reglab/statecodes huggingface dataset:
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.54 - Guaranteed renewability; cancellation and renewal restrictions

Current through June 24, 2024
(1) DEFINITION.
(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.
(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.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.56 - Certification of compliance; additional information required

Current through June 24, 2024
(1) The annual
				certification of compliance required under s.
				635.13,
				Stats., shall be submitted in the form prescribed by the office.
(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:
(a) Rate manuals or exhibits of all rating
				factors used for each class of business.
(b) Sample data of small employers including
				premiums charged and rating factors applied for case characteristics and
				benefit design characteristics.
(c)
				An inventory of case characteristics used by the small employer insurer since
				the last certification date.
(d) An
				exhibit showing the difference in new business premium rates between the
				current certification date and the last certification date.
(e) A description of how midpoint rates are
				determined.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section 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

Current through June 24, 2024
(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.
(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.
(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:
(a) The enrollment period is simultaneous for
				all the policies;
(b) The eligible
				employee may choose any one of the offered policies; and
(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).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section 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

Current through June 24, 2024
(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:
(b) The individual elected coverage under
				another policy during an enrollment period permitted under s.
				Ins
				8.59(3);
(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;
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.61 - Small employer insurers shall offer coverage to new entrants

Current through June 24, 2024
(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. 8.59(3) shall offer the new entrant the same
				choice of policies during the new entrant's enrollment period
(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.
(4) A small employer insurer may not add
				coverage restrictions or limitations under a policy because of the risk
				characteristics of a new entrant.
(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).
1995 Wis. Act 289 repealed s. 635.17, Stats. See s.
					 632.746(1),
					 Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section 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

Current through June 24, 2024
(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).
(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.
(3) The enrollment period
				required under this section shall comply with all of the following:
(a) It shall commence no later than 45 days
				after December 1, 1993, and shall last for a period of at least 90
				days.
(b) Underwritten individuals
				who are provided an opportunity to enroll under this section shall be treated
				as new entrants.
(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.
Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s.
				  632.746(1),
				  Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.63 - Small employer insurers shall offer coverage to late enrollees

Current through June 24, 2024
(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.
(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.
Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s.
				  632.746(1),
				  Stats.
(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).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.64 - Small employer insurers may not participate with a small employer to coerce, or discriminate among, eligible employees or dependents

Current through June 24, 2024
(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.
(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.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.65 - A small employer insurer shall require small employers to provide documentation to establish that waivers of coverage are voluntary and permitted

Current through June 24, 2024
(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.
(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:
(a) A
				certification that the individual who declined coverage was informed of the
				availability of coverage under the policy;
(b) That the reason for declining coverage be
				stated; and
(c) A written warning
				of the consequences which may be imposed on late enrollees.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.66 - Qualifying coverage for portability and late enrollees; transition

Current through June 24, 2024
(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:
Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s.
				  632.745(4),
				  Stats.
(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.
(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:
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
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.
(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.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.67 - Restrictive riders prohibited

Current through June 24, 2024
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.
1995 Wis. Act 289 repealed s. 635.17, Stats. See s.
					 632.748(1),
					 Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.68 - Fair marketing standards

Current through June 24, 2024
(1)
(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:
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.
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:
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
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.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter III - Small Employer Health Insurance › Section Ins 8.69 - Minimum standards for market share of basic health benefit plans in force; exemption from guarantee issuance of the basic health benefit plan

Current through June 24, 2024
(1) No small
				employer insurer may have a basic market share ratio which is significantly
				less than the basic market share ratio for all small employer insurers unless
				the insurer establishes by clear and convincing evidence that the reason the
				basic market share ratio is significantly less is because:
(a) Of a specific practice or condition that
				is beyond the control of the insurer; or
(b) The insurer uses risk characteristics to
				underwrite applications for policies to a substantially lesser extent than most
				other small employer insurers.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.70 - Purpose

Current through June 24, 2024
This subchapter implements ch. 635, Stats., by establishing
				  the basic health benefit plan that small employer insurers shall actively
				  market and offer to small employers.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.71 - Definitions

Current through June 24, 2024
(1) The definitions in s.
				635.02, Stats., apply
				to this subchapter.
(2) In this
				subchapter, "health care provider" means any of the following:
(a) A medical or osteopathic physician,
				podiatrist, physical therapist or physician's assistant licensed or certified
				under ch. 448, Stats.
(b) A
				psychologist licensed under ch. 445, Stats.
(c) A chiropractor licensed under ch. 446,
				Stats.
(d) A nurse midwife
				certified under s.
				441.15,
				Stats.
(e) A nurse practitioner
				licensed under ch. 441, Stats.
(f)
				A nurse licensed under ch. 441, Stats., who is certified as a nurse anesthetist
				by the American association of nurse anesthetists.
(g) A dentist licensed under ch. 447,
				Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.72 - Basic benefits

