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609.655(1)(a)1. 1. Is covered as a dependent child under the terms of a policy or certificate issued by a defined network plan insurer.
609.655(1)(a)2. 2. Is enrolled in a school located in this state but outside the geographical service area of the defined network plan.
609.655(1)(b) (b) "Outpatient services" has the meaning given in s. 632.89 (1) (e).
609.655(1)(c) (c) "School" means a technical college; an institution within the University of Wisconsin System; and any institution of higher education that grants a bachelor's or higher degree.
609.655(2) (2) If a policy or certificate issued by a defined network plan insurer provides coverage of outpatient services provided to a dependent student, the policy or certificate shall provide coverage of outpatient services, to the extent and in the manner required under sub. (3), that are provided to the dependent student while he or she is attending a school located in this state but outside the geographical service area of the defined network plan, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) and 609.05 (3).
609.655(3) (3) Except as provided in sub. (5), a defined network plan shall provide coverage for all of the following services:
609.655(3)(a) (a) A clinical assessment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems, conducted by a provider described in s. 632.89 (1) (e) 2., 3., or 4. who is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and who may be designated by the defined network plan.
609.655(3)(b) (b) If outpatient services are recommended in the clinical assessment conducted under par. (a), the recommended outpatient services consisting of not more than 5 visits to an outpatient treatment facility or other provider that is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and that may be designated by the defined network plan, except as follows:
609.655(3)(b)1. 1. Coverage is not required under this paragraph if the medical director of the defined network plan determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.
609.655(3)(b)2. 2. Coverage is not required under this paragraph for outpatient services provided after the dependent student has terminated his or her enrollment in the school.
609.655(4) (4)
609.655(4)(a)(a) Upon completion of the 5 visits for outpatient services covered under sub. (3) (b), the medical director of the defined network plan and the clinician treating the dependent student shall review the dependent student's condition and determine whether it is appropriate to continue treatment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems in reasonably close proximity to the school in which the student is enrolled. The review is not required if the dependent student is no longer enrolled in the school or if the coverage limits under the policy or certificate for treatment of nervous or mental disorders or alcoholism or other drug abuse problems have been exhausted.
609.655(4)(b) (b) Upon completion of the review under par. (a), the medical director of the defined network plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the defined network plan's internal grievance procedure established under s. 632.83.
609.655(5) (5)
609.655(5)(a)(a) A policy or certificate issued by a defined network plan insurer is required to provide coverage for the services specified in sub. (3) only to the extent that the policy or certificate would have covered the service if it had been provided to the dependent student by a participating provider within the geographical service area of the defined network plan.
609.655(5)(b) (b) Paragraph (a) does not permit a defined network plan to reimburse a provider for less than the full cost of the services provided or an amount negotiated with the provider, solely because the reimbursement rate for the service would have been less if provided by a participating provider within the geographical service area of the defined network plan.
609.70 609.70 Chiropractic coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (3).
609.70 History History: 1987 a. 27; 1997 a. 237; 2001 a. 16.
609.71 609.71 Disclosure of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.798.
609.71 History History: 2009 a. 146.
609.715 609.715 Coverage of alcoholism and other diseases. Defined network plans are subject to s. 632.89.
609.715 History History: 2009 a. 218 s. 14; 2011 a. 260 s. 80.
609.75 609.75 Adopted children coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.896. Coverage of health care services obtained by adopted children and children placed for adoption may be subject to any requirements that the limited service health organization, preferred provider plan, or defined network plan imposes under s. 609.05 (2) and (3) on the coverage of health care services obtained by other enrollees.
609.75 History History: 1989 a. 336; 1997 a. 237; 2001 a. 16.
609.755 609.755 Coverage of dependents. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.885.
609.755 History History: 2009 a. 28.
609.76 609.76 Coverage of student on medical leave. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (15).
609.76 History History: 2007 a. 36.
609.77 609.77 Coverage of breast reconstruction. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (13).
609.77 History History: 1997 a. 27, 237; 2001 a. 16.
609.78 609.78 Coverage of treatment for the correction of temporomandibular disorders. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (11).
