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Compliance Corner

State Updates

Commissioner Encourages Insurers to Open Special Enrollment Periods Parallel to Federal Marketplace

February 17, 2021

On February 9, 2021, Commissioner Afable issued a bulletin noting the announcement that the federal health exchange would open a three-month Special Enrollment Period (SEP) from February 15, 2021, through May 15, 2021. In this bulletin, the commissioner encouraged insurers to open special enrollment periods for health insurance products outside the marketplace. These enrollment periods must be open to all consumers. These parallel SEPs can only last for the same duration as the federal marketplace.

This information may be of use to employees who have not been able to enroll in other coverage. However, this SEP for non-exchange coverage would likely not give rise to a qualifying event that would allow employees to terminate their employer group health plan coverage. It’s also important to note that these private health plans often meet ACA requirements, but consumers would not qualify for premium tax credits in order to help pay for them.

Employers with employees in the state should be aware of this development.

Commissioner Bulletin 20210209 »

COVID-19 Immunization Coverage

January 20, 2021

On December 22, 2020, Commissioner Afable issued a bulletin in which he expects, pursuant to the CARES Act, that all self-funded and fully insured group health plans, individual health plans, and short-term limited duration plans cover, without cost sharing, all costs associated with administration of COVID-19 vaccinations. The mandate applies even if the vaccine is administered by an out-of-network provider, and regardless of whether the vaccine is single-dose or multiple doses.

Employers with plans regulated in the state should be aware of this bulletin.

COVID-19 Immunization Coverage »

State Insurance Update

November 10, 2020

On October 13, 2020, Commissioner Afable issued Bulletin 20201013, reminding health plan issuers in the state to encourage their insureds to use telemedicine whenever practicable, and to make sure that those services are available in their networks and ready to meet increased demand. This also includes a request that claims for telehealth services not be denied when those services are normally covered if they are provided in-person.

Employers with plans regulated by the state should be aware of these reminders.

Bulletin 20201013 »

Updated FMLA and Health Care Benefits Termination Posters

July 21, 2020

In June 2020, Wisconsin updated its FMLA and Cessation of Health Care Benefits posters. As background, Wisconsin law requires that all employers with 50 or more employees display a copy of the FMLA poster in the workplace. As a reminder, Wisconsin FMLA requires that such employers provide up to two-weeks of unpaid leave for an employee’s serious health condition and the serious health condition of a parent, child or spouse; and up to six-weeks of unpaid leave for the birth or adoption of a child.

In addition, employers with 50 or more employees are also required to display the Advance Notice Required When Employers Decide to Cease Providing a Health Care Benefit Plan poster. Under state law, employers must provide 60-days advance written notice of their intention to cease providing health care benefits to employees, retirees or their dependents.

With both posters recently updated, employers should be sure to utilize the updated posters to maintain compliance.

Wisconsin FMLA Poster »
Cessation of Health Care Benefits Poster »

Health Insurance Discrimination on the Basis of Gender Identity Is Illegal

July 07, 2020

On June 29, 2020, the Commissioner of Insurance released a bulletin to insurers explaining that it is unlawfully discriminatory to exclude, limit or deny benefits to an insured based on gender identity.

As background, the bulletin highlights that per Wisconsin law, insurers cannot unfairly discriminate among policyholders by offering different terms of coverage (with an exception based on classifications related to the degree of risk). In addition, it is unlawful to deny coverage or refuse benefits on the basis of sex.

The bulletin explains that since gender identity is unrelated to degree of risk and denying coverage on the basis of gender identity is discriminatory on the basis of sex, excluding coverage for services (that is otherwise covered) based on gender identity is unlawfully discriminatory. Importantly, the bulletin further provides that such discrimination is also unlawful for self-funded, non-federal group health plans.

While the bulletin is directed at insurers, employers should be aware that gender identity discrimination is prohibited and confirm their policies are compliant with this guidance.

Nondiscrimination regarding Coverage for Insureds Who are Transgender or Gender Dysphoric »
Press Release »

COVID-19 Coverage Requirements

May 27, 2020

On May 19, 2020, the Wisconsin Office of the Commissioner of Insurance (OCI) issued a notice to insurers that summarizes the federal requirements of the FFCRA and CARES Act in light of the COVID-19 public health crisis. The notice highlights that testing for COVID-19 should be provided without any out-of-pocket costs (no cost sharing). In addition, the notice explains that the CARES Act includes a broader range of services that must be covered without cost-sharing requirements, prior authorization or other medical management requirements, and requires coverage of preventative services and immunizations (when applicable) related to COVID-19.

Further, a press release dated May 19, 2020, encourages individuals to discuss with their insurer if they have received any bills with costs associated with COVID-19 testing so that those services are covered without cost sharing. 

While the notice is directed towards insurers, employers should be aware of this notice and communicate with employees accordingly.

