Current through February 24, 2025
In addition to the definitions in s.
635.02, Stats., which
apply to this subchapter, in this subchapter:
(1) "Basic market share ratio" means the
ratio of the number of risk characteristic basic health benefit plans in force
to the total number of basic health benefit plans in force.
(2) "Commissioner" means the commissioner of
insurance.
(3) "Initial enrollment
period" means a period prior to issuance of a policy during which eligible
employees, and dependents of eligible employees, are entitled to enroll in
coverage under the policy.
(4)
"Late enrollee" means an eligible employee, or dependent of an eligible
employee, who does not request coverage under a policy during an enrollment
period in which the individual is entitled to enroll in the policy, and who
subsequently requests coverage under the policy, regardless of whether the
enrollment period was held prior to, on or after the law's effective date.
"Late enrollee" does not include an individual who is a new entrant under sub.
(7) (b) or (c).
(5) "Law's
effective date" means May 12, 1992, or the first renewal date of a policy which
occurs on or after May 12, 1992, whichever is later.
(6) "Market share ratio" means the ratio of
the number of risk characteristic basic health benefit plans in force to the
total number of policies in force.
(7) "New entrant" means an eligible employee,
or the dependent of an eligible employee, who:
(a) Becomes part of an employer group on or
after the law's effective date and after commencement of an initial enrollment
period;
(b) Is a spouse, minor or
dependent under a covered employee's policy who a court orders be covered under
the policy and who requests enrollment within 30 days after issuance of the
court order; or
(c) Failed to
request enrollment in the policy during an enrollment period which commenced
prior to, on or after the law's effective date, during which the individual was
entitled to enroll in the policy, if the individual:
2. Subsequently, and on or after February 1,
1994, loses coverage under the qualifying coverage; and
3. Requests enrollment within 30 days after
termination of the qualifying coverage.
(8) "Office" means the office of the
commissioner.
(9) "Policy" means
any of the following:
(a) A group health
benefit plan issued to a small employer.
(b) An individual health benefit plan,
including, but not limited to, an individual health benefit plan which is
intended or designed to supplement a basic health benefit plan, issued by an
insurer to an eligible employee if 3 or more eligible employees of the same
small employer apply for the coverage or were intentionally excluded from
applying for reasons related to their health, and the individual health benefit
plan is in fact, or in substance, sold to, or through active cooperation of,
the small employer, including but not limited to circumstances where:
1. Premium is collected through a direct or
indirect arrangement with the small employer;
2. The individual health benefit plan is in
substance a replacement for group health benefit plan coverage provided through
the small employer;
3. The small
employer directly or indirectly contributes toward a portion of the premium for
the individual health benefit plan; or
4. An eligible employee is solicited to
purchase the individual health benefit plan on the premises of the small
employer and with the consent and cooperation of the small employer or the
small employer participates in the solicitation of the eligible
employee.
(c) For a
health benefit plan that provides coverage through a trust or association, a
certificate or other evidence of coverage, including, but not limited to,
coverage intended or designed to supplement a basic health benefit plan, issued
to an individual small employer or in fact or substance, sold to, or through
the active cooperation of, the small employer, including but not limited to
circumstances where:
1. Premium is collected
through a direct or indirect arrangement with the small employer;
2. The coverage is in substance a replacement
for group health benefit plan coverage provided through the small
employer;
3. The small employer
directly or indirectly contributes toward a portion of the premium for the
coverage; or
4. An eligible
employee is solicited to purchase the coverage on the premises of the small
employer and with the consent and cooperation of the small employer or the
small employer participates in the solicitation of the eligible
employee.
(d) A group
health benefit plan which supplements or is designed to supplement the basic
health benefit plan.
(10) "Risk characteristic" means the health
status, claims experience, duration of coverage, or any similar characteristic
related to the health status or experience of a small employer group or of any
member of a small employer group.
(11) "Risk characteristic basic health
benefit plan" means a basic health benefit plan which, when issued, is issued
to a small employer group which:
(a) Is not
eligible for any policy available from the small employer insurer, other than
the basic health benefit plan or health benefit plans that do not provide
benefits similar to or exceeding benefits provided under the basic health
benefit plan as determined under s.
Ins 8.66(1), under the underwriting
standards of the small employer insurer and based on the small employer group's
risk characteristics; or
(b) Is
assigned a rate for the basic health benefit plan which exceeds the new
business premium rate for the basic health benefit plan by 15% or
more.
(12) "Risk load"
means the percentage above the applicable base premium rate that is charged by
a small employer insurer to a small employer to reflect the risk
characteristics of the small employer group.
(13) "Underwritten individual" means an
individual who, prior to the law's effective date, requested but was excluded
from coverage, or denied coverage, under a policy, whether issued by the
current insurer or a preceding insurer, and continued to be and is an eligible
employee, or dependent of an eligible employee, of the small
employer.
