reglab/statecodes huggingface dataset:
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.84 - Benefit appeals under certain policies.

632.84
Benefit appeals under certain policies.
(1)
Definitions. In this section:
(a)
“Nursing home" has the meaning given in s. 50.01 (3).
(b)
“Nursing home insurance policy" means an individual or group insurance policy which provides coverage primarily for confinement or care in a nursing home.
(2)
Review and appeal.
(a)
Except as provided in sub. (3), an insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall establish an internal procedure by which the policyholder or the certificate holder or a representative of the policyholder or the certificate holder may appeal the denial of any benefits under the medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy. The procedure established under this paragraph shall include all of the following:
1.
The opportunity for the policyholder or certificate holder or a representative of the policyholder or certificate holder to submit a written request, which may be in any form and which may include supporting material, for review by the insurer of the denial of any benefits under the policy.
2.
Within 30 days after receiving the request under subd. 1., disposition of the review and notification to the person submitting the request of the results of the review.
(b)
An insurer shall describe the procedure established under par. (a) in every policy, group certificate and outline of coverage issued in connection with a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy.
(c)
If an insurer denies any benefits under a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy, the insurer shall, at the time the insurer gives notice of the denial of any benefits, provide the policyholder and certificate holder with a written description of the appeal process established under par. (a).
(d)
An insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall annually report to the commissioner a summary of all appeals filed under this section and the disposition of those appeals.
(3)
Exceptions. This section does not apply to a health maintenance organization, limited service health organization or preferred provider plan, as defined in s. 609.01.
History:  1987 a. 156, 403; 1989 a. 31.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.845 - Prohibiting refusal to cover services because liability policy may cover.

632.845
Prohibiting refusal to cover services because liability policy may cover.
(1)
In this section, “health care plan" has the meaning given in s. 628.36 (2) (a) 1.
(2)
An insurer that provides coverage under a health care plan may not refuse to cover health care services that are provided to an insured under the plan and for which there is coverage under the plan on the basis that there may be coverage for the services under a liability insurance policy.
History:  2009 a. 28.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.85 - Coverage without prior authorization for treatment of an emergency medical condition.

632.85
Coverage without prior authorization for treatment of an emergency medical condition.
(1)
In this section:
(a)
“Emergency medical condition" means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following:
1.
Serious jeopardy to the person's health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child.
2.
Serious impairment to the person's bodily functions.
3.
Serious dysfunction of one or more of the person's body organs or parts.
(b)
“Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
(c)
“Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.
(2)
If a health care plan or a self-insured health plan provides coverage of any emergency medical services, the health care plan or self-insured health plan shall provide coverage of emergency medical services that are provided in a hospital emergency facility and that are needed to evaluate or stabilize, as defined in section 1867 of the federal Social Security Act, an emergency medical condition.
(3)
A health care plan or a self-insured health plan that is required to provide the coverage under sub. (2) may not require prior authorization for the provision or coverage of the emergency medical services specified in sub. (2).
History:  1997 a. 155.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.853 - Coverage of drugs and devices.

632.853
Coverage of drugs and devices.
A health care plan, as defined in s. 628.36 (2) (a) 1., or a self-insured health plan, as defined in s. 632.85 (1) (c), that provides coverage of only certain specified prescription drugs or devices shall develop a process through which a physician may present medical evidence to obtain an individual patient exception for coverage of a prescription drug or device not routinely covered by the plan. The process shall include timelines for both urgent and nonurgent review.
History:  1997 a. 237.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.855 - Requirements if experimental treatment limited.

632.855
Requirements if experimental treatment limited.
(1)
Definitions. In this section:
(a)
“Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
(b)
“Self-insured health plan" has the meaning given in s. 632.85 (1) (c).
(2)
Disclosure of limitations. Subject to s. 632.87 (6), a health care plan or a self-insured health plan that limits coverage of experimental treatment shall define the limitation and disclose the limits in any agreement, policy or certificate of coverage. This disclosure shall include the following information:
(a)
Who is authorized to make a determination on the limitation.
(b)
The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.
(3)
Denial of treatment.
(am)
A health care plan or a self-insured health plan that receives a request for prior authorization of an experimental procedure that includes all of the required information upon which to make a decision shall, within 5 working days after receiving the request, issue a coverage decision. If the health care plan or self-insured health plan denies coverage of an experimental treatment, procedure, drug or device for an insured who has a terminal condition or illness, the health care plan or self-insured health plan shall, as part of its coverage decision, provide the insured with a denial letter that includes all of the following:
1.
A statement setting forth the specific medical and scientific reasons for denying coverage.
2.
Notice of the insured's right to appeal and a description of the appeal procedure.
(bm)
A health care plan or a self-insured health plan may not deny coverage under par. (am) of an experimental treatment, procedure, drug, or device for an insured if the denial violates s. 632.87 (6).
History:  1997 a. 237; 2005 a. 194.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.857 - Explanation required for restriction or termination of coverage.

