635.02 Definitions. In this chapter:
(1) “Base premium rate" means the lowest premium rate chargeable under a rating system to small employers with similar case characteristics and the same or similar benefit design characteristics in the same class of business.
(1m) “Benefit design characteristics" means covered services, cost sharing, utilization management, managed care networks and other features that differentiate plan or coverage designs.
(1p) “Bona fide association" has the meaning given in s. 632.745 (3).
(2) “Case characteristics" means the demographic, actuarially based characteristics of the employees of a small employer, and the employer, if covered, such as age, sex, and geographic location, used by a small employer insurer to determine premium rates for a small employer. “Case characteristics" does not include loss or claim history, health status, occupation, duration of coverage, or other factors related to claim experience.
(3) “Class of business" means all or a distinct grouping of small employers determined in accordance with rules promulgated by the commissioner under s. 635.05 (4).
(3g) “Employer" has the meaning given in s. 632.745 (6).
(3j) “Established geographic service area" means a geographic area within which a small employer insurer provides coverage and that has been approved by the commissioner.
(3k) “Group health benefit plan" has the meaning given in s. 632.745 (9).
(3m) “Health benefit plan" has the meaning given in s. 632.745 (11).
(4m) “Midpoint rate" means the arithmetic average of the base premium rate and the corresponding highest premium rate.
(4t) “Network plan" has the meaning given in s. 632.745 (19).
(5) “New business premium rate" means the premium rate charged or offered to small employers with similar case characteristics in the same class of business for newly issued health insurance with the same or similar benefit design characteristics.
(6) “Rating period" means the period, determined by a small employer insurer, during which a premium rate established by the small employer insurer remains in effect.
(6m) “Restricted network provision" means a provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on obtaining services or articles from health care providers that have contracted with the small employer insurer to provide health care services or articles to covered individuals.
(7)
(a) “Small employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 2 but not more than 50 employees on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 employees on the first day of the plan year.
(b) Notwithstanding par. (a), “small employer" does not include any of the following:
1. A health benefit purchasing cooperative under s. 185.99 that provides health care benefits for more than 50 individuals who are members or employees of one or more members.
2. A member of a cooperative specified in subd. 1.
3. A professional employer organization, as defined in s. 202.21 (5), or a professional employer group, as defined in s. 202.21 (4), that provides health care benefits to more than 50 employees performing services for a client, as defined in s. 202.21 (2).
4. A client of a professional employer organization or professional employer group specified in subd. 3., if the employees of the professional employer organization or professional employer group performing services for the client are offered health care benefits under a health benefit plan sponsored by the professional employer organization or professional employer group.
(8) “Small employer insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers group health benefit plans covering eligible employees of one or more small employers in this state, or that sells 3 or more individual health benefit plans to a small employer, covering eligible employees of the small employer. The term includes a health maintenance organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), and an insurer operating as a cooperative association organized under ss. 185.981 to 185.985, but does not include a limited service health organization, as defined in s. 609.01 (3).
(9) “Small group market" has the meaning given in s. 632.745 (26).
History: 1991 a. 39, 250; 1993 a. 112; 1995 a. 289, 453; 1997 a. 27; 2001 a. 16; 2005 a. 231; 2007 a. 189; 2013 a. 20.
Structure Wisconsin Statutes & Annotations