Chapter Ins 8

Ins 8.56(2) (2) In addition to the annual certification required under sub. (1), the commissioner may require a small employer insurer to furnish additional information including, but not limited to, the following, using the form and method of transmittal prescribed by the commissioner:

Ins 8.56(2)(a) (a) Rate manuals or exhibits of all rating factors used for each class of business.

Ins 8.56(2)(b) (b) Sample data of small employers including premiums charged and rating factors applied for case characteristics and benefit design characteristics.

Ins 8.56(2)(c) (c) An inventory of case characteristics used by the small employer insurer since the last certification date.

Ins 8.56(2)(d) (d) An exhibit showing the difference in new business premium rates between the current certification date and the last certification date.

Ins 8.56(2)(e) (e) A description of how midpoint rates are determined.

Ins 8.56 Note Note: The form required under sub. (1), OCI 26-051, may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison, WI 53707-7873.

Ins 8.56 History History: Cr. Register, October, 1992, No. 442, eff. 11-1-92.

Ins 8.59 Ins 8.59 Small employer insurers shall offer an initial enrollment period to all members of small employer groups; riders and discriminatory coverage are prohibited.

Ins 8.59(1) (1) A small employer insurer that offers a policy shall provide an initial enrollment period during which each eligible employee and dependent of an eligible employee is entitled to enroll in coverage under the policy.

Ins 8.59(2) (2) Except as permitted under sub. (3), a small employer insurer shall provide the same policy coverage to each eligible employee, and dependent of an eligible employee of a small employer, who is covered under a policy.

Ins 8.59(3) (3) A small employer insurer may offer, or participate in an offer, to eligible employees of a choice by the eligible employee among 2 or more policies for coverage of the eligible employee and the eligible employee’s dependents, but only if:

Ins 8.59(3)(a) (a) The enrollment period is simultaneous for all the policies;

Ins 8.59(3)(b) (b) The eligible employee may choose any one of the offered policies; and

Ins 8.59(3)(c) (c) All the policies offered provide benefits similar to or exceeding the benefits provided under the basic health benefit plan as determined under s. Ins 8.66 (1).

Ins 8.59 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94; correction in (4) made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562; CR 17-015: r. (4) Register December 2017 No. 744, eff. 1-1-18.

Ins 8.60 Ins 8.60 A small employer insurer may accept an employee’s or dependent’s waiver of coverage during an initial enrollment period only under limited conditions.

Ins 8.60(1) (1) A small employer insurer may not issue a policy unless during the initial enrollment period all the eligible employees and dependents of eligible employees elect and are provided coverage under the policy, except a small employer insurer may permit an individual to decline coverage in the initial enrollment period if the small employer insurer determines:

Ins 8.60(1)(b) (b) The individual elected coverage under another policy during an enrollment period permitted under s. Ins 8.59 (3);

Ins 8.60(1)(c) (c) The individual does not have a risk characteristic or other attribute that would be the sole cause for the small employer insurer to make a decision with respect to premiums or eligibility for a policy that is adverse to the small employer;

Ins 8.60(2) (2) A small employer insurer may permit an individual to decline coverage under a policy under sub. (1) only if the insurer complies with ss. Ins 8.64 and 8.65.

Ins 8.60 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94; correction in (1) (a), (d) and (e) made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562; CR 17-015: r. (1) (a), (d), (e) Register December 2017 No. 744, eff. 1-1-18.

Ins 8.61 Ins 8.61 Small employer insurers shall offer coverage to new entrants.

Ins 8.61(1) (1) A small employer insurer shall provide under a policy for an enrollment period during which a new entrant is entitled to enroll in coverage under the policy. The small employer insurer shall provide an enrollment period under a policy of at least 30 days after the date the new entrant is notified of the opportunity to enroll. A small employer insurer which offers more than one policy in the initial enrollment period under s. Ins 8.59 (3) shall offer the new entrant the same choice of policies during the new entrant’s enrollment period.

Ins 8.61(3) (3) A small employer insurer’s policy shall not apply, or permit an employer to apply, a probationary period which must be met before a new entrant is eligible for coverage under a small employer policy, or a similar limitation, that is longer than 6 months.

Ins 8.61(4) (4) A small employer insurer may not add coverage restrictions or limitations under a policy because of the risk characteristics of a new entrant.

