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February 15, 2019 - Introduced by Senators Erpenbach, Schachtner, Bewley,
Carpenter, Hansen, Johnson, Miller, Ringhand, Risser, Shilling, Smith,
Wirch and Larson, cosponsored by Representatives Riemer, Billings,
Considine, Crowley, Hesselbein, Pope, Sinicki, Spreitzer, Shankland,
Subeck, C. Taylor and Vruwink. Referred to Committee on Health and
Human Services.
SB37,1,12 1An Act to repeal 632.746 (1) (b), 632.746 (2) (c), (d) and (e), 632.746 (3) (a),
2632.746 (3) (d) 2. and 3., 632.746 (5) and 632.76 (2) (ac) 3.; to renumber 632.746
3(3) (d) 1.; to renumber and amend 632.746 (1) (a); to amend 40.51 (8), 40.51
4(8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 625.12 (1) (a), 625.12 (1) (e),
5625.12 (2), 625.15 (1), 628.34 (3) (a), 632.746 (2) (a), 632.746 (8) (a) (intro.),
6632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d),
7632.895 (14) (a) 1. i. and j., 632.895 (14) (b), 632.895 (14) (c), 632.895 (14) (d) 3.,
8632.895 (16m) (b), 632.895 (17) (b) 2., 632.895 (17) (c) and 632.897 (11) (a); and
9to create 609.713, 609.847, 632.728, 632.895 (13m), 632.895 (14) (a) 1. k. to o.
10and 632.895 (14m) of the statutes; relating to: coverage of preventive services,
11essential health benefits, and individuals with preexisting conditions; rating;
12and benefit limits under health plans.
Analysis by the Legislative Reference Bureau
This bill requires certain health plans to guarantee access to coverage;
prohibits plans from imposing preexisting condition exclusions; prohibits plans from

setting premiums or cost-sharing amounts based on a health status-related factors;
prohibits plans from setting lifetime or annual limits on benefits; requires plans to
cover certain essential health benefits; and requires coverage of certain preventive
services by plans without a cost-sharing contribution by an enrollee.
Coverage of individuals with preexisting conditions; rating; benefit limits.
This bill requires every individual health insurance policy, known in the bill as
a health benefit plan, to accept every individual who, and every group health
insurance policy to accept every employer that, applies for coverage, regardless of
sexual orientation, gender identity, or whether an employee or individual has a
preexisting condition. The bill allows health benefit plans to restrict enrollment in
coverage to open or special enrollment periods and requires the commissioner of the
Office of the Commissioner of Insurance to establish a statewide open enrollment
period of no shorter than 30 days for every individual health benefit plan. The bill
prohibits a group health insurance policy, including a self-insured governmental
health plan, from imposing a preexisting condition exclusion. The bill also prohibits
an individual health insurance policy from reducing or denying a claim or loss
incurred or disability commencing under the policy on the ground that a disease or
physical condition existed prior to the effective date of coverage.
A health benefit plan offered on the individual or small employer market or a
self-insured governmental health plan may not vary premium rates for a specific
plan except on the basis of whether the plan covers an individual or family, area in
the state, age, and tobacco use as specified in the bill. An individual health benefit
plan or self-insured health plan is prohibited under the bill from establishing rules
for the eligibility of any individual to enroll based on health-status related factors,
which are specified in the bill. A self-insured health plan or an insurer offering an
individual health benefit plan is also prohibited from requiring an enrollee to pay a
greater premium, contribution, deductible, copayment, or coinsurance amount than
is required of a similarly situated enrollee based on a health-status related factor.
Current state law prohibits group health benefit plans from establishing rules of
eligibility or requiring greater premium or contribution amounts based on a
health-status related factor. The bill adds to these current law requirements for
group health benefit plans that the plan may not require a greater deductible,
copayment, or coinsurance amount based on a health-status related factor.
Under the bill, an individual or group health benefit plan or a self-insured
governmental health plan may not establish lifetime or annual limits on the dollar
value of benefits for an enrollee or a dependent of an enrollee under the plan.
The requirements and prohibitions in this bill related to coverage of individuals
with preexisting conditions and prohibition of lifetime and annual benefit limits also
apply to short-term, limited-duration health insurance policies.