609.78 History History: 1997 a. 27, 237; 2001 a. 16.
609.79 609.79 Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (12).
609.79 History History: 1997 a. 27, 237; 2001 a. 16.
609.80 609.80 Coverage of mammograms. Defined network plans are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be subject to any requirements that the defined network plan imposes under s. 609.05 (2) and (3) on the coverage of other health care services obtained by enrollees.
609.80 History History: 1989 a. 129; 1997 a. 237; 2001 a. 16.
609.805 609.805 Coverage of contraceptives. Defined network plans are subject to s. 632.895 (17).
609.805 History History: 2009 a. 28.
609.81 609.81 Coverage related to HIV infection. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 631.93. Defined network plans are subject to s. 632.895 (9).
609.81 History History: 1989 a. 201; 1989 a. 359 s. 389; 1997 a. 237; 2001 a. 16.
609.82 609.82 Coverage without prior authorization for emergency medical condition treatment. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.85.
609.82 History History: 1997 a. 237; 2001 a. 16.
609.83 609.83 Coverage of drugs and devices. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.853.
609.83 History History: 1997 a. 237; 2001 a. 16.
609.837 609.837 Copayment equality for oral and injected chemotherapy. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.867.
609.837 History History: 2013 a. 186.
609.84 609.84 Experimental treatment. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.855.
609.84 History History: 1997 a. 237; 2001 a. 16.
609.85 609.85 Coverage of lead screening. Health maintenance organizations and preferred provider plans are subject to s. 632.895 (10).
609.85 History History: 1993 a. 450.
609.86 609.86 Coverage of hearing aids, cochlear implants, and related treatment for infants and children. Defined network plans are subject to s. 632.895 (16).
609.86 History History: 2009 a. 14.
609.87 609.87 Coverage of treatment for autism spectrum disorders. Defined network plans are subject to s. 632.895 (12m).
609.87 History History: 2009 a. 28.
609.875 609.875 Coverage of colorectal cancer screening. Defined network plans are subject to s. 632.895 (16m).
609.875 History History: 2009 a. 346 s. 8; 2011 a. 260 s. 80.
609.88 609.88 Coverage of immunizations. Defined network plans are subject to s. 632.895 (14).
609.88 History History: 1999 a. 115; 2001 a. 16.
609.89 609.89 Written reason for coverage denial. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 631.17.
609.89 History History: 1999 a. 95; 2001 a. 16.
609.90 609.90 Restrictions related to domestic abuse. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 631.95.
609.90 History History: 1999 a. 95; 2001 a. 16.
609.91 609.91 Restrictions on recovering health care costs.
609.91(1)(1) Immunity of enrollees and policyholders. Except as provided in sub. (1m) or (1p), an enrollee or policyholder of a health maintenance organization insurer is not liable for health care costs that are incurred on or after January 1, 1990, and that are covered under a policy or certificate issued by the health maintenance organization insurer, if any of the following applies:
609.91(1)(a) (a) The health care is provided by a provider who satisfies any of the following:
609.91(1)(a)1. 1. Is an affiliate of the health maintenance organization insurer.
609.91(1)(a)2. 2. Owns at least 5% of the voting securities of the health maintenance organization insurer.
609.91(1)(a)3. 3. Is entitled, alone or with one or more affiliates, to solely select one or more board members of the health maintenance organization insurer, or has an affiliate that is entitled to solely select one or more board members of the health maintenance organization insurer.
609.91(1)(a)4. 4. Is entitled to have one or more board members of the health maintenance organization insurer serve exclusively as a representative of the provider, one or more of the provider's affiliates or the provider and its affiliates, except this subdivision does not apply to an individual practice association or an affiliate of an individual practice association.
609.91(1)(a)5. 5. Is an individual practice association that is represented, or its affiliate is represented, on the board of the health maintenance organization insurer, and at least 3 of the board members of the health maintenance organization represent one or more individual practice associations.
609.91(1)(am) (am) The health care is provided by a provider under a contract with, or through membership in, a person who satisfies par. (a) 1., 2., 3., 4. or 5.
