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632.885(2)(b)1. 1. The child is a full-time student, regardless of age.
632.885(2)(b)3. 3. The child was called to federal active duty in the national guard or in a reserve component of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher education.
632.885(2)(b)4. 4. The child was under the age of 27 years when called to federal active duty under subd. 3.
632.885(2)(c) (c) For any policy year or plan year beginning before January 1, 2014, health insurance coverage or a self-insured health plan described in par. (a) that is a grandfathered health plan is required to provide dependent coverage for an adult child described in par. (a) or (b) only if the child is not eligible for coverage under an eligible employer-sponsored plan other than the health insurance coverage or self-insured health plan.
632.885(3m) (3m)Defining dependent; uniform terms. An insurer or self-insured health plan described in sub. (2) may not do any of the following:
632.885(3m)(a) (a) Define "dependent" for purposes of eligibility for dependent coverage of children other than in terms of the relationship between a child and an applicant or insured.
632.885(3m)(b) (b) Vary the terms of coverage under the health insurance coverage or self-insured health plan on the basis of age except for children 26 years of age or older.
632.885 History History: 2009 a. 28; 2011 a. 32.
632.885 Cross-reference Cross-reference: See also s. Ins 3.34, Wis. adm. code.
632.89 632.89 Coverage of mental disorders, alcoholism, and other diseases.
632.89(1)(1) Definitions. In this section:
632.89(1)(a) (a) "Collateral" means a member of an insured's immediate family, as defined in s. 632.895 (1).
632.89(1)(at) (at) "Group health benefit plan" has the meaning given in s. 632.745 (9).
632.89(1)(b) (b) "Health benefit plan" has the meaning given in s. 632.745 (11).
632.89(1)(c) (c) "Hospital" means any of the following:
632.89(1)(c)1. 1. A hospital licensed under s. 50.35.
632.89(1)(c)2. 2. An approved private treatment facility as defined in s. 51.45 (2) (b).
632.89(1)(c)3. 3. An approved public treatment facility as defined in s. 51.45 (2) (c).
632.89(1)(d) (d) "Inpatient hospital services" means services for the treatment of nervous and mental disorders or alcoholism and other drug abuse problems that are provided in a hospital to a bed patient in the hospital.
632.89(1)(dm) (dm) "Licensed mental health professional" means a clinical social worker who is licensed under ch. 457, a marriage and family therapist who is licensed under s. 457.10, or a professional counselor who is licensed under s. 457.12.
632.89(1)(e) (e) "Outpatient services" means nonresidential services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems provided to an insured and, if for the purpose of enhancing the treatment of the insured, a collateral by any of the following:
632.89(1)(e)1. 1. A program in an outpatient treatment facility, if both are approved by the department of health services, the program is established and maintained according to rules promulgated under s. 51.42 (7) (b) and the facility is certified under s. 51.04.
632.89(1)(e)2. 2. A licensed physician who has completed a residency in psychiatry, in an outpatient treatment facility or the physician's office.
632.89(1)(e)3. 3. A psychologist licensed under ch. 455.
632.89(1)(e)4. 4. A licensed mental health professional practicing within the scope of his or her license under ch. 457 and applicable rules.
632.89(1)(em) (em) "Self-insured health plan" has the meaning given in s. 632.745 (24).
632.89(1)(f) (f) "Transitional treatment arrangements" means services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems that are provided to an insured in a less restrictive manner than are inpatient hospital services but in a more intensive manner than are outpatient services, and that are specified by the commissioner by rule under sub. (4).
632.89(2) (2)Required coverage for group plans.
632.89(2)(a)(a) Conditions covered. A group health benefit plan and a self-insured health plan shall provide coverage of nervous and mental disorders and alcoholism and other drug abuse problems if required by pars. (c) to (dm) and as provided in pars. (c) to (dm) and subs. (3) to (3f).
632.89(2)(c) (c) Coverage of inpatient hospital services. If a group health benefit plan or a self-insured health plan provides coverage of any inpatient hospital treatment, the plan shall provide coverage for inpatient hospital services for the treatment of conditions under par. (a).
632.89(2)(d) (d) Coverage of outpatient services. If a group health benefit plan or a self-insured health plan provides coverage of any outpatient treatment, the plan shall provide coverage for outpatient services for the treatment of conditions under par. (a).
632.89(2)(dm) (dm) Coverage of transitional treatment arrangements. If a group health benefit plan or a self-insured health plan provides coverage of any inpatient hospital treatment or any outpatient treatment, the plan shall provide coverage for transitional treatment arrangements for the treatment of conditions under par. (a).
632.89(3) (3)Limitations. For a group health benefit plan and a self-insured health plan that provide coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems, and for an individual health benefit plan that provides coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems, the exclusions and limitations; deductibles; copayments; coinsurance; annual and lifetime payment limitations; out-of-pocket limits; out-of-network charges; day, visit, or appointment limits; limitations regarding referrals to nonphysician providers and treatment programs; and duration or frequency of coverage limits under the plan may be no more restrictive for coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems than the most common or frequent type of treatment limitations applied to substantially all other coverage under the plan. The plan shall include in any overall deductible amount or annual or lifetime limit or out-of-pocket limit for the plan, expenses incurred for the treatment of nervous and mental disorders or alcoholism and other drug abuse problems.
