Guaranteed Wisconsin Health Insurance Coverage Under HIPAA

Guaranteed Issue

An employer that employs at least 2 but not more than 50 employees is considered a small employer. Insurance companies that market group health insurance coverage to small employers are required to accept every small employer that applies for a group health benefit plan. Although coverage is guaranteed, the cost of group coverage is reflective of the health experience of the group.

Discrimination Prohibited

An insurer may not impose any restrictions on an employee or dependent in a group health benefit plan or establish eligibility standards that are based on an individual's health status, medical condition, claims experience, receipt of health care, medical history, genetic information, disability, or evidence of insurability, including conditions arising out of acts of domestic violence. Riders that exclude coverage for specific medical conditions cannot be added to an individual's coverage under a group health benefit plan.

Coverage Must Be Offered To All "Eligible Employees"

Under Wisconsin insurance laws, if an insurance company offers a group health benefit plan to an employer, the insurer must offer coverage to all of the "eligible employees" of the employer and their dependents. An insurer may not offer coverage to only certain members in the group or to only part of the group, except for an "eligible employee" who has not yet satisfied an applicable waiting period, if any. An "eligible employee" means an employee who works on a permanent basis and has a normal work week of 30 or more hours. It does not include an employee who works on a temporary or substitute basis.

Insurers may allow eligible employees of a small employer and their dependents to decline or waive coverage under a group health benefit plan in only certain cases, such as when an individual has coverage under another health benefit plan other than the Health Insurance Risk-Sharing Plan (HIRSP), the annualized premium to be paid by an eligible employee would exceed 10% of the annualized gross earnings of the eligible employee, or when an individual does not have a risk characteristic that would be the sole cause for the insurer to make a decision with respect to premiums for a policy that is adverse to the small employer.

In addition, an insurer must offer coverage to new "eligible employees" who become eligible for coverage after the commencement of the employer's coverage, and to their dependents regardless of health condition or claims experience, except for an "eligible employee" who has not yet satisfied an applicable waiting period, if any.