632.857
Explanation required for restriction or termination of coverage.
If an insurer restricts or terminates an insured's coverage for the treatment of a condition or complaint and, as a result, the insured becomes liable for payment for all of his or her treatment for the condition or complaint, the insurer shall provide on the explanation of benefits form a detailed explanation of the clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer's restriction or termination of coverage.
History:  2007 a. 20.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.867 - Oral and injected chemotherapy.

632.867
Oral and injected chemotherapy.
(1)
Definitions. In this section:
(a)
“Chemotherapy" means drugs and biologics that kill cancer cells directly, including antineoplastics, biologic response modifiers, hormone therapy, and monoclonal antibodies, and that are used to do any of the following:
1.
Cure a specific cancer.
2.
Control tumor growth when cure is not possible.
3.
Shrink tumors before surgery or radiation therapy.
4.
Destroy microscopic cancer cells that may be present after a tumor is removed by surgery to prevent a cancer recurrence.
(b)
“Disability insurance policy" has the meaning given in s. 632.895 (1) (a).
(c)
“Self-insured health plan" has the meaning given in s. 632.85 (1) (c).
(2)
Copayment, deductible, or coinsurance requirements; limitations.
(a)
Except as provided in par. (am), a disability insurance policy that covers injected or intravenous chemotherapy and oral chemotherapy, or a self-insured health plan that covers injected or intravenous chemotherapy and oral chemotherapy, may not require a higher copayment, deductible, or coinsurance amount for oral chemotherapy than it requires for injected or intravenous chemotherapy, regardless of the formulation or benefit category determination by the policy or plan.
(am)
A disability insurance policy or self-insured health plan that limits copayments paid by a covered individual to no more than $100 for a 30-day supply of oral chemotherapy medication is considered to comply with this section. On January 1, 2016, and on each January 1 annually thereafter, a disability insurance policy or self-insured health plan may adjust the $100 limit under this paragraph by an amount that does not exceed the percentage increase in the U.S. consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.
(b)
A disability insurance policy or a self-insured health plan may not comply with par. (a) by increasing the copayment, deductible, or coinsurance amount required for injected or intravenous chemotherapy that is covered under the policy or plan.
(c)
Notwithstanding par. (a), for a disability insurance policy, or self-insured health plan, that is a high deductible health plan, as defined in 26 USC 223 (c) (2), par. (a) applies only after the plan enrollee's deductible has been satisfied for the year.
History:  2013 a. 186.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.873 - Restrictions relating to fees for dental services.

632.873
Restrictions relating to fees for dental services.
(1)
Definitions. In this section, unless the context requires otherwise:
(a)
“Covered service" means, with respect to dental or related services specified in a policy or plan that provides coverage for those services, a service provided by a dentist or at the direction of a dentist to an insured under the policy or an enrollee of the plan for which the policy or plan makes payment, administered consistently with policies traditionally governing covered services, or for which the policy or plan would make payment but for the application of contractual limitations of deductibles, copayments, coinsurance, waiting periods, annual maximums, lifetime maximums applicable to the same course of treatment, frequency limitations, or alternative benefit payments.
(b)
“Policy" means a policy, certificate, or contract of insurance that provides only limited-scope dental benefits.
(c)
“Related service" means a service that is commonly provided, by a dentist or at the direction of a dentist, in conjunction with a dental service.
(2)
Prohibitions on setting fees.
(a)
1.
A contract between an insurer offering a policy that provides coverage for dental and related services and a dentist for the provision of dental and related services to an insured under the policy may not require the dentist to provide a service to an insured under the policy at a fee set by the insurer unless the service is a covered service under the policy.
2.
A policy that provides coverage for dental and related services may not provide nominal or de minimis coverage for a dental or related service for the sole purpose of avoiding the requirements under subd. 1.
(b)
An administrator providing 3rd-party administration services or a provider network for a plan that provides coverage for dental and related services may not require any dentist in the administrator's provider network that is eligible to provide services under the plan to charge set fees for dental or related services provided to enrollees of the plan that are not covered services under the plan.
(3)
Prohibition on charges. A dentist who, under a contract with an insurer offering a policy that provides coverage for dental and related services, provides dental or related services to an insured under the policy may not charge the insured more than the dentist's usual nondiscounted fee for a dental or related service that is not a covered service under the policy.
History:  2013 a. 26.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.88 - Policy extension for handicapped children.

