Regulation by the office of the commissioner of insurance of self-insured health plans offered by a city, town, village, county, or school district, providing a penalty, and granting rule-making authority

Current law requires that if a self-insured governmental health plan covers dependent children, the plan must also cover adopted children. Among other requirements, self-insured governmental health plans must develop procedures for physicians to request an exception for a plan participant for drugs or devices that are routinely not covered under the plan, must specify any limits on coverage of experimental treatment, may not require preauthorization for emergency services if the plan covers emergency services, and may not exclude coverage for treatment of a condition by a dentist if the treatment is covered when performed by another health care provider.

This bill expands the authority of OCI to regulate a self-insured health plan of a city, village, town, county, or school district (governmental body), similar to the way OCI currently regulates insurers offering a health insurance policy or group health benefit plan. The bill allows OCI to require a governmental body that provides a self-insured health plan to provide reports pertaining to the self-insured health plan and to reply to requests for information made to a person with authority over the self-insured health plan. OCI may examine the affairs of the governmental body as they relate to the self-insured health plan. The bill allows OCI to seek an injunction or temporary restraining order for a violation of the statutes pertaining to a self-insured governmental health plan and allows forfeitures and criminal penalties to be imposed for those violations. OCI must promulgate rules regarding the level of reserves and surpluses that the governmental body must maintain with respect to its self-insured health plan. The governmental body may reinsure the self-insured health plan under this bill but must report the name of the reinsurer to OCI. The bill applies laws pertaining to rehabilitation and liquidation of insurers and the insurance security fund to governmental bodies, with respect to a self-insured health plan.

The bill imposes coverage requirements on self-insured governmental health plans similar to requirements imposed on health insurance policies and group health benefit plans. Self-insured governmental health plans, under the bill, may not limit coverage of HIV treatment if limits are not imposed on other illnesses or medical conditions, may not refuse to provide or renew coverage based on the health plan participant being a victim of domestic violence, must establish an internal grievance procedure and an independent review plan for the review of adverse and experimental treatment determinations, may not exclude coverage of treatment by a licensed chiropractor, must provide an explanation for a restriction or termination of coverage, must cover home care in certain circumstances, must cover skilled nursing care meeting certain requirements, must cover maternity and newborn children, must cover diabetes treatment and diabetic supplies, may not deny coverage based on possible coverage under a liability policy, and must cover mammograms, among other requirements.

Because this bill creates a new crime or revises a penalty for an existing crime, the Joint Review Committee on Criminal Penalties may be requested to prepare a report concerning the proposed penalty and the costs or savings that are likely to result if the bill is enacted.