Coverage of essential health benefits and preventive services
This bill requires certain health insurance policies, known in the bill as
disability insurance policies, and governmental self-insured health plans to cover
essential health benefits that will be specified by the commissioner of insurance by
rule. The bill specifies a list of requirements that the commissioner must follow when
establishing the essential health benefits including certain limitations on cost

sharing and the following general categories of benefits, items, or services in which
the commissioner must require coverage: ambulatory patient services, emergency
services, hospitalization, maternity and newborn care, mental health and substance
use disorder services, prescription drugs, rehabilitative and habilitative services
and devices, laboratory services, preventive and wellness services and chronic
disease management, and pediatric services. If an essential health benefit specified
by the commissioner is also subject to its own mandated coverage requirement, the
bill requires the disability insurance policy or self-insured health plan to provide
coverage under whichever requirement provides the insured or plan participant with
more comprehensive coverage.
This bill requires health insurance policies and governmental self-insured
health plans to cover certain preventive services and to provide coverage of those
preventive services without subjecting that coverage to deductibles, copayments, or
coinsurance. The preventive services for which coverage is required are specified in
the bill. The bill also specifies certain instances when cost-sharing amounts may be
charged for an office visit associated with a preventive service.
This proposal may contain a health insurance mandate requiring a social and
financial impact report under s. 601.423, stats.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB37,1 1Section 1. 40.51 (8) of the statutes is amended to read:
SB37,3,62 40.51 (8) Every health care coverage plan offered by the state under sub. (6)
3shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.728, 632.746
4(1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853,
5632.855, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and
6632.896.
SB37,2 7Section 2. 40.51 (8m) of the statutes is amended to read:
SB37,3,118 40.51 (8m) Every health care coverage plan offered by the group insurance
9board under sub. (7) shall comply with ss. 631.95, 632.728, 632.746 (1) to (8) and (10),
10632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.867,
11632.885, 632.89, and 632.895 (11) (8) and (10) to (17).
SB37,3 12Section 3. 66.0137 (4) of the statutes is amended to read:
SB37,4,7
166.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
2a village provides health care benefits under its home rule power, or if a town
3provides health care benefits, to its officers and employees on a self-insured basis,
4the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
5632.728, 632.746 (1) and (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853,
6632.855, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) (8) to (17), 632.896,
7and 767.513 (4).
SB37,4 8Section 4. 120.13 (2) (g) of the statutes is amended to read:
SB37,4,129 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
1049.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.728, 632.746 (1) and (10) (a) 2. and (b)
112., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.867, 632.87 (4) to (6), 632.885,
12632.89, 632.895 (9) (8) to (17), 632.896, and 767.513 (4).
SB37,5 13Section 5. 185.983 (1) (intro.) of the statutes is amended to read:
SB37,4,2114 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
15cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
16646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
17601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
18631.95, 632.72 (2), 632.728, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798,
19632.85, 632.853, 632.855, 632.867, 632.87 (2) to (6), 632.885, 632.89, 632.895 (5) and
20(8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but
21the sponsoring association shall:
SB37,6 22Section 6. 609.713 of the statutes is created to read:
SB37,4,24 23609.713 Essential health benefits; preventive services. Defined network
24plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).
SB37,7 25Section 7. 609.847 of the statutes is created to read:
SB37,5,3
1609.847 Preexisting condition discrimination and certain benefit
2limits prohibited.
Limited service health organizations, preferred provider plans,
3and defined network plans are subject to s. 632.728.
SB37,8 4Section 8. 625.12 (1) (a) of the statutes is amended to read:
SB37,5,65 625.12 (1) (a) Past and prospective loss and expense experience within and
6outside of this state, except as provided in s. 632.728.
SB37,9 7Section 9. 625.12 (1) (e) of the statutes is amended to read:
SB37,5,98 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors,
9including the judgment of technical personnel.
SB37,10 10Section 10. 625.12 (2) of the statutes is amended to read:
SB37,5,1911 625.12 (2) Classification. Risks Except as provided in s. 632.728, risks may
12be classified in any reasonable way for the establishment of rates and minimum
13premiums, except that no classifications may be based on race, color, creed or
14national origin, and classifications in automobile insurance may not be based on
15physical condition or developmental disability as defined in s. 51.01 (5). Subject to
16s. ss. 632.365 and 632.728, rates thus produced may be modified for individual risks
17in accordance with rating plans or schedules that establish reasonable standards for
18measuring probable variations in hazards, expenses, or both. Rates may also be
19modified for individual risks under s. 625.13 (2).
