SB 174

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.