Current through June 24, 2024
Subject to the limitations and restrictions under s.
				  Ins
				  8.75 and copayments and coinsurance under s.
				  Ins 8.77,
				  each plan shall provide coverage for all of the following, if medically
				  necessary:
(1)Professional services by
				a health care provider acting within the scope and limitations of his or her
				license or certificate or a person acting under the direction of a health care
				provider, including all of the following:
(a)
				Office, outpatient, inpatient and emergency room visits including treatment
				rendered during those visits.
(b)
				Surgical services including postoperative care following inpatient or
				outpatient surgery.
(c) Services of
				an assistant surgeon if necessary to perform surgery.
(d) Anesthesia services.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.73 - Health insurance mandates

Current through June 24, 2024
A plan shall comply with the health insurance mandates, as
				  defined in s.
				  601.423,
				  Stats., and may not exclude or limit coverage for any mandate except as
				  provided in s.
				  Ins
				  8.75(3).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.74 - Policy title; term

Current through June 24, 2024
(1) The policy form for a plan submitted to
				the office of the commissioner of insurance for approval under s.
				631.20,
				Stats., shall be entitled "basic health benefit plan."
(2) The term period for plan coverage shall
				not be less than 12 months.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.75 - Limitations and restrictions

Current through June 24, 2024
(1) PREEXISTING
				CONDITIONS. Section 635.17(1), Stats., applies to a plan subject to this
				subchapter.
Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s.
				  632.746,
				  Stats.
(2) ANNUAL MAXIMUM.
				The annual calendar year maximum benefit for a plan is $30,000 per insured
				individual. Charges for a hospitalization which extends from one calendar year
				to another shall be subject to the calendar year maximum for the year in which
				each charge was incurred and only one $100 copayment shall apply to the
				confinement.
(3) LIMITATION ON
				COVERAGE FOR MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT. The annual calendar
				year benefit payable for treatment of a covered person for nervous and mental
				disorders and alcoholism and other drug abuse is $1,400. A plan may not apply
				the cost of outpatient prescription drugs used in the treatment of nervous and
				mental disorders or alcoholism or other drug abuse toward the annual limit
				specified in this subsection.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.76 - Policy terms; exclusions; limitations

Current through June 24, 2024
(1) Except as
				otherwise provided in this subchapter, a plan's policy terms shall be defined
				consistently with the definitions in the small employer insurer's other small
				group health benefit plans.
(2) A
				plan may exclude from coverage or limit coverage for specified conditions and
				services other than those required under s.
				Ins 8.72
				butmayexclude or limit only those conditions and services which are generally
				excluded from coverage or limited under the small employer insurer's other
				small group health benefit plans.
(3) A plan may apply the same limitations on
				provider choice, coverage and geographical service area that apply under the
				small employer insurer's other small group health benefit plans.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.77 - Copayments; coinsurance

Current through June 24, 2024
(1) DEFINITIONS. In this section:
(a) "Primary care provider" means any of the
				following:
1. If the plan is an indemnity
				plan, a preferred provider organization or health maintenance organization that
				does not require the insured to designate a primary provider, the physician who
				normally provides care to the insured, if the physician is any of the
				following:
a. A physician who is not
				certified by any specialty board.
b. A physician certified by the American
				board of family practice.
c. A
				physician certified by the American board of internal medicine.
d. A physician certified by the American
				board of obstetrics and gynecology.
e. A physician certified by the American
				board of pediatrics.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.78 - Participation; enrollment

Current through June 24, 2024
(1) PARTICIPATION.
(a) A small employer insurer shall offer a
				plan to any small employer meeting the definition of eligible employer in s.
				635.20(2), Stats., regardless of the number required for participation in other
				small group health benefit plans offered by the small employer insurer.
Note: 1997 Wis. Act 27 repealed s. 635.20.
(b) In par. (c), the number of persons in a
				group means the number of eligible employees without other qualifying coverage,
				as defined in s.
				635.02(5m),
				Stats.
Note: 1995 Wis. Act 289 repealed s.
				  635.02(5m).
(c) A small employer insurer may
				impose participation requirements on a plan offered to a small employer, not to
				exceed the following:
1. For a group of more
				than 10 persons: 70% of the group.
2. For a group of 10 persons: 6
				participants.
3. For a group of 8
				or 9 persons: 5 participants.
4.
				For a group of 7 persons: 4 participants.
5. For a group of 5 or 6 persons: 3
				participants.
6. For a group of 2
				to 4 persons: 2 participants.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.79 - Managed care options

