Section 632.746. Preexisting condition; portability; restrictions; and special enrollment periods.

 

(1)  

(a) Subject to subs. (2) and (3) , an insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant's or beneficiary's enrollment date under the plan.

(b) A preexisting condition exclusion under par. (a) may not extend beyond 12 months, or 18 months with respect to a late enrollee, after the participant's or beneficiary's enrollment date under the plan.

(2)  

(a) An insurer offering a group health benefit plan may not treat genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

(b) An insurer offering a group health benefit plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition.

(c) Subject to par. (e) , an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is born.

(d) Subject to par. (e) , an insurer offering a group health benefit plan may not impose a preexisting condition exclusion with respect to an individual who is adopted or placed for adoption before attaining the age of 18 years and who is covered under creditable coverage on the last day of the 30-day period beginning with the day on which the individual is adopted or placed for adoption. This paragraph does not apply to coverage before the day on which the individual is adopted or placed for adoption.

(e) Paragraphs (c) and (d) do not apply to an individual after the end of the first continuous period during which the individual was not covered under any creditable coverage for at least 63 days. For purposes of this paragraph, any waiting period or affiliation period for coverage under a group health plan or group health benefit plan shall not be taken into account in determining the period before enrollment in the group health plan or group health benefit plan.

(3)  

(a) The length of time during which any preexisting condition exclusion under sub. (1) may be imposed shall be reduced by the aggregate of the participant's or beneficiary's periods of creditable coverage on his or her enrollment date under the group health benefit plan.

(b) With respect to enrollment of an individual under a group health plan or a group health benefit plan, a period of creditable coverage after which the individual was not covered under any creditable coverage for a period of at least 63 days before enrollment in the group health plan or group health benefit plan may not be counted. For purposes of this paragraph, the period specified in 2009 Wisconsin Act 11 , section 9126 (2) (i) , or any waiting period or affiliation period for coverage under the group health plan or group health benefit plan shall not be taken into account in determining the period before enrollment in the group health plan or group health benefit plan.

(c) No period of creditable coverage before July 1, 1996, may be counted. Individuals who need to establish creditable coverage for periods before July 1, 1996, and who would have such coverage but for this paragraph may be given credit for creditable coverage for such periods through the presentation of documents or other means provided by the federal secretary of health and human services, consistent with section 104 of P.L. 104-191 .

(d)

1. An insurer offering a group health benefit plan shall count a period of creditable coverage without regard to the specific benefits for which the individual had coverage during the period.

2. Notwithstanding subd. 1. , an insurer offering a group health benefit plan may elect to apply par. (a) on the basis of coverage of benefits within each of several classes or categories of benefits specified in regulations issued by the federal department of health and human services under P.L. 104-191 . The election shall be made on a uniform basis for all participants and beneficiaries. Under the election, an insurer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within the class or category.

3. An insurer that makes an election under subd. 2. shall prominently state in any disclosure statements concerning the coverage offered, and to each employer at the time of the offer or sale of coverage, that the insurer has made the election and what the effect of the election is.

(e) Periods of creditable coverage shall be established through the presentation of certifications described in sub. (4) or in any other manner specified in regulations issued by the federal department of health and human services under P.L. 104-191 .

(4)  

(a) On and after October 1, 1996, an insurer that provides health benefit plan coverage shall provide the certification described in par. (b) upon the happening of any of the following events:

1. An individual ceases to be covered under the health benefit plan or otherwise becomes covered under a federal continuation provision. The certification required under this subdivision may be provided, to the extent practicable, at a time consistent with notices required under any applicable federal continuation provision or s. 632.897 .

2. An individual ceases to be covered under a federal continuation provision.

3. Upon the request of an individual that is made not later than 24 months after the date of the cessation of the individual's coverage under subd. 1. or 2. , whichever is later.

(b) The certification required under this subsection shall be a written certification that includes all of the following information:

1. The period of creditable coverage of the individual under the health benefit plan and the coverage, if any, under the federal continuation provision.

2. The waiting period, if any, or affiliation period, if any, imposed with respect to the individual for coverage under the health benefit plan.

(c) Upon the happening after June 30, 1996, and before October 1, 1996, of an event described in par. (a) 1. to 3. , an insurer providing health benefit plan coverage shall provide a certification described in par. (b) if the individual with respect to whom the certification is provided requests the certification in writing.

(d) If an individual seeks to establish creditable coverage with respect to a period for which a certification is not required because of the happening of an event described in par. (a) 1. to 3. before July 1, 1996, all of the following apply:

1. The individual may present other credible evidence of the coverage in order to establish the period of creditable coverage.

