Statutes, codes, and regulations
Wisconsin Administrative Code
Agency - Office of the Commissioner of InsuranceChapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance
Subchapter III - Small Employer Health Insurance
Section Ins 8.69 - Minimum standards for market share of basic health benefit plans in force; exemption from guarantee issuance of the basic health benefit plan

Wis. Admin. Code Office of the Commissioner of Insurance Ins 8.69

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Current through December 30, 2024
Section Ins 8.69 - Minimum standards for market share of basic health benefit plans in force; exemption from guarantee issuance of the basic health benefit plan
(1) No small employer insurer may have a basic market share ratio which is significantly less than the basic market share ratio for all small employer insurers unless the insurer establishes by clear and convincing evidence that the reason the basic market share ratio is significantly less is because:
(a) Of a specific practice or condition that is beyond the control of the insurer; or
(b) The insurer uses risk characteristics to underwrite applications for policies to a substantially lesser extent than most other small employer insurers.
(2) No small employer insurer may have a market share ratio which is significantly less than the market share ratio for all small employer insurers unless the small employer insurer establishes by clear and convincing evidence that the reason the market share ratio is significantly less is because:
(a) Of a specific practice or condition that is beyond the control of the insurer; or
(b) The insurer uses risk characteristics to underwrite applications for policies to a substantially lesser extent than most other small employer insurers.
(3) For the purpose of this section:
(a) A small employer insurer's basic market share ratio is presumed to be significantly less than the basic market share ratio for all small employer insurers if the small employer insurer's basic market share ratio is less than a number equal to q-2. For the purpose of this paragraph:
1. 'm' is the number of basic health benefit plans the small employer insurer has in force; and
2. 'q' is the basic market share ratio for all small employer insurers.
(b) A small employer insurer's market share ratio is presumed to be significantly less than the market share ratio for all small employer insurers if the small employer insurer's market share ratio is less than a number equal to p-2. For the purpose of this paragraph:
1. 'n' is the number of policies the small employer insurer has in force; and
2. 'p' is the market share ratio for all small employer insurers.
(4) A small employer insurer shall submit an application for an exemption under s. 635.26(3) (a), Stats., in the form prescribed by the commissioner. Any application for an exemption under s. 635.26(3) (a), Stats., shall include the small employer insurer's basic market share ratio and market share ratio and shall address whether the small employer insurer has ratios which are, or are likely to be, significantly higher than the ratios for all small employer insurers and the reasons why the small employer insurer ratios are, or are likely to be, significantly higher than the ratio for all small employer insurers.

Note: 1997 Wis. Act 27 repealed s. 635.26, Stats. See s. 635.19(6), Stats.

(5) Each small employer insurer shall file, in the form prescribed by the commissioner:
(a) Within 45 days after the end of each quarter calendar year in calendar years 1993, 1994 and 1995:
1. The number of risk characteristic basic health benefit plans it has in force at the end of the previous quarter calendar year;
2. The number of risk characteristic basic health benefit plans it issued in the previous quarter calendar year;
3. The number of basic health benefit plans it has in force at the end of the previous quarter calendar year;
4. The number of basic health benefit plans it issued in the previous quarter calendar year;
5. The total number of policies it has in force at the end of the previous quarter calendar year;
6. The total number of policies it issued in the previous quarter calendar year;
7. Its basic market share ratio for the previous quarter calendar year;
8. Its market share ratio for the previous quarter calendar year;
9. The total number of applications for any policy which the small employer insurer received in the previous quarter calendar year, regardless of whether, or what type of, a policy was issued, and which the small employer insurer:
a. Rejected, or would have rejected, for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan; or
b. Assigned, or would have assigned, a rate for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan, which exceeds the new business premium rate for the policy by 15% or more; and
10. The total number of applications for any policy which the small employer insurer received in the previous quarter calendar year, regardless of whether, or what type of, a policy was issued.
(b) By March 1 of each year:
1. The number of risk characteristic basic health benefit plans it had in force at the end of the previous calendar year;
2. The number of risk characteristic basic health benefit plans it issued in the previous calendar year;
3. The number of basic health benefit plans it had in force at the end of the previous calendar year;
4. The number of basic health benefit plans it issued in the previous calendar year;
5. The total number of policies it had in force at the end of the previous calendar year;
6. The total number of policies it issued in the previous calendar year;
7. Its basic market share ratio for the previous calendar year;
8. Its market share ratio for the previous calendar year;
9. The total number of applications for any policy which the small employer insurer received in the previous calendar year, regardless of whether, or what type of, a policy was issued, and which the small employer insurer:
a. Rejected, or would have rejected, for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan; or
b. Assigned, or would have assigned, a rate for each policy available from the small employer insurer, other than the basic health benefit plan or a policy that does not provide benefits similar to or exceeding benefits provided under the basic health benefit plan, which exceeds the new business premium rate for the policy by 15% or more; and
10. The total number of applications for any policy which the small employer insurer received in the previous calendar year, regardless of whether, or what type of, a policy was issued.
(6) A small employer insurer shall obtain sufficient information to comply with sub. (5) and shall maintain the information and the documentation required under sub. (5) for 3 years or until the issued policy, if any, terminates, whichever is later.
(7) A small employer insurer shall establish procedures for determining whether a basic health benefit plan is a risk characteristic basic health benefit plan and shall document the basis for each such determination.

Note: Copies of forms referred to in this section may be obtained without charge from the Office of the Commissioner of Insurance by sending a written request to P. O. Box 7873, Madison, Wisconsin 53707-7873.

Subchapter IV - Basic Health Benefit Plan For Small Employers

Wis. Admin. Code Office of the Commissioner of Insurance Ins 8.69

Cr. Register, November, 1993, No. 455, eff. 2-1-94.