632.88
Policy extension for handicapped children.
(1)
Termination of coverage. Every hospital or medical expense insurance policy or contract that provides that coverage of a dependent child of a person insured under the policy shall terminate upon attainment of a limiting age for dependent children specified in the policy shall also provide that the age limitation may not operate to terminate the coverage of a dependent child while the child is and continues to be both:
(a)
Incapable of self-sustaining employment because of intellectual disability or physical handicap; and
(b)
Chiefly dependent upon the person insured under the policy for support and maintenance.
(2)
Proof of incapacity. The insurer may require that proof of the incapacity and dependency be furnished by the person insured under the policy within 31 days of the date the child attains the limiting age, and at any time thereafter except that the insurer may not require proof more frequently than annually after the 2-year period immediately following attainment of the limiting age by the child.
History:  1975 c. 375; 2011 a. 126.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.885 - Coverage of dependents.

632.885
Coverage of dependents.
(1)
Definitions. In this section:
(af)
“Eligible employer-sponsored plan" has the meaning given in 26 USC 5000A (f) (2).
(ar)
“Grandfathered health plan" has the meaning given under section 1251 of the Patient Protection and Affordable Care Act (P.L. 111-148).
(at)
“Health insurance coverage" has the meaning given in 42 USC 300gg-91 (b) (1).
(b)
“Insured" includes an enrollee.
(c)
“Self-insured health plan" has the meaning given in s. 632.745 (24).
(2)
Requirement to offer dependent coverage.
(a)
Subject to ss. 632.88 and 632.895 (5), and except as provided in pars. (b) and (c), every insurer that offers health insurance coverage that provides dependent coverage of children, and every self-insured health plan that provides dependent coverage of children, shall provide coverage for any child of an applicant or insured as a dependent of the applicant or insured if the child is under the age of 26.
(b)
Except as provided in par. (c), the coverage requirement under this section applies to an adult child who satisfies all of the following criteria:
1.
The child is a full-time student, regardless of age.
3.
The child was called to federal active duty in the national guard or in a reserve component of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher education.
4.
The child was under the age of 27 years when called to federal active duty under subd. 3.
(c)
For any policy year or plan year beginning before January 1, 2014, health insurance coverage or a self-insured health plan described in par. (a) that is a grandfathered health plan is required to provide dependent coverage for an adult child described in par. (a) or (b) only if the child is not eligible for coverage under an eligible employer-sponsored plan other than the health insurance coverage or self-insured health plan.
(3m)
Defining dependent; uniform terms. An insurer or self-insured health plan described in sub. (2) may not do any of the following:
(a)
Define “dependent" for purposes of eligibility for dependent coverage of children other than in terms of the relationship between a child and an applicant or insured.
(b)
Vary the terms of coverage under the health insurance coverage or self-insured health plan on the basis of age except for children 26 years of age or older.
History:  2009 a. 28; 2011 a. 32.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.8985 - Prohibiting abortion coverage.

632.8985
Prohibiting abortion coverage.
(1)
In this section, “abortion" has the meaning given in s. 253.10 (2) (a).
(2)
A qualified health plan, as defined in 42 USC 18021 (a), that is offered through any American health benefit exchange, as described in 42 USC 18031, that is operating in the state may not cover any abortion the performance of which is ineligible for funding under s. 20.927.
History:  2011 a. 218.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.899 - Medical savings accounts study.

