SB 40

This bill generally sets certain requirements and limitations on health

insurance coverage in the event the federal Patient Protection and Affordable Care

Act no longer preempts state law on the topic. Currently, the Affordable Care Act

generally allows premium rates to be based only on individual or family coverage,

rating area, age, and tobacco use; requires group and individual health insurance

policies to accept every employer and individual that applies for coverage, known as

guaranteed issue, and renew health insurance coverage at the option of the sponsor

or individual; and prohibits health insurance policies from imposing preexisting

condition exclusions. If those requirements and limitations of the Affordable Care

Act become no longer enforceable or no longer preempt state law, all of the following

apply under the bill:

1. Every individual health benefit plan must accept every individual in this

state who applies for coverage and every group health benefit plan must accept every

employer in this state that applies for coverage, regardless of whether any individual

or employee has a preexisting condition. A health benefit plan may restrict

enrollment in coverage to open or special enrollment periods, and the commissioner

of insurance must ensure a statewide 45-day open enrollment period allowing

individuals, including individuals who do not have coverage, to enroll in coverage.

Health benefit plans must provide special enrollment periods for certain qualifying

events described in federal law.

2. A health benefit plan offered on the individual or small employer market or

a self-insured governmental health plan may not vary premium rates for a specific

plan on any basis except age, tobacco use, area in the state, and whether the plan

covers an individual or a family.

3. A health benefit plan or a self-insured governmental health plan may not

impose a preexisting condition exclusion. A preexisting condition exclusion is

defined in the bill as a limitation or exclusion of benefits relating to a condition based

on the fact that the condition was present before the date of enrollment for the

coverage, whether or not any medical advice, diagnosis, care, or treatment was

recommended or received before the date of enrollment for coverage.

4. A health benefit plan or a self-insured governmental health plan is

prohibited from imposing an annual or lifetime limit on the dollar value of benefits

under the plan.

The Affordable Care Act exempts certain plans from complying with the act's

provisions. Similarly, any health benefit plan that is exempt from a provision of the

Affordable Care Act is exempt from complying with the corresponding provision of

this bill.

This proposal may contain a health insurance mandate requiring a social and

financial impact report under s. 601.423, stats.