Ins 8.61(5) (5) A small employer insurer may assess a risk load to the premium rate associated with a new entrant, consistent with the requirements of s. 635.05, Stats., and s. Ins 8.52 (3) (d).

Ins 8.61 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94; corrections in (2) and (6) made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562; CR 17-015: r. (2), (6) Register December 2017 No. 744, eff. 1-1-18.

Ins 8.62 Ins 8.62 Small employer insurers shall offer an open enrollment for individuals excluded prior to enactment or application of the small employer health insurance law.

Ins 8.62(1) (1) A small employer insurer shall provide an enrollment period during which underwritten individuals who were excluded or denied coverage prior to the law’s effective date are entitled to enroll in coverage under the policy currently held by the small employer. Notice of the enrollment period shall [be] given as required under sub. (4).

Ins 8.62(2) (2) A small employer insurer may require an individual who requests enrollment under this section to sign a statement indicating that the individual sought coverage under a policy issued to the employer, other than as a late enrollee, and that the coverage was not offered to the individual. If the individual provides the statement it is presumed that the individual is an underwritten individual and entitled to enroll under this section.

Ins 8.62(3) (3) The enrollment period required under this section shall comply with all of the following:

Ins 8.62(3)(a) (a) It shall commence no later than 45 days after December 1, 1993, and shall last for a period of at least 90 days.

Ins 8.62(3)(b) (b) Underwritten individuals who are provided an opportunity to enroll under this section shall be treated as new entrants.

Ins 8.62(3)(c) (c) The terms of coverage offered to an underwritten individual under sub. (1) may exclude coverage for preexisting medical conditions only if the policy currently held by the small employer contains such an exclusion, the exclusion complies with s. 635.17 (1), Stats., and the exclusion period is reduced by the number of days between the date the individual was excluded or denied coverage and the date coverage is provided to the individual under this section.

Ins 8.62 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.746 (1), Stats.

Ins 8.62(4) (4) A small employer insurer shall provide written notice of the right to enroll under this section to each small employer insured under a policy offered by the insurer. The notice shall be mailed at least 30 days before commencement of the enrollment period and shall clearly describe the rights granted under this section and the process for enrollment of the underwritten individuals in the policy. The insurer shall provide the employer with sufficient copies of the notice to distribute to each eligible employee and shall ask the employer to promptly distribute a copy to each eligible employee. The small employer insurer shall make reasonable efforts to obtain from the small employer certification that the notice was promptly distributed to all eligible employees.

Ins 8.62(5) (5) A small employer insurer may assess a risk load to the premium rate associated with an underwritten individual, consistent with the requirements of s. 635.05, Stats., and s. Ins 8.52 (3) (d).

Ins 8.62(6) (6) The requirement under sub. (1) to offer an enrollment period applies regardless of whether the small employer insurer required to make the offer was the insurer of the employer when the individual was originally excluded or denied coverage.

Ins 8.62 History History: Cr. Register, November, 1993, No. 455, eff. 12-1-93.

Ins 8.63 Ins 8.63 Small employer insurers shall offer coverage to late enrollees.

Ins 8.63(1) (1) A small employer insurer shall provide under a policy for an enrollment period during which a late enrollee is entitled to enroll in coverage under the policy. The small employer insurer shall provide an enrollment period of at least 30 days after the date the late enrollee requests coverage and is notified of the opportunity to enroll.

Ins 8.63(2) (2) A small employer insurer may exclude coverage of a late enrollee who elects coverage for no more than 18 months or provide for up to an 18-month preexisting condition exclusion, but if both a period of exclusion from coverage and a preexisting condition exclusion are applied by the small employer insurer under the policy the combined period may not exceed 18 months from the date the individual applies for coverage under the policy. A small employer insurer may require that the late enrollee remain continuously employed by, or remain a dependent of an eligible employee continuously employed by, the small employer for the entire period of exclusion permitted under this subsection. A small employer insurer may not impose a preexisting condition exclusion under s. 635.17 (1), Stats., in addition to an exclusion permitted under this subsection.

Ins 8.63 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.746 (1), Stats.

Ins 8.63(3) (3) A small employer insurer may assess a risk load to the premium rate associated with a late entrant, consistent with the requirements of s. 635.05, Stats., and s. Ins 8.52 (3) (d).