632.899
Medical savings accounts study.
If the federal government enacts legislation providing for a federal income tax exemption for amounts deposited in a medical savings account and for any interest, dividends or other gain that accrues in the account if redeposited in the account, the commissioner shall conduct a study, to be completed within 4 years after the enactment of the federal legislation, of individuals and groups that had coverage under a high cost-share health plan, as defined in s. 632.898 (1) (c), 1995 stats., and that terminated that coverage in order to enroll in a health benefit plan that was not a high cost-share health plan, as defined in s. 632.898 (1) (c), 1995 stats. The commissioner shall submit a report of all findings, conclusions and recommendations to the appropriate standing committees in the manner provided under s. 13.172 (3).
History:  1997 a. 27; 2007 a. 96.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.91 - Definition.

632.91
Definition.
In this subchapter:
(1)
“Insured employee" means an employee of a fraternal or of a subsidiary or other affiliate of a fraternal who is provided insurance benefits by the fraternal under s. 614.10 (2) (c) 2. but is not a member of the fraternal.
(2)
“Owner" means the owner of a policy or certificate issued by a fraternal in accordance with s. 614.10.
History:  1989 a. 336; 1991 a. 189; 1997 a. 177.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.93 - The fraternal contract.

632.93
The fraternal contract.
(1)
Issuance of certificate. A fraternal shall issue to each owner a policy or certificate specifying the benefits provided and containing at least in substance all sections of the laws of the fraternal which might result in the termination of coverage or the reduction of benefits. The policy or certificate, any riders or endorsements attached thereto, the laws of the fraternal, and the application and declarations made in connection therewith and signed by the applicant, constitute the agreement between the fraternal and the owner, and the policy or certificate shall so state.
(2)
Changes in laws of fraternals. Except as provided in s. 614.24 (1m), any changes in the laws of a fraternal made subsequent to the issuance of a policy or certificate bind the owner and any beneficiary under the policy or certificate as if they had been in force at the time of the application, so long as they do not destroy or diminish benefits promised in the policy or certificate.
(3)
Proof of terms. Copies of any documents mentioned in subs. (1) and (2), certified by the secretary or corresponding officer of the fraternal, are evidence of the terms and conditions of the contract.
(4)
Inapplicable provisions. Sections 631.13 and 632.44 (2) do not apply to fraternal contracts.
(5)
Grace period. Every fraternal certificate shall contain a provision entitling the owner to a grace period of not less than one month, or 30 days at the fraternal's option, for the payment of any premium due except the first, during which the death benefit shall continue in force. A fraternal may specify in the grace period provision that the overdue premium will be deducted from the death benefit in the event of death before it is paid.
(6)
Compliance with other provisions. If a fraternal's laws provide for expulsion or suspension of a member for any reason other than nonpayment of premium or under s. 632.46, the fraternal's insurance certificate shall contain a provision that if a member is expelled or suspended for any reason other than nonpayment of premium or under s. 632.46, the expelled member, or other owner who was provided insurance benefits under s. 614.10 on the application of the expelled member, has the right to maintain the policy in force by continuing payment of the required premium.
(7)
Scope of application. This section applies to all contracts made by a fraternal beginning 6 months after December 18, 1979. A fraternal may elect to have this section apply at an earlier date, so long as it applies simultaneously to all such contracts and the fraternal gives the commissioner at least 30 days' notice of intention to adopt this section.
History:  1975 c. 373; 1979 c. 102 ss. 179 to 182, 237; 1987 a. 361; 1989 a. 336; 1997 a. 177.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.95 - Fraud in obtaining membership.

632.95
Fraud in obtaining membership.
Subject to s. 632.46, any certificate of membership secured by misrepresentation in or with reference to any application for membership or documentary or other proof for the purpose of obtaining membership in or noninsurance benefit from the fraternal is void, if the fraternal relied on it and it is either material or fraudulent.
History:  1975 c. 373.
Legislative Council Note, 1975: This section continues the contractual portion of s. 208.38, edited with a change in meaning, to include nonfraudulent but material misrepresentation, and also to subject the provision to the rule of incontestability provided in s. 632.46. [Bill 643-S]
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.96 - Beneficiaries in fraternal contracts.

632.96
Beneficiaries in fraternal contracts.
(1)
Any owner may designate as beneficiary any person permitted by the laws of the fraternal. Those laws shall authorize the designation of the estate of a member or insured employee as beneficiary.
(2)
Subject to sub. (1), s. 632.48 applies.
History:  1975 c. 373, 421; 1989 a. 336; 1997 a. 177.
Legislative Council Note, 1975: Sub. (1) states a rule slightly more restrictive of the range of permitted beneficiaries than for commercial life insurance; this reflects the nature of the fraternal. Sub. (2) applies the general provision for life insurance, subject to sub. (1). [Bill 643-S]
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.97 - Application of proceeds of credit insurance policy.

