantiating documentation or any particular circumstance that requires special treatment that prevents timely payment from being made on the claim.