Wisconsin Administrative Code

Ins 7.02 Bureau of financial analysis and examinations forms. Form Number 21-002 21-004 21-005 21-030 21-031 21-032 21-040 21-050 21-051 21-063 21-064 21-190 22-007 22-008 22-009 22-010 22-011 22-020 22-030 22-040 22-041 22-050 Title Application for Certificate of Authority— Dome…

Ins 7.04 Division of regulation and enforcement. (1) COMPLAINTS SECTION. Form Number 51-011 51-013 51-020 Title Complaint Review Request Letter Complaint Follow-up—Provide Information Within 5 days Complaint Follow-up—Recontact the Complainant (2) BUREAU OF MARKET REGULATION. For…

Ins 8.11 County and school district self-insured employee health care benefits: excess or stop-loss insurance requirements. (1) PURPOSE. This section interprets ss. 59.52 (11) (c) and 120.13 (2) (c), Stats., for the purpose of prescribing detailed requirements for excess or stop-…

Ins 8.20 Purpose. This subchapter interprets and implements ch. 633, Stats. History: Cr. Register, April, 1992, No. 436, eff. 5-1-92.

Ins 8.22 Definitions. In this subchapter: (1) XAdministratorY has the meaning given in s. 633.01 (1), Stats. (2) XCommissionerY means the commissioner of insurance. (3) XEmployeeY has the meaning given in s. 633.01 (2), Stats. (4) XOfficeY means the office of the commissioner. (5…

Ins 8.24 Exemptions. (1) Each of the following is exempt from ch. 633, Stats., and this subchapter for the portion of its business subject to regulation under the specified sections: (a) An administrator of one or more self-insured, partially insured or divided insurance worker[s…

Ins 8.26 Licensing. (1) APPLICATION. A person applying for a new or renewal license as an administrator shall submit an application to the office in the form prescribed by the office. With the application, the person shall submit all of the following: (a) With the initial applica…

Ins 8.28 Performance bond requirements. (1) A performance bond required under s. 633.14 (1) (b) or (2) (b), Stats., shall be continuous in form, shall be issued by an insurer authorized to do a surety business in this state and shall be in favor of the commissioner and payable to…

Ins 8.30 Notification to office. An administrator shall notify the office in writing of any of the following within 30 days after the date of the occurrence: (1) The cessation of business activities as an administrator. A notification under this subsection shall include the name …

Ins 8.32 Audit. In order to determine whether the financial resources of an administrator are adequate to safeguard the interests of the public and persons covered by a plan, or to determine the appropriate bond amount under s. Ins 8.28, the office may order the administrator to …

Ins 8.40 Purpose. This subchapter interprets and implements ch. 635, Stats. History: Cr. Register, October, 1992, No. 442, eff. 11-1-92; am. Register, November, 1993, No. 455, eff. 2-1-94; correction made under s. 13.93 (2m) (b) 7., No. 744, eff. 1-1-18.

Ins 8.42 Definitions. In addition to the definitions in s. 635.02, Stats., which apply to this subchapter, in this subchapter: (1) XBasic market share ratioY means the ratio of the number Ins 8.42 of risk characteristic basic health benefit plans in force to the total number of b…

Ins 8.44 Applicability; exclusion. (1) Chapter 635, Stats., and this subchapter apply to a policy issued to, or renewal for, an employer if the number of eligible employees in this state was not less than 2 nor more than 25 during at least 50% of the number of weeks the employer …

Ins 8.46 Required policy provisions. Each policy shall include all of the following: (1) On the face page or first page, a statement that the policy is guaranteed renewable except for the reasons stated in the policy, which shall be consistent with s. 635.07 (1) and (2), Stats. N…

Ins 8.48 Solicitation; disclosure requirements. (1) AGENTS. Before completing an application for a policy, an agent shall provide the small employer or representative of the small employer or the individual applicant with a form stating the information required under s. 635.11 (1…

Ins 8.49 Uniform employee application form. (1) (a) In accordance with s. 635.10, Stats., small employer insurers shall use the small employer uniform employee application form as the only acceptable form when small employers apply for coverage from small employer insurers. Small…