632.97
Application of proceeds of credit insurance policy.
Payment to a creditor of any amounts insured under the terms of a credit insurance policy reduces the debt proportionately. This rule does not apply to an insurance policy on which the debtor pays no part of the premium, directly or indirectly.
History:  1975 c. 375.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.98 - Worker's compensation insurance.

632.98
Worker's compensation insurance.
Sections 102.31, 102.315, and 102.62 apply to worker's compensation insurance.
History:  1975 c. 375, 421; 1979 c. 102; 2007 a. 185.
2023 Wisconsin Statutes & Annotations › Chapter 632 - Insurance contracts in specific lines. › 632.99 - Certifications of disability.

632.99
Certifications of disability.
For the purpose of insurance policies that they issue, every insurer doing a health or disability insurance business in this state shall afford equal weight to a certification of disability signed by a physician with respect to matters within the scope of the physician's professional license, to a certification of disability signed by a chiropractor with respect to matters within the scope of the chiropractor's professional license, and to a certification of disability signed by a podiatrist with respect to matters within the scope of the podiatrist's professional license. This section does not require an insurer to treat any certification of disability as conclusive evidence of disability.
History:  1981 c. 55; 2009 a. 113.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.01 - Definitions.

633.01
Definitions.
In this chapter:
(1)
“Administrator" means a person who directly or indirectly solicits or collects premiums or charges or otherwise effects coverage or adjusts or settles claims for an employee benefit plan, but does not include the following persons if they perform these acts under the circumstances specified for each:
(a)
An employer on behalf of its employees or the employees of a subsidiary or affiliated employer.
(b)
A union on behalf of its members.
(c)
A creditor on behalf of its debtor, if to obtain payment, reimbursement or other method of satisfaction from an employee benefit plan for any part of a debt owed to the creditor by the debtor.
(d)
A financial institution that is subject to supervision or regulation in performing these acts by federal or other state authorities.
(e)
A company that issues credit cards and provides advances for, or collects premiums or charges from, its credit card holders, if the company does not adjust or settle claims.
(f)
An attorney who adjusts or settles claims in the normal course of practice or employment as an attorney, if the attorney does not collect charges or premiums.
(g)
An agent licensed in this state whose activities are limited to the sale of insurance.
(h)
An insurer authorized to do an insurance business in this state if the insurer performs these acts in the normal course of its insurance business.
(2)
“Employee" means any of the following or a family member or dependent of any of the following:
(a)
An active or retired wage or salary earner whose services are or were used by an employer.
(b)
A member of a union, trust or association.
(c)
A college or university student.
(d)
A person receiving continued group coverage under s. 632.897.
(2g)
“Employee benefit plan" means an insured or wholly or partially self-insured employee benefit plan which by means of direct payment, reimbursement or other arrangement provides to one or more employees who are residents of this state benefits or services that include, but are not limited to, benefits for medical, surgical or hospital care, benefits in the event of sickness, accident, disability or death, or benefits in the event of unemployment or retirement.
(2r)
“Enrollee” has the meaning given in s. 632.861 (1) (b).
(3)
“Insured employee" means an employee who is a resident of this state and who is covered under an employee benefit plan.
(4g)
“Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
(4r)
“Prescription drug benefit” has the meaning given in s. 632.865 (1) (e).
(5)
“Principal" means a person, including an insurer, that uses the services of an administrator to provide an employee benefit plan.
(6)
“Self-insured health plan" has the meaning given in s. 632.85 (1) (c).
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.04 - Written agreement required.