Current through June 24, 2024
A small employer insurer that offers health benefit plans
				  with one or more managed care options in the small employer market shall offer
				  purchasers of a basic health benefit plan at least one managed care option. If
				  the option offered is a preferred provider plan, as defined under s.
				  609.01(4),
				  Stats., the small employer insurer, in order to encourage the use of health
				  care providers that participate in the plan, may increase any copayment
				  specified in s.
				  Ins
				  8.77(2) or the percentage of an
				  insured's coinsurance under s.
				  Ins
				  8.77(3) if the insured uses a
				  nonparticipating health care provider.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.80 - Rating

Current through June 24, 2024
(1) In establishing the new business premium
				rate for the plan, a small employer insurer shall take into account the
				experience of all of its small employer health benefit plans. The differences
				between the plan's new business premium rate and the insurer's new business
				premium rates for all other small employer health benefit plans shall be based
				solely on the differences in the plan designs and not on the actual or
				anticipated experience of those insured under the basic health benefit
				plan.
(2)
(a)
1.
				Except as provided in par. (b), the plan shall apply a higher rate to smokers
				than to nonsmokers. The rate applied to smokers shall be no higher than
				permitted under s.
				111.35(3),
				Stats. The small employer insurer shall provide the small employer with enough
				copies of the statements required under s.
				111.35(3)
				(a) 2. and (b) 2., Stats., for distribution
				to all plan participants.
2. For
				the purpose of complying with s.
				635.05, Stats.,
				and s.
				Ins
				8.52, smoking status shall be treated as a case
				characteristic.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance › Subchapter IV - Basic Health Benefit Plan For Small Employers › Section Ins 8.81 - Form approval and marketing

Current through June 24, 2024
(1) Except as
				provided in s. 635.26(2m) to (4), Stats., each small employer insurer shall
				file its basic health benefit plan policy form with the commissioner of
				insurance under s.
				631.20,
				Stats., before October 1, 1993.
Note: 1997 Wis. Act 27 repealed s. 635.26, Stats. See s.
				  635.19(2),
				  Stats.
(2) Except as
				provided in s. 635.26(2m) to (4), Stats., no small employer insurer shall
				market any health benefit plan to small employers on and after December 1, 1993
				unless its basic health benefit plan policy form has been filed with and
				approved by the commissioner of insurance under s.
				631.20,
				Stats.
1997 Wis. Act 27 repealed s. 635.26, Stats. See 635.19 (2),
					 Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter I - Definitions › Section Ins 9.01 - Definitions

Current through June 24, 2024
In this chapter, and for the purposes of applying ch. 609,
				  Stats.:
(1) "Acceptable letter of
				credit" means a clean, unconditional, irrevocable letter of credit issued by a
				Wisconsin bank or any other financial institution acceptable to the
				commissioner which renews on an annual basis for a 3-year term unless written
				notice of nonrenewal is given to the commissioner and the limited service
				health organization at least 60 days prior to the renewal date.
(2) "Commissioner" means the "commissioner of
				insurance" of this state or the commissioner's designee.
(3) "Complaint" means any expression of
				dissatisfaction expressed to an insurer by an enrollee, or an enrollee's
				authorized representative, about the insurer or its participating
				providers.
(3m) "Defined network
				plan" has the meaning provided under s.
				609.01(1b),
				Stats., and includes Medicare select policies and certificates, as defined in
				s. Ins 3.39(3) (vm) and (ve), respectively, and health benefit plans that
				contract for use of participating providers.
(4) "Expedited grievance" means a grievance
				where the standard resolution process may include any of the following:
(a) Serious jeopardy to the life or health of
				the enrollee or the ability of the enrollee to regain maximum
				function.
(b) In the opinion of a
				physician with knowledge of the enrollee's medical condition, would subject the
				enrollee to severe pain that cannot be adequately managed without the care or
				treatment that is the subject of the grievance.
(c) It is determined to be an expedited
				grievance by a physician with knowledge of the enrollee's medical
				condition.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter I - Definitions › Section Ins 9.015 - Scope

Current through June 24, 2024
This chapter applies to all insurers offering a defined
				  network plan, a preferred provider plan or a limited service health
				  organization plan except to an insurer offering a preferred provider plan that
				  also meets the subject matter of s.
				  632.745(11)
				  (b) 9, Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.02 - Purpose

