SB70,,86478647(b) An insurer offering an individual health benefit plan or a self-insured health 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 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 plan.

SB70,,86488648(c) Nothing in this subsection prevents an insurer offering an individual health benefit plan or a self-insured health plan from establishing premium discounts or rebates or modifying otherwise applicable cost sharing in return for adherence to programs of health promotion and disease prevention.

SB70,,86498649(4) Premium rate variation. A health benefit plan offered on the individual or small employer market or a self-insured health plan may vary premium rates for a specific plan based only on the following considerations:

SB70,,86508650(a) Whether the policy or plan covers an individual or a family.

SB70,,86518651(b) Rating area in the state, as established by the commissioner.

SB70,,86528652(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.

SB70,,86538653(d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB70,,86548654(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.

SB70,,86558655(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:

SB70,,86568656(a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB70,,86578657(b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB70,,86588658(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.

SB70,,86598659(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.

SB70,,86608660(b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

SB70,,86618661(c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

SB70,,86628662(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.

SB70,,86648664632.746 (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.

SB70,,86678667632.746 (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.