SB37,11 20Section 11. 625.15 (1) of the statutes is amended to read:
SB37,6,321 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may
22itself establish rates and supplementary rate information for one or more market
23segments based on the factors in s. 625.12 and, if the rates are for motor vehicle
24liability insurance, subject to s. 632.365, or the insurer may use rates and
25supplementary rate information prepared by a rate service organization, with

1average expense factors determined by the rate service organization or with such
2modification for its own expense and loss experience as the credibility of that
3experience allows.
SB37,12 4Section 12. 628.34 (3) (a) of the statutes is amended to read:
SB37,6,115 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
6charging different premiums or by offering different terms of coverage except on the
7basis of classifications related to the nature and the degree of the risk covered or the
8expenses involved, subject to ss. 632.365, 632.728, 632.746 and 632.748. Rates are
9not unfairly discriminatory if they are averaged broadly among persons insured
10under a group, blanket or franchise policy, and terms are not unfairly discriminatory
11merely because they are more favorable than in a similar individual policy.
SB37,13 12Section 13. 632.728 of the statutes is created to read:
SB37,6,14 13632.728 Coverage of persons with preexisting conditions; guaranteed
14issue; benefit limits.
(1) Definitions. In this section:
SB37,6,1515 (a) “Health benefit plan” has the meaning given in s. 632.745 (11).
SB37,6,1616 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
SB37,6,22 17(2) Guaranteed issue. (a) Every individual health benefit plan shall accept
18every individual in this state who, and every group health benefit plan shall accept
19every employer in this state that, applies for coverage, regardless of sexual
20orientation, gender identity, or whether or not any employee or individual has a
21preexisting condition. A health benefit plan may restrict enrollment in coverage
22described in this paragraph to open or special enrollment periods.
SB37,6,2523 (b) The commissioner shall establish a statewide open enrollment period of no
24shorter than 30 days for every individual health benefit plan to allow individuals,
25including individuals who do not have coverage, to enroll in coverage.
SB37,7,5
1(3) Prohibiting discrimination based on health status. (a) An individual
2health benefit plan or a self-insured health plan may not establish rules for the
3eligibility of any individual to enroll, or for the continued eligibility of any individual
4to remain enrolled, under the plan based on any of the following health
5status-related factors in relation to the individual or a dependent of the individual:
SB37,7,66 1. Health status.
SB37,7,77 2. Medical condition, including both physical and mental illnesses.
SB37,7,88 3. Claims experience.
SB37,7,99 4. Receipt of health care.
SB37,7,1010 5. Medical history.
SB37,7,1111 6. Genetic information.
SB37,7,1312 7. Evidence of insurability, including conditions arising out of acts of domestic
13violence.
SB37,7,1414 8. Disability.
SB37,7,2115 (b) An insurer offering an individual health benefit plan or a self-insured
16health plan may not require any individual, as a condition of enrollment or continued
17enrollment under the plan, to pay, on the basis of any health status-related factor
18under par. (a) with respect to the individual or a dependent of the individual, a
19premium or contribution or a deductible, copayment, or coinsurance amount that is
20greater than the premium or contribution or deductible, copayment, or coinsurance
21amount respectively for a similarly situated individual enrolled under the plan.
SB37,7,2522 (c) Nothing in this subsection prevents an insurer offering an individual health
23benefit plan or a self-insured health plan from establishing premium discounts or
24rebates or modifying otherwise applicable cost sharing in return for adherence to
25programs of health promotion and disease prevention.
SB37,8,3
1(4) Premium rate variation. A health benefit plan offered on the individual or
2small employer market or a self-insured health plan may vary premium rates for a
3specific plan based only on the following considerations:
SB37,8,44 (a) Whether the policy or plan covers an individual or a family.
SB37,8,55 (b) Rating area in the state, as established by the commissioner.
SB37,8,86 (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.
SB37,8,99 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
SB37,8,11 10(5) Annual and lifetime limits. An individual or group health benefit plan or
11a self-insured health plan may not establish any of the following:
SB37,8,1312 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
13of an enrollee under the plan.
SB37,8,1514 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent
15of an enrollee under the plan.
