Last Updated: April 5, 2018
Comprehensive Health Form Filing Requirements—Individual and Small Group Markets
Federal law requires that beginning on or after January 1, 2014, all non-grandfathered individual and small group comprehensive health insurance plans comply with all requirements of the Affordable Care Act (ACA) including, but not limited to, essential health benefits (EHB), actuarial value (AV) requirements (also referred to as Metal Levels), guaranteed availability, and rating rules. All existing Wisconsin insurance laws not in conflict with federal law continue to apply.
Federal regulations and guidance relevant to individual and small group comprehensive health insurance requirements under the ACA may be found on the
Center for Consumer Information & Insurance Oversight (CCIIO) Web site.
Form Filing Requirements
Section 631.20, Wis. Stat., provides that Wisconsin is a file and use state and that insurers file their forms with the Office of the Commissioner of Insurance (OCI) 30 days prior to use. The file and use requirement applies to individual and small group plan filings whether the plan is being offered on the federally facilitated marketplace (FFM), off the FFM or both. Form filings affecting plans submitted to the FFM for Qualified Health Plan (QHP) certification for 2019 must be received at OCI or have a submission date in SERFF of no later than July 2, 2018. Form filings affecting only plans that will be non-QHPs in 2019 must be submitted by October 1, 2018 (30 days prior to the individual open enrollment period). Filings will be reviewed in order of receipt and will be accepted at any point prior to the deadlines listed above.
OCI's policy form checklists for Group Health - Comprehensive and Individual Health - Comprehensive plan filings are available in the
Policy Forms Checklists section of the OCI Web site.
For detailed form filing requirements, please see
Policy Form Filing Requirements Table—ACA-Compliant Plans.
Essential Health Benefits
Federal law requires that all comprehensive individual and small group health insurance policies issued on or after January 1, 2014, provide coverage of the essential health benefits (EHB) package as defined in the Affordable Care Act (ACA). The ACA provides that each state may select a benchmark plan to serve as the standard for plans required to offer EHB in the state. If a state does not exercise the option to select a benchmark plan, the default is the largest plan by enrollment in the largest product by enrollment in the state's small group market.
Wisconsin's benchmark plan is the largest plan by enrollment in the largest product by enrollment in the small group market. For Wisconsin's 2019 EHB benchmark plan, please refer to the federal
2017 EHB Benchmark Plan Summary document for detailed information on benefits included in the plan. For QHP issuers, the federal Plan & Benefits Template instructions are available at
Plan & Benefits Template Instructions. The 2014-2016 benchmark plan information is also available at
Wisconsin EHB Benchmark Plan Summary and the revised 2014-2016 federal instructions are available at
Revised Benchmark Benefits Instructions.
Please note that the summary document may not capture all of the benefits included in the benchmark plan. All benefits in the Wisconsin benchmark plan are EHBs in this state and all plans in the individual and small group markets must offer, at a minimum, benefits that are substantially equal to the EHB benchmark plan, including: covered benefits (including Wisconsin mandates), limitations on coverage and prescription drug benefits. Plan offerings are not restricted to EHBs, so plans may offer additional benefits.
Links to the complete plan language for the Wisconsin benchmark plan are provided below.
Part 1 - Certificate with Prescription Drug Rider
Part 2 - Drug Formulary
Dental Form and Rate Filing Requirements - Stand-Alone Dental Plans and other Dental Insurance Plans
Insurers wishing to offer in Wisconsin a marketplace-certified stand-alone dental plan (SADP) that meets the standards related to the pediatric dental essential health benefits must comply with all Wisconsin policy form and rate filing requirements. In order to be eligible for marketplace certification as an SADP for plan year 2019, all relevant policy forms and rates must be received at OCI or have a submission date in SERFF of no later than July 2, 2018. In addition, insurers must include with the form filing the following federal documents completed and signed by a qualified actuary: (1)
Stand-Alone Dental Plan Actuarial Value Supporting Documentation and Justification and (2)
Stand-Alone Dental Plans – Description of EHB Allocation. Insurers that want to offer in Wisconsin SADPs off the FFM that are marketplace-certified should also include documents (1) and (2) with their policy form filing. Off-Exchange certified dental plans for plan year 2019 must be submitted to OCI by October 1, 2018 (30 days prior to the individual open enrollment period).
For detailed form filing requirements, see
Policy Form and Rate Filing Requirements Table - Stand-Alone Dental Plans and other Dental Insurance Plans.