2. An insurer may not be subject to any penalty or enforcement action with respect to the crediting or not crediting of the individual's coverage under subd. 1. if the insurer has sought to comply in good faith with any applicable requirements under this subsection.

(5)  

(a) If an insurer that made an election under sub. (3) (d) 2. enrolls an individual for coverage under a group health benefit plan and the individual provides a certification under sub. (4) , upon the request of that insurer or the group health benefit plan the insurer that issued the certification shall promptly disclose to the requesting insurer or group health benefit plan information on coverage of classes or categories of health benefits available under the coverage on which the certification was based.

(b) The insurer providing the information may charge the requesting insurer or plan for the reasonable cost of disclosing the information.

(c) An insurer providing information under this subsection shall comply with regulations issued by the federal department of health and human services under section 2701 (e) (3) of P.L. 104-191 .

(6)  An insurer offering a group health benefit plan shall permit an employee who is not enrolled but who is eligible for coverage under the terms of the group health benefit plan, or a participant's or employee's dependent who is not enrolled but who is eligible for coverage under the terms of the group health benefit plan, to enroll for coverage under the terms of the plan if all of the following apply:

(a) The employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent.

(b) The employee or participant stated in writing at the time coverage was previously offered that coverage under a group health plan or health insurance coverage was the reason for declining enrollment under the insurer's group health benefit plan. This paragraph applies only if the insurer required such a statement at the time coverage was previously offered and provided the employee or participant, at the time coverage was previously offered, with notice of the requirement and the consequences of the requirement.

(c) The employee or dependent is currently covered under the group health plan or health insurance or, under the terms of the group health benefit plan, the employee or participant requests enrollment no later than 30 days after the date on which the coverage under par. (a) is exhausted or terminated.

(7)  

(a) If par. (b) applies, an insurer offering a group health benefit plan shall provide for a special enrollment period during which any of the following may occur:

1. A person who marries an individual and who is otherwise eligible for coverage may be enrolled under the plan as a dependent of the individual.

2. A person who is born to, adopted by or placed for adoption with, an individual may be enrolled under the plan as a dependent of the individual.

3. An individual who has met any waiting period applicable to becoming a participant under the plan, who is eligible to be enrolled under the plan and who failed to enroll during a previous enrollment period or such an individual's spouse, or both, may be enrolled under the plan.

(b) An insurer under par. (a) is required to provide for a special enrollment period if all of the following apply:

1. The group health benefit plan makes coverage available for dependents of participants under the plan.

2. The individual is a participant under the plan, or the individual has met any waiting period applicable to becoming a participant under the plan and is eligible to be enrolled under the plan but failed to enroll during a previous enrollment period.

3. A person becomes a dependent of the individual through marriage, birth, adoption or placement for adoption.

(c) A special enrollment period provided for under this subsection shall be for a period of not less than 30 days and shall begin on the later of either of the following:

1. The date dependent coverage is made available under the group health benefit plan.

2. The date of the marriage, birth, adoption or placement for adoption described in par. (a) , whichever is applicable.

(d) If an individual seeks to enroll a dependent during the first 30 days of a special enrollment period, the coverage of the dependent shall become effective on the following date:

1. If the person becomes a dependent through marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received.

2. If the person becomes a dependent through birth, the date of birth.

3. If the person becomes a dependent through adoption or placement for adoption, the date of the adoption or placement for adoption.

(7m)  

(a) In this subsection, “terms of the group health benefit plan" does not include any requirements under the group health benefit plan related to enrollment periods or waiting periods.

(b) An insurer offering a group health benefit plan shall permit, as provided in par. (c) , an employee who is not enrolled but who is eligible for coverage under the terms of the group health benefit plan, or a participant's or employee's dependent who is not enrolled but who is eligible for coverage under the terms of the group health benefit plan, to enroll for coverage under the terms of the plan if all of the following apply:

1. The employee or dependent is eligible for benefits under the Medical Assistance program under s. 49.471 or 49.472 or for coverage under the Badger Care health care program under s. 49.665 .

2. The department of health services will purchase coverage under the group health benefit plan on behalf of the employee or dependent because the department of health services has determined that paying the portion of the premium for which the employee is responsible will not be more costly than providing the medical assistance or the coverage under the Badger Care health care program, whichever is applicable.

(c) An insurer permitting an employee or dependent to enroll under this subsection shall provide for an enrollment period of not less than 30 days, beginning on the date on which the department of health services makes the determination under par. (b) 2.