Current through June 24, 2024
This subchapter establishes financial standards for health
				  maintenance organizations and limited service health organizations doing
				  business in Wisconsin. These requirements are in addition to any other
				  statutory or administrative rule requirements that apply to health maintenance
				  organizations and limited service health organizations.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.04 - Financial requirements

Current through June 24, 2024
The following are the minimum financial requirements for
				  compliance with this section unless a different amount is ordered by the
				  commissioner:
(1) CAPITAL. Unless
				otherwise ordered by the commissioner the minimum capital or permanent surplus
				of:
(a) A health maintenance organization
				insurer first licensed or organized on or after July 1, 1989, is
				$750,000;
(b) A health maintenance
				organization insurer first licensed or organized prior to July 1, 1989, is
				$200,000;
(c) The minimum capital
				or permanent surplus requirement for an insurer licensed to write only limited
				service health organization business shall be not less than $75,000. The
				commissioner may accept the deposit or letter of credit under sub. (3) to
				satisfy the minimum capital or permanent surplus requirement under this par.
				(c), if the insurer licensed to write only limited service health organization
				business demonstrates to the satisfaction of the commissioner that it does not
				retain any risk of financial loss because all risk of loss has been transferred
				to providers through provider agreements.
(d) Any other insurer writing health
				maintenance organization or limited service health organization business, is
				the amount of capital or required surplus required under the statutes governing
				the organization of the insurer.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.05 - Business plan

Current through June 24, 2024
All applications for certificates of incorporation and
				  certificates of authority of a health maintenance organization insurer or an
				  insurer licensed to write only limited service health organization business
				  shall include a proposed business plan. In addition to the items listed in ss.
				  611.13(2)
				  and
				  613.13(1),
				  Stats., the following information shall be contained in the business
				  plan:
(1) ORGANIZATION TYPE.
(a) The type of health maintenance
				organization insurer, including whether the providers affiliated with the
				organization will be salaried employees, group contractors, or individual
				contractors.
(b) The type of
				limited service health organization insurer including:
1. The name and address of the insurer
				licensed to write only limited service health organization business and the
				names and addresses of individual providers, if any, who control the insurer
				licensed to write only limited service health organization business,
				and;
2. The type of organization,
				including information on whether providers will be salaried employees of the
				organization or individual or group contractors.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.06 - Changes in the business plan

Current through June 24, 2024
(1) A health
				maintenance organization insurer or an insurer licensed to write only limited
				service health organization business shall file a written report of any
				proposed substantial change in its business plan. The insurer shall file the
				report at least 30 days prior to the effective date of the change. The office
				may disapprove the change. The insurer may not enter into any transaction,
				contract, amendment to a transaction or contract or take action or make any
				omission that is a substantial change in the insurer's business plan prior to
				the effective date of the change or if the change is disapproved. Substantial
				changes include changes in articles and bylaws, organization type, geographical
				service areas, provider agreements, provider availability, plan administration,
				financial projections and guarantees and any other change that might affect the
				financial solvency of the plan. Any changes in the items listed in s.
				Ins
				9.05(4) shall be filed under this
				section.
(2) A change in the
				quality assurance plan conducted in accordance with s.
				Ins
				9.40 and s.
				609.32, Stats.,
				is not a reportable change in a business plan.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.07 - Copies of provider agreements

Current through June 24, 2024
(1) Notwithstanding
				any claim of trade secret or proprietary information, all insurers offering a
				defined network plan, preferred provider plan or limited service health
				organization shall, upon request, from the commissioner, make available to the
				commissioner all executed copies of any provider agreements between the insurer
				and intermediate entities or individual providers. Any party to a provider
				agreement may assert that a portion of the contracts contain trade secrets, and
				the commissioner may withhold that portion to the extent it may be withheld
				under s.
				Ins
				6.13.
(2)
				All health maintenance organization insurers or insurers licensed to write only
				limited service health organization business shall file with the commissioner,
				prior to doing business, copies of all executed provider agreements and other
				contracts covering liabilities of the health maintenance organization. For
				contracts with providers, a list of providers executing a standard contract and
				a copy of the form of the contract may be filed instead of copies of the
				executed contracts.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.08 - Other reporting requirements

