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Compliance Corner

State Updates

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 »

Recent Ruling on Association Health Plans

June 25, 2019

On May 2, 2019, Commissioner Afable released Bulletin 20190502, which acknowledges the federal court decision to invalidate the DOL’s new association health plan (AHP) rule. As background, the rule broadened the eligibility standards for a group of employers to be considered a “bona fide association” by allowing groups of unrelated employers to join associations and offer health coverage together.

This bulletin merely confirms that associations in Wisconsin can’t sponsor plans under the AHP’s new rules, and can only rely on the rules that were in place before. Additionally, as supported by Wisconsin statutes, insurers who have issued AHPs in accordance with the rules that have now been vacated must continue to pay claims for the full term of those plans.

This guidance does not present any new information. However, employers in Wisconsin that were looking to join an AHP should be aware that the eligibility for that AHP will have to be what it was under the DOL’s previous rules.

Bulletin 20190502 »

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

June 11, 2019

On April 3, 2019, 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, 2020, as long as the transitional policy ends by December 31, 2020.

As background, on March 25, 2019, 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.

Bulletin 20190403 »

Coverage for Prescription Eye Drops

May 15, 2018

On April 17, 2018, Gov. Walker signed AB 876 into law, creating Wisconsin Act 305. The law specifies that if a health insurance policy provides coverage for prescription eye drops, the policy must allow coverage for a refill beginning when 75 percent of the days have passed from the most recent covered filling of the prescription. The requirement also applies to a self-insured health plan of the state or of a county, city, town, village or school district. This requirement is generally effective for health plans delivered, issued for delivery or renewed in Wisconsin on or after Jan. 1, 2019.

Wisconsin Act 305 »

Extension of Non-PPACA-Compliant Small Group and Individual Policies and Plans

March 21, 2017

On Mar. 6, 2017, Wisconsin Commissioner of Insurance Nickel released a bulletin related to the extension of non-PPACA-compliant small group and individual policies and plans. As background, on Feb. 23, 2017, the federal government announced an additional transition policy that allows insurers (if allowed by the state) to renew non-grandfathered non-PPACA-compliant plans (this transitional relief has been extended twice before). Such policies are not required to be in compliance with certain PPACA mandates including community rating, coverage of essential health benefits, prohibition on pre-existing condition exclusions and the annual out-of-pocket maximum limit.

The Bulletin states that Wisconsin will allow insurers to renew policies in the individual market and the small group market according to the extended transitional policy. Insurers may use either early renewal or short policy years to implement the extension. Employers with non-PPACA-compliant plans should work with their insurer on any policy extension.

Bulletin »

IRS Releases Notice 2016-75 Regarding the Tax Credit for Employee Health Insurance Expenses of Certain Small Employers in Wisconsin

December 13, 2016

On Dec. 2, 2016, the IRS released Notice 2016-75, which provides an exception allowing certain small employers in specified Wisconsin counties to claim the small business health care tax credit, even though they did not purchase coverage through the Small Business Health Options Program (SHOP). This is because no qualified health plan was available in those counties for all or part of 2016.

The exemption applies to employers whose principal business address is in Pierce, Polk or St. Croix Counties and who purchased group health coverage outside of the SHOP. The coverage must otherwise meet the criteria for claiming the tax credit including:

  • The employer has fewer than 25 full-time equivalent employees;
  • The average annual wage of its employees is less than $51,800 (for 2016); and
  • The employer pays a uniform percentage for all employees equal to at least 50 percent of the premium cost of employee-only coverage.

Finally, the exemption applies to 2016 plan years, including those months in 2017 for non-calendar year plans.

IRS Notice 2016-75 »

Transitional Policies

November 07, 2016

On July 18, 2016, Wisconsin Insurance Deputy Commissioner J.P. Wieske provided additional information regarding non-grandfathered small group transitional policies. The Wisconsin Insurance Commissioner Nickel had previously announced that insurers in the state are permitted to renew such plans with policy years beginning on or before Oct. 1, 2016. This is related to the March 5, 2014, CMS announcement of a two-year extension to the transitional policy for non-PPACA-compliant health benefit plans. The plans must have existed before Oct. 1, 2013, and are not required to be in compliance with certain PPACA mandates including community rating, coverage of essential health benefits, prohibition on pre-existing condition exclusions and the annual out-of-pocket maximum limit.

In the new bulletin, Deputy Commissioner Wieske clarifies that the plans may be extended through Dec. 31, 2017, even if that results in a policy year greater than 12 months.

Small employers that renew a policy with an insurer for a period greater than 12 months should be aware of how that decision impacts some of the employer’s compliance obligations. Specifically, if the plan is contributory and the employees contribute on a pre-tax basis, Section 125 requires that employees have an opportunity at least once per year to change their elections. Thus, even if the rates and policy are in place for greater than 12 months with the insurer, the employer would still be required to have an open enrollment period after 12 months.

Bulletin »

June 1, 2016

June 01, 2016

On April 1, 2016, Gov. Walker signed SB 517 into law, creating Act 345. The new law requires employers with 50 or more employees working in Wisconsin to provide 6 weeks of unpaid leave (within a 12 month period) to eligible employees who are serving as bone marrow or organ donors. The law does not apply to governmental employers. Employees are eligible if they have worked for the employer for 52 weeks and at least 1,000 hours in the most recent 52 week period.

Employers may request certification from a health care provider. While on leave, the employer must provide the employee with an opportunity to continue coverage under the group health plan under the same terms and conditions as if they were an active employee. Upon return, the employee would be reinstated to the same or equivalent position.

The law is effective July 1, 2016. Affected employers should review their employee handbooks and revise as necessary. Additionally, there is a posting requirement, but the Wisconsin Department of Workforce Development has not yet made the poster available. Importantly, while the law applies to employers with 50 or more employees, employers with 25 to 49 employees are required to post their policies regarding bone marrow and organ donor leave.

Act 345 »

March 22, 2016

March 22, 2016

On March 16, 2016, Insurance Commissioner Nickel issued a bulletin regarding transitional policies. As discussed in the March 8, 2016, edition of Compliance Corner, CMS announced an extension for small group transitional policies. Such policies are not required to be in compliance with certain PPACA mandates including community rating, coverage of essential health benefits, prohibition on pre-existing condition exclusions and the annual out-of-pocket maximum limit. The policy must have been in place on Dec. 13, 2013.

The bulletin confirms that insurers in Wisconsin have the option of renewing non-PPACA compliant small group glans on or before Oct. 1, 2017. Employers are permitted to change from one non-compliant plan to another if the new plan was available for purchase before Dec. 31, 2013. The plans must be the same type of product with the same benefits, insurer and primary network.

Bulletin »

WI State Updates - 2015 Jan 20 No.01

October 20, 2015

On Oct. 12, 2015, Insurance Commissioner Nickel issued a bulletin related to the definition of small group under state law. Wisconsin insurance statutes define a small group as an employer with 2 to 50 employees. Because the federal provision mandating the change of small group to 100 employees is no longer in effect as a result of the PACE Act, Wisconsin will keep the definition of small group at 50 employees. Thus, groups with 51 to 100 employees will continue to be rated as large groups and will not be required to switch to the small group market in 2016.

Bulletin »

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