Ins 8.63 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94.

Ins 8.64 Ins 8.64 Small employer insurers may not participate with a small employer to coerce, or discriminate among, eligible employees or dependents.

Ins 8.64(1) (1) A small employer insurer may not accept a waiver of coverage, if the insurer, or an insurance intermediary for the insurer, reasonably should know that the small employer pressured or unfairly induced the eligible employee or dependent of an eligible employee to decline coverage due to the individual’s risk characteristics.

Ins 8.64(2) (2) An insurance intermediary shall notify a small employer insurer in writing, prior to submitting an application for coverage with the insurer on behalf of a small employer, or prior to transmittal of a waiver, of any circumstances that would indicate that the small employer pressured or unfairly induced an eligible employee or dependent of an eligible employee to decline coverage due to the individual’s risk characteristics.

Ins 8.64 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94.

Ins 8.65 Ins 8.65 A small employer insurer shall require small employers to provide documentation to establish that waivers of coverage are voluntary and permitted.

Ins 8.65(1) (1) A small employer insurer shall require each small employer that applies for a policy, as part of the application process, to provide a complete list of eligible employees and dependents of eligible employees of the small employer. The small employer insurer shall require the small employer to provide appropriate supporting documentation, such as the state unemployment or worker’s compensation quarterly reporting forms, to verify the information required under this subsection.

Ins 8.65(2) (2) A small employer insurer shall secure a waiver signed by the eligible employee on behalf of the employee or the dependent of the employee with respect to each eligible employee, and each dependent of an eligible employee, who declines an offer of coverage under a policy, whether during an initial enrollment period, as a new entrant or as an underwritten individual. The small employer insurer shall include on the waiver and require:

Ins 8.65(2)(a) (a) A certification that the individual who declined coverage was informed of the availability of coverage under the policy;

Ins 8.65(2)(b) (b) That the reason for declining coverage be stated; and

Ins 8.65(2)(c) (c) A written warning of the consequences which may be imposed on late enrollees.

Ins 8.65(3) (3) A small employer insurer shall obtain, with respect to each individual who submits a waiver under sub. (2) in connection with an initial enrollment period, information sufficient to establish that the waiver may be accepted under s. Ins 8.60 (1).

Ins 8.65(4) (4) A small employer insurer shall maintain waivers required under sub. (2), the information required to be obtained under sub. (3) and notifications under s. Ins 8.64 (2), for a period of 3 years or until the policy terminates, whichever is later.

Ins 8.65(5) (5) A small employer insurer may not issue coverage to a small employer that refuses to provide the list required under sub. (1), a waiver required under sub. (2) or information required under sub. (3).

Ins 8.65 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94.

Ins 8.66 Ins 8.66 Qualifying coverage for portability and late enrollees; transition.

Ins 8.66(1) (1) For the purpose of determining whether a health benefit plan or other health benefit arrangement is qualifying coverage under s. 635.17, Stats., or under this subchapter:

Ins 8.66 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.745 (4), Stats.

Ins 8.66(1)(a) (a) A health insurance policy, certificate or other health benefit arrangement is employer-based if an employer sponsors the plan or arrangement or makes a contribution to the plan or arrangement.

Ins 8.66(1)(b) (b) A health insurance policy, certificate or other benefit arrangement provides benefits similar to or exceeding the benefits provided under the basic health benefit plan if the policy, certificate or other benefit arrangement provides benefits that:

Ins 8.66(1)(b)1. 1. Have an actuarial value as considered for a normal distribution of groups that is not substantially less than the actuarial value of the basic health benefit plan; or

Ins 8.66(1)(b)2. 2. Provides coverage for hospitalization and physician services that is substantially similar to or exceeds the coverage for those services in the basic health benefit plan.

Ins 8.66(1)(c) (c) A small employer insurer shall evaluate a previous or existing policy, certificate or other benefit arrangement taken as a whole and shall not base its determination on the fact that one or more portions of the previous or existing policy, certificate or benefit arrangement provides less coverage than the comparable portion of the basic health benefit plan.

Ins 8.66(2) (2) For the purposes of s. 635.17 (1) (b), Stats., an individual has previous qualifying coverage with respect to a particular service if the previous policy, certificate or other benefit arrangement covering the individual was qualifying coverage and provided any benefit with respect to the service.