633.04
Written agreement required.
An administrator may not administer an employee benefit plan in the absence of a written agreement between the administrator and a principal. The administrator and principal shall each retain a copy of the written agreement for the duration of the agreement and for 5 years thereafter. The written agreement shall contain the following terms:
(1)
That the administrator and principal shall each retain a copy of the written agreement as provided under this section.
(2)
If a policy is issued to a trust, that the administrator shall retain a copy of the trust agreement for the duration of the trust agreement and for 5 years thereafter.
(3)
If the principal is an insurer, that payments to an administrator shall be treated as provided in s. 633.05.
(4)
That the administrator shall maintain and retain books and records pertaining to a principal dating back 5 years at all times or until delivered to the principal by the administrator, with the right of examination and audit as provided in s. 633.06 (1), and the right of inspection and any restrictions on the right of inspection, as provided in s. 633.06 (2).
(5)
If the principal is an insurer, that advertising shall be approved as provided in s. 633.07.
(6)
If the principal is an insurer, that the terms, as required by s. 633.08, specify any underwriting responsibilities which the insurer has delegated to the administrator.
(7)
That funds shall be collected and received as provided in s. 633.09 (1), that funds shall be paid and deposited as provided in s. 633.09 (1), that fiduciary account records shall be maintained and provided as provided in s. 633.09 (2), that interest shall be treated as provided in s. 633.09 (3) or that other terms shall specify treatment of interest, that withdrawals for payments of claims are not permitted as provided in s. 633.09 (4) (a), and that other withdrawals are permitted only as provided under s. 633.09 (4) (b).
(8)
That claims are to be paid as provided in s. 633.10.
(9)
That compensation to an administrator shall be paid as provided in s. 633.11.
(10)
That notification shall be given as provided in s. 633.12.
(11)
That an administrator has been licensed as provided in s. 633.13 (1) or need not be licensed as provided in s. 633.13 (2).
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.05 - Payment to administrator.

633.05
Payment to administrator.
If a principal is an insurer, payment to the administrator of a premium or charge by or on behalf of an insured employee is payment to the insurer, but payment of a return premium or claim by the insurer to the administrator is not payment to an insured employee until the payment is received by the insured employee. This section does not limit any right of the insurer against the administrator for failure to make payments to the insurer or an insured employee.
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.06 - Examination and inspection of books and records.

633.06
Examination and inspection of books and records.
(1)
The commissioner may examine, audit or accept an audit of the books and records of an administrator or pharmacy benefit manager as provided for examination of licensees under s. 601.43 (1), (3), (4) and (5), to be conducted as provided in s. 601.44, and with costs to be paid as provided in s. 601.45.
(2)
A principal that uses an administrator may inspect the books and records of the administrator, subject to any restrictions set forth in ss. 146.81 to 146.835 and in the written agreement required under s. 633.04, for the purpose of enabling the principal to fulfill its contractual obligations to insured employees.
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.07 - Approval of advertising.

633.07
Approval of advertising.
An administrator may not use any advertising for an employee benefit plan underwritten by an insurer unless the insurer approves the advertising in advance.
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.08 - Underwriting responsibilities.

633.08
Underwriting responsibilities.
If a principal is an insurer, any underwriting responsibilities regarding eligibility that the insurer has delegated to an administrator shall be set forth in the written agreement required under s. 633.04.
History:  1991 a. 39.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.09 - Accounts.

633.09
Accounts.
(1)
Moneys held in fiduciary capacity. An administrator shall hold in a fiduciary capacity all moneys that the administrator collects or receives on behalf of other persons. Within 2 business days after collection or receipt of such moneys, the administrator either shall pay the moneys to the persons entitled to them or shall deposit the moneys in a fiduciary account established and maintained by the administrator in a financial institution.
(2)
Fiduciary account records. An administrator shall maintain fiduciary account records in accordance with generally accepted accounting principles. The administrator shall retain the fiduciary account records pertaining to a principal for at least 5 years beginning on the date of creation of the records. If an administrator deposits in a fiduciary account moneys that the administrator has collected on behalf of more than one principal, the administrator shall keep records of the account that clearly indicate deposits made under sub. (1) and withdrawals made under sub. (4) on behalf of each principal. Upon request by a principal, the administrator shall provide the principal copies of those portions of the records pertaining to deposits and withdrawals made on behalf of the principal and shall otherwise permit inspection by the principal as provided under s. 633.06 (2).
(3)
Interest on deposits. Interest earned on moneys deposited in a fiduciary account is the property of the principal unless otherwise provided in the written agreement required under s. 633.04.
(4)
Withdrawals from fiduciary account.
(a)
An administrator may not pay any claim by withdrawal from a fiduciary account.
(b)
An administrator may make the following payments from a fiduciary account:
1.
To a principal, the funds belonging to the principal.
2.
To an employee benefit plan policyholder for payment to a principal, the funds belonging to the principal.
3.
To an insured employee, the funds belonging to the insured employee.
4.
To another account maintained in the name of a principal, the funds belonging to the principal.
5.
To a claims paying account, the funds belonging to a principal for payment of claims owed by the principal.
6.
To the administrator, commissions, fees or charges owed the administrator by a principal.
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.10 - Payment of claims.