Notice to Insurers »
Press Release »

COVID-19 Law Enacted

April 28, 2020

On April 15, 2020, the 2019 Wisconsin Act 185 (COVID-19 law) was signed into law by Gov. Evers. Further, on April 21, 2020, the Office of the Commissioner of Insurance issued a bulletin summarizing the COVID-19 law. Highlights of the newly enacted law are summarized below.

  • Insurers who offer a defined network plan (or preferred provider plan) are required to provide coverage from nonparticipating providers when there are limitations on access to participating providers due to the public health emergency for services, treatment or supplies related to COVID-19. In the event an insured receives services, treatment or supplies related to COVID-19 from a nonparticipating provider, the plan may not require the insured to pay more than the insured would have from a participating provider.
  • Insurers are prohibited from creating eligibility rules related to diagnosis of COVID-19. In addition, coverage cannot be cancelled, rate filing cannot be modified and a grace period cannot be refused based on an insured’s current or past COVID-19 diagnosis.
  • Coverage for COVID-19 testing is required without cost sharing if the plan includes coverage for testing of infectious disease.
  • Policies are prohibited from 1) requiring prior authorization for early refills of prescription drugs; 2) restricting the period of time that a prescription drug may be refilled; and 3) imposing a limitation on the quantity of the refill if the quantity is less than a 90-day supply.

Employers should be aware of these requirements.

2019 Wisconsin Act 185 »
Bulletin: April 21, 2020 »

Extended Relief for Non-ACA-Compliant Small Group and Individual Policies and Plans

March 31, 2020

On March 26, 2020, Commissioner Afable released a bulletin that extended the ability of health insurance carriers in the individual and small group market to continue transitional health insurance plans that renew for a policy year starting on or before October 1, 2021, as long as the transitional policy ends by December 31, 2021.

As background, on January 31, 2020, CMS provided guidance for a transition policy extension that allows insurers the option to renew non-grandfathered non-ACA-compliant plans, as long as the state allows for such an extension. Such transition policies are not required to be in compliance with certain ACA mandates including community rating, coverage of essential health benefits, prohibition on pre-existing condition exclusions and the annual out-of-pocket maximum limit. This bulletin applies this most recent federal extension to Wisconsin and allows the issuer to renew these non-ACA compliant plans.

Small employers that are interested in renewing their non-ACA-compliant plan should work with their advisors and insurers.

Extension of Transitional Health Insurance Plans through December 31, 2021 »

Insurance Updates Due to COVID-19: Medicaid Coverage for Telemedicine, Grace Periods for Premium Payments and Small Employer Coverage Guidance

March 31, 2020

Recently, the Department of Health Services and the Office of the Commissioner of Insurance (OCI) released updates — all of which provided guidance on testing and/or treatment related to COVID-19 and its impact on health and welfare benefit administration. Highlights include:

  • ForwardHealth Update No. 2020-09: The Wisconsin Department of Health Services, in an effort to respond to the COVID-19 emergency, will allow Medicaid coverage of telehealth services for all originating sites.
  • Bulletin – March 20, 2020: The OCI provides guidance to insurers regarding regulatory requirements during the COVID-19 public health emergency. As part of the guidance, insurers are urged to provide flexibility (in a non-discriminatory manner) to insureds who are incurring economic hardship (e.g., noncancellation periods, grace period for premium payments).
  • OCI Guidance: The OCI confirms that insurers and employer policyholders may offer coverage to employees working less than 30 hours per week. However, this can only be done if the offer is made to all employees in a non-discriminatory manner. For reference, generally state law requires eligibility as one who works a workweek of 30 or more hours for small employers (between 2-50 employees).

Employers should be aware of these developments.

ForwardHealth Update No. 2020-09 »
Bulletin: March 20, 2020 »
OCI Guidance on Small Employer Coverage »

COVID-19 Coverage

March 17, 2020

On March 6, 2020, the Commissioner of Insurance issued a Bulletin requesting insurers, self-funded plans, pharmacy benefit managers and cooperative health plans (“Health Plan Issuers”) to remove any barriers to testing and treatment for COVID-19. Specifically, the Office of the Commissioner of Insurance requests Health Plan Issuers providing coverage to Wisconsin residents take the following measures, effective immediately:

  • Be readily available to provide accurate information to assist consumers with questions about coverage related to COVID-19.
  • Waive any cost sharing for COVID-19 testing, as well as waive any cost sharing for office visits (including provider office visits, urgent care visits, hospital visits or emergency services) when such visit is related to COVID-19.
  • Ensure any telehealth programs are robust and able to meet any increase in demand.
  • Do not use prior authorization request as a barrier to access to treatment (and should be prepared to expedite prior authorization requests, grievances and appeal processes).
  • Cover any immunizations at no cost sharing for all covered individuals in the event an immunization becomes available.

The above requests are not exhaustive. Employers with employees in Wisconsin should consult their carriers, as applicable, and be aware of the Commissioner’s requests when addressing questions regarding health insurance coverage and COVID-19.

Bulletin: Coronavirus (COVID-19) Coverage Request »

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