(8)  

(a) A health maintenance organization that offers a group health benefit plan and that does not impose any preexisting condition exclusion under sub. (1) with respect to a particular coverage option may impose an affiliation period for that coverage option, but only if all of the following apply:

1. The affiliation period is applied uniformly without regard to any health status-related factors.

2. The affiliation period does not exceed 2 months, or 3 months with respect to a late enrollee.

(b) A health maintenance organization that imposes an affiliation period under this subsection is not required to provide health care services or benefits during the affiliation period. A health maintenance organization may not charge a premium to a participant or beneficiary for any coverage that is provided during an affiliation period. An affiliation period shall begin on the enrollment date and run concurrently with any waiting period under the group health benefit plan.

(c) A health maintenance organization under par. (a) may use methods other than those described in par. (a) to address adverse selection, if the methods are approved by the commissioner.

(9)  

(a) Except as provided in pars. (b) and (c) , requirements used by an insurer in determining whether to provide coverage under a group health benefit plan to an employer, including requirements for minimum participation of eligible employees and minimum employer contributions, shall be applied uniformly among all employers that apply for or receive coverage from the insurer.

(b) An insurer may do all of the following:

1. Vary its minimum participation requirements or minimum employer contribution requirements only by the size of the employer group based on the number of eligible employees.

2. Unless the commissioner by rule permits more frequent change, increase the minimum participation requirements or minimum employer contribution requirements no more than one time during a calendar year and, except as otherwise permitted under this subsection, only if the requirements are applied uniformly to all employers applying for coverage and to all renewing employers effective on the date of renewal.

3. Except as limited or restricted by rule of the commissioner, establish separate participation requirements or employer contribution requirements that uniformly apply to all employers that provide a choice of coverage to employees or their dependents. Except as limited or restricted by rule of the commissioner, an insurer may establish separate uniform requirements based on the number or type of choice of coverage provided by the employer.

(c) Except as provided in par. (b) , an insurer may vary requirements used by the insurer in determining whether to provide coverage under a group health benefit plan to a large employer, but only if the requirements are applied uniformly among all large employers that have the same number of eligible employees.

(d) In applying minimum participation requirements with respect to an employer, an insurer may not count eligible employees who have other coverage that is creditable coverage in determining whether the applicable percentage of participation is met, except that an insurer may count eligible employees who have coverage under another health benefit plan that is sponsored by that employer and that is creditable coverage.

(e) This subsection does not apply to a group health benefit plan offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7) .

(10)  

(a)

1. Except as provided in rules promulgated under subd. 3. or 4. , if an insurer offers a group health benefit plan to an employer, the insurer shall offer coverage to all of the eligible employees of the employer and their dependents. Except as provided in rules promulgated under subd. 3. or 4. , an insurer may not offer coverage to only certain individuals in an employer group or to only part of the group, except for an eligible employee who has not yet satisfied an applicable waiting period, if any.

2. Except as provided in rules promulgated under subd. 3. , if the state or a county, city, village, town or school district offers coverage under a self-insured health plan, it shall offer coverage to all of its eligible employees and their dependents. Except as provided in rules promulgated under subd. 3. , the state or a county, city, village, town or school district may not offer coverage to only certain individuals in the employer group or to only part of the group, except for an eligible employee who has not yet satisfied an applicable waiting period, if any.

3. The secretary of employee trust funds, with the approval of the group insurance board, shall promulgate rules related to offering coverage to eligible employees under a group health benefit plan, or a self-insured health plan, offered by the state under s. 40.51 (6) or by the group insurance board under s. 40.51 (7) . The rules shall conform to the intent of subds. 1. and 2. and may not allow the state or the group insurance board to refuse to offer coverage to an eligible employee or dependent for reasons related to health condition.

4. The commissioner may promulgate rules permitting exceptions to the requirement under subd. 1. for classes of eligible employees or their dependents. No rule promulgated under this subdivision may permit an insurer to refuse to offer to provide coverage to an eligible employee or his or her dependent for reasons related to health condition.

(b)

1. An insurer may not modify a group health benefit plan with respect to an employer or an eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the group health benefit plan.

2. The state or a county, city, village, town or school district may not modify a self-insured health plan with respect to an eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the self-insured health plan.

3. Nothing in this paragraph limits the authority of the group insurance board to fulfill its obligations as trustee under s. 40.03 (6) (d) or to design or modify procedures or provisions pertaining to enrollment, premium transmitted or coverage of eligible employees for health care benefits under s. 40.51 (1) .

1997 a. 27 ; 2003 a. 33 ; 2007 a. 20 ss. 3679 , 9121 (6) (a) ; 2009 a. 11 .