633.10
Payment of claims.
An administrator shall pay claims from funds paid to the claims paying account under s. 633.09 (4) (b) 5. on drafts or checks authorized in advance by the principal.
History:  1991 a. 39.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.11 - Claim adjustment compensation.

633.11
Claim adjustment compensation.
If an administrator adjusts or settles claims under an employee benefit plan, the commission, fees or charges that the principal pays the administrator may not be based on the employee benefit plan's loss experience. This section does not prohibit compensation based on the number or amount of premiums or charges collected, or the number or amount of claims paid or processed by the administrator.
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.12 - Notification required.

633.12
Notification required.
(1)
An administrator shall prepare sufficient copies of a written notice approved in advance by the principal for distribution to all insured employees of the principal and either shall distribute the copies to the insured employees or shall provide the copies to the principal for distribution to the insured employees. The written notice shall contain all of the following:
(a)
The names and addresses of the administrator and the principal.
(b)
An explanation of the respective rights and responsibilities of the administrator, the principal and the insured employees.
(c)
A statement of the extent to which the employee benefit plan is insured or self-insured, and an explanation of the terms “insured" and “self-insured".
(2)
If an administrator collects premiums or charges from a person on behalf of a principal, at least once in every year, prior to collecting the premiums or charges, the administrator shall provide written notice to the person stating the amount of the premiums or charges.
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.13 - License required.

633.13
License required.
(1)
General. Except as provided in sub. (2), a person may not perform, offer to perform or advertise any service as an administrator or a pharmacy benefit manager unless the person has obtained a license under s. 633.14. A pharmacy benefit manager that also performs services as an administrator need only obtain an administrator license under s. 633.14.
(2)
Exemptions. The commissioner may exempt by rule certain classes of administrators from the requirement of sub. (1) if the commissioner determines any of the following:
(a)
That the functions that the administrators perform do not require special competence or trustworthiness or otherwise do not require the regulatory surveillance of a licensing requirement.
(b)
That other safeguards make a licensing requirement unnecessary.
(3)
Responsibilities of principal. A principal may not use the services of an administrator unless the administrator furnishes proof of licensure under s. 633.14 or exemption under sub. (2). An insurer or a self-insured health plan may not use the services of a pharmacy benefit manager unless the pharmacy benefit manager furnishes proof of licensure under s. 633.14.
History:  1991 a. 39; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.16 - Regulation.

633.16
Regulation.
Nothing in this chapter gives the commissioner the authority to impose requirements on an employee benefit plan that is exempt from state law under 29 USC 1144 (b).
History:  1991 a. 39; Stats. 1991 s. 633.16; 2021 a. 9.
The commissioner lacks authority to regulate administrators of self-funded or self-insured employee benefit plans. 80 Atty. Gen. 290.
2023 Wisconsin Statutes & Annotations › Chapter 633 - Employee benefit plan administrators, principals, and pharmacy benefit managers. › 633.17 - Rule-making authority.

633.17
Rule-making authority.
The commissioner shall promulgate rules necessary for the implementation of this chapter, in addition to the rules permitted under s. 633.13 (2) and required under ss. 633.14 (3) and 633.15 (1) (b).
History:  1991 a. 39.
2023 Wisconsin Statutes & Annotations › Chapter 635 - Small employer health insurance. › 635.01 - Scope.

635.01
Scope.
This chapter applies to all group health insurance plans, policies or certificates, written on risks or operations in this state, providing coverage for employees of a small employer, or employees of a small employer and the employer, and to individual health insurance policies, written on risks or operations in this state, providing coverage for employees of a small employer, or employees of a small employer and the employer when 3 or more are sold to or through a small employer.
History:  1991 a. 39; 1997 a. 27.
2023 Wisconsin Statutes & Annotations › Chapter 635 - Small employer health insurance. › 635.05 - Rate regulation.