Current through June 24, 2024
(1) ANNUAL STATEMENT. All
										insurers authorized to write health maintenance organization business and insurers licensed to write only
										limited service health organization business shall file with the commissioner by March 1 of each year an
										annual statement for the preceding year. A health maintenance organization insurer and limited service health
										organization insurer shall use the current health annual statement blank prepared by the national association
										of insurance commissioners.
(a) A health maintenance organization insurer
										shall include with its annual statement a statement of covered expenses, and a special procedures opinion
										from a certified public accountant, in the form prescribed by the commissioner as appendix A.
(b) A health maintenance organization insurer shall file a quarterly
										report, including a report concerning covered expenses, in a form prescribed by the commissioner within 45
										days after the close of each of the first 3 calendar quarters of the year unless the commissioner has
										notified the insurer that another reporting schedule is appropriate.
(c) A health maintenance organization insurer shall include with its annual
										audit financial reports filed under s. Ins 50.05 a statement of covered expenses and an audit opinion
										concerning the statement. Both the statement and opinion shall be in the form prescribed by the commissioner
										as appendix B and are due no later than May 1 of each year.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.09 - Notice of election and termination of hold harmless

Current through June 24, 2024
(1) A notice of
				election to be exempt from s.
				609.91(1)
				(b), Stats., or a notice of termination of
				election to be subject to s.
				609.91(1)
				(c), Stats., in accord with s.
				609.925(1),
				Stats., is effective only if filed on the form prescribed by the commissioner
				and if the form is properly completed.
(2) A notice of termination of election to be
				exempt from s.
				609.91(1)
				(b), Stats., in accord with s.
				609.92(4),
				Stats., or a notice of termination of election to be subject to s.
				609.91(1)
				(c), Stats., in accord with s.
				609.925(2),
				Stats., shall be filed on the form prescribed by the commissioner. Notices
				described in this subsection that are filed with the commissioner but are not
				on the prescribed form or are not properly completed are nevertheless
				effective.
(3) In accordance with
				s.
				609.93,
				Stats., a provider may not exercise an election under s.
				609.92
				or
				609.925,
				Stats., separately from a clinic or an individual practice association with
				respect to health care costs arising from health care provided under a contract
				with, or through membership in, the individual practice association or provided
				through the clinic.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.10 - Receivables from affiliates

Current through June 24, 2024
A receivable, note or other obligation of an affiliate to a
				  health maintenance organization insurer and limited service health organization
				  insurer shall be valued at zero by the insurer for all purposes including, but
				  not limited to, the purpose of reports or statements filed with the office,
				  unless the commissioner specifically approves a different value. The different
				  value shall be not more than the amount of the receivable, note or other
				  obligation which is fully secured by a security interest in cash or cash
				  equivalents held in a segregated account or trust.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.11 - Receivables from Individual Practice Association ("IPA")

Current through June 24, 2024
After December 31, 1990, a health maintenance organization
				  insurer shall value receivables, notes or obligations of individual practice
				  associations as defined under s.
				  600.03(23g),
				  Stats., at zero for all purposes including, but not limited to, the purpose of
				  reports or statements filed with the office, unless the receivable, note or
				  obligation is fully secured by a security interest in cash or cash equivalents
				  held in a segregated account or trust.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.12 - Incidental or immaterial indemnity business in health maintenance organizations

Current through June 24, 2024
(1) Except as provided by sub. (2), insurance
				business is not incidental or immaterial under s.
				609.03(3)
				(a) 3, Stats., if a health maintenance
				organization insurer issues coverage which is not typically included in a
				health maintenance organization or limited service health organization policy
				and the insurer does any of the following:
(a) Markets the policy containing the
				coverage.
(b) The total premium for
				policies containing the coverage exceeds or is projected to exceed 5% of total
				premium earned in any 12-month period.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.14 - Nondomestic HMO

Current through June 24, 2024
No certificate of authority may be issued under ch. 618,
				  Stats., to a person to do health maintenance organization or limited service
				  health organization business in this state unless the person is organized and
				  regulated as an insurer and domiciled in the United States.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations › Section Ins 9.15 - Time period

Current through June 24, 2024
In accordance with s.
				  227.116,
				  Stats., the commissioner shall review and make a determination on an
				  application for a certificate of authority within 60 business days after it has
				  been received.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.20 - Scope

Current through June 24, 2024
This subchapter applies to all insurers offering a defined
				  network plan, preferred provider plan or limited service health organization in
				  this state. The insurer shall ensure that the requirements of this subchapter
				  are met by all defined network plans, preferred provider plans or limited
				  service health organizations issued by the insurer. The commissioner may
				  approve an exemption to this subchapter for an insurer to market a defined
				  network plan, preferred provider plan or limited service health organization if
				  the insurer files the plan with the commissioner and the commissioner
				  determines that all of the following conditions are met:
(1) The coverage involves ancillary coverage
				with minimal cost controls, such as minimal cost controls involving vision,
				prescription cards or transplant centers.
(2) The cost controls are unlikely to
				significantly affect the pattern of practice.
(3) The exemption is consistent with the
				purpose of this subchapter.