Ins 8.50 Underwriting restriction. In determining whether to issue or continue to provide coverage to a small employer, a small employer insurer may not consider the occupation of the employees of the small employer or the type of business in which the small employer is engaged. …

Ins 8.52 Regulation of rates and rate changes. (1) IDENTIFICATION OF THE SET OF MIDPOINT RATES. (a) Each small employer insurer shall identify a set of rates applicable to all combinations of case characteristics and benefit design characteristics that serves as the set of midpoi…

Ins 8.54 Guaranteed renewability; cancellation and renewal restrictions. (1) DEFINITION. (a) In this section, Xmedically underwritten policyY means a policy that is issued after the small employer insurer has, for purposes of risk selection, used information about the group[s cla…

Ins 8.56 Certification of compliance; additional information required. (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 co…

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. (1) A small employer insurer that offers a policy shall provide an initial enrollment period during which each eli…

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. (1) A small employer insurer may not issue a policy unless during the initial enrollment period all the eligible employe…

Ins 8.61 Small employer insurers shall offer coverage to new entrants. (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 enr…

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. (1) A small employer insurer shall provide an enrollment period during which underwritten individuals who were ex…

Ins 8.63 Small employer insurers shall offer coverage to late enrollees. (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…

Ins 8.64 Small employer insurers may not participate with a small employer to coerce, or discriminate among, eligible employees or dependents. (1) A small employer insurer may not accept a waiver of coverage, if the insurer, or an insurance intermediary for the insurer, reasonabl…

Ins 8.65 A small employer insurer shall require small employers to provide documentation to establish that waivers of coverage are voluntary and permitted. (1) A small employer insurer shall require each small employer that applies for a policy, as part of the application process…

Ins 8.66 Qualifying coverage for portability and late enrollees; transition. (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 repe…

Ins 8.67 Restrictive riders prohibited. 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 …

Ins 8.68 Fair marketing standards. (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…

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. (1) No small employer insurer may have a basic market share ratio which is significantly less than the basic market share ratio …

Ins 8.70 Purpose. 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. History: Cr. Register, June, 1993, No. 450, eff. 7-1-93; correction in (intro.) made under …

Ins 8.71 Definitions. (1) The definitions in s. 635.02, Stats., apply to this subchapter. (2) In this subchapter, Xhealth care providerY means any of the following: (a) A medical or osteopathic physician, podiatrist, physical the chapter was last published. 23 COMMISSIONER OF INS…

Ins 8.72 Basic benefits. 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 w…

Ins 8.73 Health insurance mandates. 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). History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.74 Policy title; term. (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 Xbasic health benefit plan.Y (2) The term period for plan coverage shall not be less than 12 months. Histor…

Ins 8.75 Limitations and restrictions. (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 …

Ins 8.76 Policy terms; exclusions; limitations. (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 covera…

Ins 8.78 Participation; enrollment. (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 benef…

Ins 8.79 Managed care options. 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…

Ins 8.80 Rating. (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 b…

Ins 8.81 Form approval and marketing. (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 …

Ins 9.01 Definitions. In this chapter, and for the purposes of applying ch. 609, Stats.: (1) XAcceptable letter of creditY means a clean, unconditional, irrevocable letter of credit issued by a Wisconsin bank or any other financial institution acceptable to the commissioner which…

Ins 9.015 Scope. Subchapter II — Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations Ins 9.02 Purpose. Ins 9.03 Scope. Ins 9.04 Financial requirements. Ins 9.05 Business plan. Ins 9.06 Changes in the business plan. Ins 9.07 Copies of p…

Ins 9.02 Purpose. 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…

Ins 9.03 Scope. This subchapter applies to all insurers writing health maintenance organization or limited service health organization business in this state. History: Cr. Register, February, 2000, No. 530, eff. 3-1-00. Ins 9.04 Financial requirements. The following are 2 the min…

Ins 9.05 Business plan. 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 addit…

Ins 9.06 Changes in the business plan. (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 r…

Ins 9.07 Copies of provider agreements. (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 availabl…

Ins 9.08 Other reporting requirements. (1) ANNUAL 4 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 an…