Ins 8.66 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.746 (1) and (3), Stats.

Ins 8.66(3) (3) To the extent necessary to comply with this section and s. 635.17, Stats., a small employer insurer shall ascertain the source of previous or existing coverage of each eligible employee and each dependent of an eligible employee at the time the employee or dependent initially enrolls in the health benefit plan provided by the small employer insurer. The small employer insurer shall contact the source of previous or existing coverage to resolve any questions about the benefits or limitations related to the previous or existing coverage.

Ins 8.66 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.746, Stats.

Ins 8.66(4) (4) No small employer insurer may renew or issue a policy after November 30, 1993, unless the policy includes a provision complying with s. 635.17 (1) (b), Stats., as to qualifying coverage defined in s. 635.02 (5m) (b) and (c), Stats., in addition to qualifying coverage defined in s. 635.02 (5m) (a), Stats. An insurer shall administratively comply with s. 635.17 (1) (b), Stats., for all policies in force on or after July 1, 1993, with respect to qualifying coverage defined under s. 635.02 (5m) (b) and (c), Stats., for all individuals who commence coverage under a policy after June 30, 1993. All small employer insurers shall establish and disseminate policies and procedures designed to ensure compliance with this subsection by not later than December 1, 1993.

Ins 8.66 Note Note: 1995 Wis. Act 289 repealed ss. 635.02 (5m) and 635.17, Stats. See ss. 632.745 (4) and 632.746 (1), Stats.

Ins 8.66(5) (5) An insurer, on request, shall provide to the current insurer of a small employer copies of pertinent health benefit plan provisions, a statement of coverage available and other information reasonably necessary to enable the current insurer to comply with subs. (1) to (3).

Ins 8.66 History History: Cr. Register, November, 1993, No. 455, eff. 12-1-93.

Ins 8.67 Ins 8.67 Restrictive riders prohibited. A restrictive rider, endorsement or other provision that would violate s. 635.17 (3) (b), Stats., and that was in force on May 12, 1992, may not remain in force beyond the first renewal date of the policy and a small employer insurer shall delete the rider, endorsement or other provision after the law’s effective date.

Ins 8.67 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.748 (1), Stats.

Ins 8.67 History History: Cr. Register, November, 1993, No. 455, eff. 2-1-94.

Ins 8.68 Ins 8.68 Fair marketing standards.

Ins 8.68(1) (1) 

Ins 8.68(1)(a) (a) Unless otherwise permitted under par. (b), (c) or (d), a small employer insurer shall actively market its health benefit plans to all small employers and without regard to the size of the small employer group by:

Ins 8.68(1)(a)1. 1. Actively marketing in each segment of the small employer market the basic health benefit plan and at least one form of a policy which provides benefits which materially exceed benefits provided under the basic health benefit plan.

Ins 8.68(1)(a)2. 2. Actively marketing in each area of the state the basic health benefit plan and at least one form of a policy which provides benefits which materially exceed benefits provided under the basic health benefit plan, except a small employer insurer which is, and is likely to remain, in compliance with s. Ins 8.69 may:

Ins 8.68(1)(a)2.a. a. Limit marketing to the provider service areas for the health maintenance organization or preferred provider plans if it limits the policies it offers to the basic health benefit plan and policies which are health maintenance organization plans or preferred provider plans; or

Ins 8.68(1)(a)2.b. b. Limit its marketing of policies to selected areas which the small employer insurer can demonstrate by clear and convincing evidence are selected for justifiable business reasons other than desirable demographic characteristics related to risk selection.

Ins 8.68(1)(b) (b) A small employer insurer may limit marketing and issuance of the basic health benefit plan under s. 635.26 (2m) or (4), Stats., or may limit marketing and issuance of other forms of policies, or both, to a particular segment of the market, only if the segment is not based on the size of the small employer group and the small employer insurer:

Ins 8.68 Note Note: 1997 Wis. Act 27 repealed s. 635.26, Stats. See s. 635.19 (2), Stats.

Ins 8.68(1)(b)1. 1. Files with the commissioner on or after February 1, 1994, in the form prescribed by the commissioner, a request for approval to limit its marketing of policies;