609.91(1)(b) (b) The health care is provided by a provider who is not subject to par. (a) or (am) and who does not elect to be exempt from this paragraph under s. 609.92, and the health care satisfies any of the following:
609.91(1)(b)1. 1. Is provided by a hospital or an individual practice association.
609.91(1)(b)2. 2. Is physician services provided under a contract with the health maintenance organization insurer or by a participating provider of the health maintenance organization insurer.
609.91(1)(b)3. 3. Is services, equipment, supplies or drugs that are ancillary or incidental to services described in subd. 2. and are provided by the contracting provider or participating provider.
609.91(1)(c) (c) The health care is provided by a provider who is not subject to par. (a), (am) or (b) with regard to that health care and who elects under s. 609.925 to be subject to this paragraph.
609.91(1)(d) (d) The liability is for the portion of health care costs that exceeds the amount that the health maintenance organization insurer has agreed, in a contract with the provider of the health care, to pay the provider for that health care.
609.91(1m) (1m)Immunity of medical assistance recipients. An enrollee, policyholder or insured under a policy issued by an insurer to the department of health services under s. 49.45 (2) (b) 2. to provide prepaid health care to medical assistance recipients is not liable for health care costs that are covered under the policy.
609.91(1p) (1p)Immunity for certain medicare recipients. An enrollee, policyholder, or insured under a policy issued by an insurer under Part C of Medicare under 42 USC 1395w-21 to 1395w-28 or Part D of Medicare under 42 USC 1395w-101 to 1395w-152 to provide prepaid health care, fee-for-service health care, or drug benefits to enrollees of Part C or Part D of Medicare is not liable for health care costs that are covered under the policy.
609.91(2) (2)Prohibited recovery attempts. No person may bill, charge, collect a deposit from, seek remuneration or compensation from, file or threaten to file with a credit reporting agency or have any recourse against an enrollee, policyholder or insured, or any person acting on their behalf, for health care costs for which the enrollee, policyholder or insured, or person acting on their behalf, is not liable under sub. (1), (1m), or (1p).
609.91(3) (3)Deductibles, copayments and premiums. Subsections (1) to (2) do not affect the liability of an enrollee, policyholder or insured for any deductibles, copayments or premiums owed under the policy or certificate issued by the health maintenance organization insurer or by the insurer described in sub. (1m) or (1p).
609.91(4) (4)Conditions not affecting the immunity. The immunity of an enrollee, policyholder or insured for health care costs, to the extent of the immunity provided under this section and ss. 609.92 to 609.935, is not affected by any of the following:
609.91(4)(a) (a) An agreement, other than a notice of election or termination of election in accordance with s. 609.92 or 609.925, entered into by the provider, the health maintenance organization insurer, the insurer described in sub. (1m) or (1p) or any other person, at any time, whether oral or written and whether implied or explicit, including an agreement that purports to hold the enrollee, policyholder or insured liable for health care costs.
609.91(4)(b) (b) A breach of or default on an agreement by the health maintenance organization insurer, the insurer described in sub. (1m) or (1p) or any other person to compensate the provider, directly or indirectly, for health care costs, including health care costs for which the enrollee, policyholder or insured is not liable under sub. (1), (1m), or (1p).
609.91(4)(c) (c) The insolvency of the health maintenance organization insurer or any person contracting with the health maintenance organization insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the health maintenance organization insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the health maintenance organization insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee or policyholder is not liable under sub. (1).
609.91(4)(cm) (cm) The insolvency of the insurer described in sub. (1m) or (1p) or any person contracting with the insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee, policyholder or insured is not liable under sub. (1m) or (1p).
609.91(4)(d) (d) The inability of the provider or other person who is owed compensation for health care costs to obtain compensation from the health maintenance organization insurer, the insurer described in sub. (1m) or (1p), or any other person for health care costs for which the enrollee, policyholder or insured is not liable under sub. (1), (1m), or (1p).
609.91(4)(e) (e) The failure of a health maintenance organization insurer to comply with s. 609.94.
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2011-12 Wisconsin Statutes updated though 2013 Wis. Act 380 and all Supreme Court Orders entered before June 30, 2014. Published and certified under s. 35.18. Changes effective after July 1, 2014 are designated by NOTES. (Published 7-1-14)