635.05
Rate regulation.
Notwithstanding ch. 625, the commissioner shall promulgate rules:
(1)
Establishing restrictions on premium rates that a small employer insurer may charge a small employer such that the premium rates charged to small employers with similar case characteristics for the same or similar benefit design characteristics do not vary from the midpoint rate for those small employers by more than 35 percent of that midpoint rate.
(2)
Establishing restrictions on increases in premium rates that a small employer insurer may charge a small employer such that:
(a)
The percentage increase in the premium rate for a new rating period does not exceed the sum of the following:
1.
The percentage change in the new business premium rate measured from the first day of the prior rating period to the first day of the new rating period, or the percentage change in the base premium rate in the case of a class of business for which the small employer insurer is not issuing new policies.
2.
An adjustment, not to exceed 15 percent per year, adjusted proportionally for rating periods of less than one year, for such rating factors as claim experience, health status, occupation, and duration of coverage, determined in accordance with the small employer insurer's rate manual or rating procedures.
3.
An adjustment for a change in case characteristics or in benefit design characteristics, determined in accordance with the small employer insurer's rate manual or rating procedures.
(b)
The percentage increase in the premium rate for a new rating period for a policy issued before August 15, 1991, does not exceed the sum of par. (a) 1. and 3., unless premium rates are in compliance with the rules promulgated under sub. (1).
(3)
Requiring the premium rate of a policy issued before August 15, 1991, to comply with the rules promulgated under sub. (1) no later than 3 years after August 15, 1991.
(4)
Defining the terms necessary for compliance with this section.
(5)
Ensuring that small employers are classified using objective criteria.
(6)
Ensuring that rating factors are applied objectively and consistently within a class of business.
History:  1991 a. 39, 250; 2001 a. 16; 2021 a. 114.
2023 Wisconsin Statutes & Annotations › Chapter 635 - Small employer health insurance. › 635.10 - Uniform employee application.

635.10
Uniform employee application.
Beginning no later than August 1, 2003, every small employer insurer shall use the uniform employee application form developed by the commissioner by rule under s. 601.41 (8) (b) when a small employer applies for coverage under a group health benefit plan offered by the small employer insurer.
History:  2001 a. 109.
2023 Wisconsin Statutes & Annotations › Chapter 635 - Small employer health insurance. › 635.11 - Disclosure of rating factors and renewability provisions.

635.11
Disclosure of rating factors and renewability provisions.
(1m)
Before the sale of a plan or policy subject to this chapter, a small employer insurer shall disclose to a small employer all of the following:
(a)
The small employer insurer's right to increase premium rates and the factors limiting the amount of increase.
(b)
The extent to which benefit design characteristics and case characteristics affect premium rates.
(c)
The extent to which rating factors and changes in benefit design characteristics and case characteristics affect changes in premium rates.
(d)
The small employer's renewability rights.
(e)
As part of the small employer insurer's solicitation and sales materials, the availability of the information under par. (f).
(f)
Upon the request of the small employer, the following information:
1.
The provisions, if any, of the plan or policy relating to preexisting condition exclusions.
2.
The benefits and premiums available under all health insurance coverage offered by the small employer insurer for which the small employer is qualified.
(2m)
Information required to be disclosed under this section shall be provided in a manner that is understandable to a small employer and shall be sufficient to reasonably inform a small employer of the small employer's rights and obligations under the health insurance coverage.
(3m)
A small employer insurer is not required under this section to disclose information that is proprietary or trade secret information under applicable law.
History:  1991 a. 39, 250, 315; 1997 a. 27.
2023 Wisconsin Statutes & Annotations › Chapter 635 - Small employer health insurance. › 635.13 - Records.

635.13
Records.
A small employer insurer shall maintain at its principal place of business complete and detailed records relating to its rating methods and practices and its renewal underwriting methods and practices, and shall make the records available to the commissioner upon request.
History:  1991 a. 39, 250; 1997 a. 27; 2015 a. 90.
2023 Wisconsin Statutes & Annotations › Chapter 635 - Small employer health insurance. › 635.15 - Temporary suspension of rate regulation.

635.15
Temporary suspension of rate regulation.
The commissioner may suspend the operation of all or any part of s. 635.05 with respect to one or more small employers for one or more rating periods upon the written request of a small employer insurer and a finding by the commissioner that the suspension is necessary in light of the financial condition of the small employer insurer or that the suspension would enhance the efficiency and fairness of the small employer health insurance market.
History:  1991 a. 39, 250.