SB37,8,23 16(6) Short-term plans. This section and s. 632.76 apply to every short-term,
17limited-duration health insurance policy. In this subsection, “short-term,
18limited-duration health insurance policy” means health coverage that is provided
19under a contract with an insurer, has an expiration date specified in the contract that
20is less than 12 months after the original effective date of the contract, and, taking
21into account renewals or extensions, has a duration of no longer than 36 months in
22total. “Short-term, limited-duration health insurance policy” includes any
23short-term policy subject to s. 632.7495 (4).
SB37,14 24Section 14. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and
25amended to read:
SB37,9,7
1632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health
2benefit plan may, with respect to a participant or beneficiary under the plan, not
3impose a preexisting condition exclusion only if the exclusion relates to a condition,
4whether physical or mental, regardless of the cause of the condition, for which
5medical advice, diagnosis, care or treatment was recommended or received within
6the 6-month period ending on the participant's or beneficiary's enrollment date
7under the plan
on a participant or beneficiary under the plan.
SB37,15 8Section 15. 632.746 (1) (b) of the statutes is repealed.
SB37,16 9Section 16. 632.746 (2) (a) of the statutes is amended to read:
SB37,9,1310 632.746 (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
.
SB37,17 14Section 17. 632.746 (2) (c), (d) and (e) of the statutes are repealed.
SB37,18 15Section 18. 632.746 (3) (a) of the statutes is repealed.
SB37,19 16Section 19 . 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).
SB37,20 17Section 20 . 632.746 (3) (d) 2. and 3. of the statutes are repealed.
SB37,21 18Section 21 . 632.746 (5) of the statutes is repealed.
SB37,22 19Section 22. 632.746 (8) (a) (intro.) of the statutes is amended to read:
SB37,9,2320 632.746 (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:
SB37,23 24Section 23 . 632.748 (2) of the statutes is amended to read:
SB37,10,7
1632.748 (2) An insurer offering a group health benefit plan may not require any
2individual, as a condition of enrollment or continued enrollment under the plan, to
3pay, on the basis of any health status-related factor with respect to the individual
4or a dependent of the individual, a premium or contribution or a deductible,
5copayment, or coinsurance amount
that is greater than the premium or contribution
6or deductible, copayment, or coinsurance amount respectively for a similarly
7situated individual enrolled under the plan.
SB37,24 8Section 24. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:
SB37,10,169 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years
10from the date of issue of the policy may be reduced or denied on the ground that a
11disease or physical condition existed prior to the effective date of coverage, unless the
12condition was excluded from coverage by name or specific description by a provision
13effective on the date of loss. This paragraph does not apply to a group health benefit
14plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance
15policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s.
16632.85 (1) (c)
.
SB37,10,2217 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability
18commencing after 12 months from the date of issue of under an individual disability
19insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the
20ground that a disease or physical condition existed prior to the effective date of
21coverage, unless the condition was excluded from coverage by name or specific
22description by a provision effective on the date of the loss
.
SB37,11,423 2. Except as provided in subd. 3., an An individual disability insurance policy,
24as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495
25(4) and (5),
may not define a preexisting condition more restrictively than a condition

1that was present before the date of enrollment for the coverage, whether physical or
2mental, regardless of the cause of the condition, for which and regardless of whether
3medical advice, diagnosis, care, or treatment was recommended or received within
412 months before the effective date of coverage
.
SB37,25 5Section 25. 632.76 (2) (ac) 3. of the statutes is repealed.
SB37,26 6Section 26. 632.795 (4) (a) of the statutes is amended to read:
SB37,11,187 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the
8same policy form and for the same premium as it originally offered in the most recent
9enrollment period, subject only to the medical underwriting used in that enrollment
10period. Unless otherwise prescribed by rule, the insurer may apply deductibles,
11preexisting condition limitations, waiting periods , or other limits only to the extent
12that they would have been applicable had coverage been extended at the time of the
13most recent enrollment period and with credit for the satisfaction or partial
14satisfaction of similar provisions under the liquidated insurer's policy or plan. The
15insurer may exclude coverage of claims that are payable by a solvent insurer under
16insolvency coverage required by the commissioner or by the insurance regulator of
17another jurisdiction. Coverage shall be effective on the date that the liquidated
18insurer's coverage terminates.
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