Signature of Spouse (if applicable) Date signed Printed Name
I have had full opportunity to read and consider this form. I understand that, by signing this form, I authorize the uses and disclosures of protected health information described in this form. I understand that I may only revoke authorization for myself or my minor child(ren) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW.
___________________________________ ________________ _________________________________
Signature of Adult Dependent Date signed Printed Name
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child(ren) (if applicable)
If signing for more than one child, please list the names of each child for whom you are signing:
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent:
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child (if minor received
treatment with knowledge of parent)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
Uniform Employee Application
OCI 26-501 (R 6/2010)
Ins 8.50Ins 8.50 Underwriting restriction. In determining whether to issue or continue to provide coverage to a small employer, a small employer insurer may not consider the occupation of the employees of the small employer or the type of business in which the small employer is engaged. Ins 8.50 HistoryHistory: Cr. Register, October, 1992, No. 442, eff. 11-1-92. Ins 8.52Ins 8.52 Regulation of rates and rate changes. Ins 8.52(1)(1) Identification of the set of midpoint rates. Ins 8.52(1)(a)(a) Each small employer insurer shall identify a set of rates applicable to all combinations of case characteristics and benefit design characteristics that serves as the set of midpoint rates for policies issued to small employers. These rates shall be represented by any combination of rates and rating factors that satisfy the following: Ins 8.52(1)(a)1.1. All differences among rates in the set shall be in accordance with the insurer’s rate manual or rating procedures and shall be based on the actuarially determined values of the differences in case characteristics and benefit design characteristics. Ins 8.52(1)(a)2.2. The differences among the rates may not reflect any differences due to such factors as the claim experience, health status and duration of coverage of an individual policy or a collection of policies grouped according to anything other than case characteristics or benefit design. Ins 8.52(1)(b)(b) The set of midpoint rates identified in par. (a) shall apply during a specified period which shall not be less than one calendar month. Ins 8.52(2)(a)(a) For a new policy issued on or after March 15, 1992, the following table lists the maximum percent a rate may vary from the midpoint rate applicable to policies with the same case characteristics and benefit design characteristics according to the effective date of any rate applied to that policy: Ins 8.52(2)(b)(b) For a policy issued before March 15, 1992, an insurer shall comply with the rate variance restriction specified in par. (a) 2 no later than August 15, 1994. Ins 8.52(3)(3) Premium rate changes; documentation and restrictions. Ins 8.52(3)(a)(a) For the purpose of complying with s. 635.02 (2), Stats., and this subsection,“class of business” means a group of policies with the same or similar benefit design whose rates are based wholly or partly on their aggregate loss experience. Ins 8.52(3)(b)(b) For a policy renewed on or after March 15, 1993, an insurer shall maintain sufficient documentation so that each of the following distinct components can be identified: Ins 8.52(3)(b)1.1. The percentage change in the new business premium rate measured from the rating period in which the small employer was last rated to the current rating period or, in the case of a class of business for which the insurer is not issuing new policies, the corresponding change in the base premium rate. Ins 8.52(3)(b)2.2. The percentage change due to adjustments in case characteristics, determined in accordance with the insurer’s rate manual or rating procedures. Ins 8.52(3)(b)3.3. The percentage change due to adjustments in benefit design, determined in accordance with the insurer’s rate manual or rating procedures. Ins 8.52(3)(b)4.4. The percentage change due to such rating factors as claim experience, health status and duration of coverage, determined in accordance with the insurer’s rate manual or rating procedures. Ins 8.52(3)(c)(c) Each renewal rate, regardless of whether the rate represents an increase, shall be limited to the previous rate adjusted by the combination of the 4 components specified in par. (b) with the following restrictions on the experience component specified in par. (b) 4.: Ins 8.52(3)(c)1.1. For a policy issued on or after March 15, 1992, the experience component shall be limited to 15% per year, adjusted proportionately for rating periods of less than one year. Ins 8.52(3)(c)2.2. For a policy issued before March 15, 1992, subd. 1. applies, except if the premium rate exceeds the midpoint rate by more than the percentage specified in sub. (2) (a) for the applicable period for policies with the same case characteristics and benefit design characteristics, the experience component may not exceed 0%. Ins 8.52(3)(d)(d) For a rate change made before the end of the policy term due to the addition of a new entrant, late enrollee, underwritten individual or a new dependent of an insured employee, par. (c) applies, except that: Ins 8.52(3)(d)1.1. The new business rate change component specified in par. (b) 1. may not be applied at that time. Ins 8.52(3)(d)2.2. The experience component specified in par. (b) 4. may not exceed 15% per year, adjusted proportionately to the time remaining in the policy term. Ins 8.52(3)(d)3.3. The experience component specified in par. (b) 4., when combined with the experience component of the last scheduled rate renewal and any other subsequent rate changes during the current policy term, shall not exceed the limit specified in par. (c) 1. or 2., whichever applies. Ins 8.52(4)(a)(a) On or before December 1, every small employer insurer shall annually file with the commissioner the small employer insurer’s lowest available monthly new business premium rates which will be in effect the following January 1. The filing shall be made on a form provided by the commissioner and shall require all of the following information as may apply to the type of plan offered: Ins 8.52(4)(a)1.1. For an indemnity plan, the rates shall be based on the insurer’s plan that is closest to a plan that features a $500.00 annual deductible and 80%/20% coinsurance. Ins 8.52(4)(a)2.2. For a defined network plan, the rates shall be based on a plan which is actuarially equivalent to the features described in subd. 1. Ins 8.52(4)(a)3.3. For all plans, the rates shall be specified for family and single plans, by group size and by the geographical criteria that are used by the insurer. Ins 8.52(4)(a)4.4. The commissioner may require additional information be provided in the form as appropriate to implement this subsection. Ins 8.52 NoteNote: OCI 26-500, the form described in this subsection may be obtained without charge by contacting the Office of the Commissioner of Insurance PO Box 7873, Madison WI. 53707-7873. The form is also available on the OCI website at oci.wi.gov
Ins 8.52(4)(b)(b) Small employer insurers who file rates with the commissioner as described in this subsection will be in compliance with the requirements of s. 635.12, Stats. Ins 8.52 HistoryHistory: Cr. Register, October, 1992, No. 442, eff. 11-1-92; am. (3) (d) (intro.), Register, November, 1993, No. 455, eff. 2-1-94; CR 02-043: cr. (4), Register October 2002 No. 562, eff. 11-1-02. Ins 8.54Ins 8.54 Guaranteed renewability; cancellation and renewal restrictions. Ins 8.54(1)(a)(a) In this section, “medically underwritten policy” means a policy that is issued after the small employer insurer has, for purposes of risk selection, used information about the group’s claim experience or the health history or medical records of one or more persons eligible for coverage. Ins 8.54(1)(b)(b) Notwithstanding par. (a), a small employer insurer may apply medical underwriting standards to an individual who originally declined and later applies for coverage under a nonmedically underwritten policy without converting that policy to a medically underwritten policy. Ins 8.54(2)(a)(a) In this section, each of the following is a separate class of business, regardless of variations in policy forms, marketing methods or duration of coverage among small employers in the class of business: Ins 8.54(2)(a)2.2. All small employers with policies that are not medically underwritten. Ins 8.54(2)(a)3.3. All small employers whose policies constitute a block of business assumed by the small employer insurer under a specific assumption treaty with an insurer that is not an affiliate. Ins 8.54(2)(b)(b) No small employer insurer may establish a class of business other than one specified in par. (a). Ins 8.54(3)(3) Guaranteed renewability. Except as provided in s. 635.07, Stats., a policyholder has the right to renew a policy on the same terms subject to the premium rate restrictions specified in s. Ins 8.52 (3). The subsection does not prohibit a small employer insurer from offering a policyholder renewal with altered benefit design characteristics if the offer is available to all policyholders in the same class of business without regard to claim experience. Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749, Stats. Ins 8.54(4)(4) Nonrenewal or termination based on participation requirements. Ins 8.54(4)(a)(a) A small employer insurer that intends to nonrenew a policy or terminate a policy under s. 635.07 (1) (d), Stats., because the number of eligible employees is less than the number required to keep the policy in force shall do all of the following: Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (2), Stats. Ins 8.54(4)(a)1.1. Notify the small employer of its intent to nonrenew or terminate and the reason for the nonrenewal or termination. The notice shall be given as required under s. 631.36, Stats., for a nonrenewal or at least 20 days before the termination date for a termination. Ins 8.54(4)(a)2.2. Offer to continue the small employer’s coverage for not less than 60 days after the nonrenewal or termination date in order to allow the small employer to increase the number of eligible employees to the required number. Ins 8.54(4)(a)3.3. Provide the additional coverage, if the small employer accepts the offer under subd. 2. before the nonrenewal or termination date and pays the premium for the additional coverage at the rate in effect at the time the additional coverage is provided. Ins 8.54(4)(b)(b) A small employer insurer may not nonrenew a policy or terminate a policy under s. 635.07 (1) (d), Stats., if the reason the number of eligible employees is less than the required number is due to an employee’s sickness or injury, approved leave of absence or temporary layoff. The small employer insurer may establish participation requirements and reasonable verification procedures as part of the policy or employer agreement. Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (2), Stats. Ins 8.54(4)(c)(c) A small employer insurer may not take into consideration factors related to an individual small employer’s claim experience in deciding whether to nonrenew a policy or terminate a policy under s. 635.07 (1) (d), Stats. Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (3), Stats. Ins 8.54(4)(d)(d) A small employer insurer that intends to terminate a policy under s. 635.07 (1) (a) to (c) or (e), Stats., shall comply with the notice requirements under s. 631.36 (2) (b) and (c), (4), (6) and (7), Stats. Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (2), Stats. Ins 8.54(5)(a)(a) If a small employer insurer ceases to renew policies issued to all small employers in the same class of business under s. 635.07 (2), Stats., the small employer insurer may not establish any new class of business during the 5-year period beginning with the latest expiration date for policies in effect in the class of business that is not renewed. Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (3), Stats. Ins 8.54(5)(b)(b) At least one year before a small employer insurer ceases to renew policies under s. 635.07 (2), Stats., the small employer insurer shall provide the office with all of the following information: Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (3), Stats. Ins 8.54(5)(b)2.2. The number of small employers and the total number of eligible employees affected by the decision not to renew. Ins 8.54(5)(b)3.3. The number of small employers in other classes of the small employer insurer’s business that are not affected by the decision not to renew. Ins 8.54(5)(c)(c) The commissioner may order an examination under s. 601.43, Stats., in order to determine the premium rate history and obtain information on the profitability of the nonrenewed class of business. Ins 8.54(5)(d)(d) At least one year before a small employer insurer ceases to renew policies under s. 635.07 (2), Stats., the small employer insurer shall provide written notice of that intent to all affected small employers and the insurance regulatory agency in each state in which an affected insured individual resides. The notice shall include all of the following: Ins 8.54 NoteNote: 1995 Wis. Act 289 repealed s. 635.07, Stats. See s. 632.749 (3), Stats. Ins 8.54(5)(d)1.1. The reason for the decision to terminate coverage for the class of business.