632.89(3c) (3c)Exemption for cost increase.
632.89(3c)(a)(a) Notwithstanding sub. (3), an employer that provides health care coverage for its employees through a group health benefit plan or a self-insured health plan that provides coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems may elect for the employer's plan to be exempt from the requirements under sub. (3) during the plan year following any plan year in which, as a result of the requirements under sub. (3), there is an increase under the plan in the employer's total cost of coverage for the treatment of physical conditions and nervous and mental disorders and alcoholism and other drug abuse problems by a percentage that exceeds either of the following:
632.89(3c)(a)1. 1. Two percent in the first plan year in which the requirements apply.
632.89(3c)(a)2. 2. One percent in any plan year after the first plan year in which the requirements apply.
632.89(3c)(b) (b) A cost increase specified under par. (a) may not be determined until the employer's group health benefit plan or self-insured health plan has complied with the requirements under sub. (3) for at least the first 6 months of the plan year for which the increase is to be determined. The cost increase shall be determined, and certified, by a qualified actuary, as defined in s. 623.06 (1c). A copy of the actuary's determination, and all underlying documentation that the actuary relied on in making the determination, shall be filed with and, in accordance with rules promulgated by the commissioner, retained by the insurer issuing the group health benefit plan or by the self-insured health plan.
632.89(3c)(c) (c) A group health benefit plan or a self-insured health plan that qualifies for an exemption under par. (a) and for which the employer providing coverage under the plan has elected for the plan to be exempt from the requirements under sub. (3) during a plan year shall promptly notify all enrollees under the plan.
632.89(3c)(d) (d) Regardless of a cost increase as specified in par. (a), an employer may elect for the employer's plan to continue to be subject to the requirements under sub. (3). If an employer elects for the employer's plan to be exempt from the requirements under sub. (3), during the plan year in which it is exempt the group health benefit plan or self-insured health plan shall comply with the coverage requirements under s. 632.89 (2) (a) to (dm), 2007 stats.
632.89(3f) (3f)Exemption for small employers.
632.89(3f)(a)(a) Notwithstanding sub. (3), an employer that provides health care coverage for its employees through a group health benefit plan that provides coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems may elect for the employer's plan to be exempt from the requirements under sub. (3) during a plan year if, on the first day of the plan year, the employer will have fewer than 10 eligible employees, as defined in s. 632.745 (5).
632.89(3f)(b) (b) A group health benefit plan that qualifies for an exemption under par. (a) and for which the employer providing coverage under the plan has elected for the plan to be exempt from the requirements under sub. (3) during a plan year shall promptly notify all enrollees under the employer's plan. During the plan year in which it is exempt from the requirements under sub. (3), the group health benefit plan shall comply with the coverage requirements under s. 632.89 (2) (a) to (dm), 2007 stats.
632.89(3p) (3p)Availability of plan information. A group health benefit plan and a self-insured health plan that provide coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems, and an individual health benefit plan that provides coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems, shall, upon request, make available to any current or potential insured, participant, beneficiary, or contracting provider the criteria for determining medical necessity under the plan with respect to that coverage. If a group health benefit plan or a self-insured health plan that provides coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems denies any particular insured, participant, or beneficiary coverage for services for that treatment, or if an individual health benefit plan that provides coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems denies any particular insured coverage for services for that treatment, the plan shall, upon request, make the reason for the denial available to the insured, participant, or beneficiary, in addition to complying with s. 632.857, if applicable.
632.89(4) (4)Rules.
632.89(4)(a)(a) The commissioner shall specify by rule the services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems, including but not limited to day hospitalization, that are covered under sub. (2) (dm).
632.89(4)(b)1.1. The commissioner shall promulgate rules for the administration of this section, including rules that specify the information that must be provided in the notices under subs. (3c) (c) and (3f) (b) and the manner in which the notices must be given, that specify who is responsible for the actuarial study and determination under sub. (3c) (b), and that specify retention requirements for the determination and underlying documentation. In promulgating the rules, the commissioner shall follow, as a minimum standard, any relevant federal regulations or guidelines that are in effect.
632.89(4)(b)2. 2. Using the procedure under s. 227.24, the commissioner may promulgate the rules under subd. 1. for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the commissioner is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to make a finding of emergency for a rule promulgated under this subdivision.
632.89(4m) (4m)Liability to the state or county. For any insurance policy issued on or after January 1, 1981, any insurer providing hospital treatment coverage is liable to the state or county for any costs incurred for services an inpatient health care facility, as defined in s. 50.135 (1), or community-based residential facility, as defined in s. 50.01 (1g), owned or operated by a state or county, provides to a patient regardless of the patient's liability for the services, to the extent that the insurer is liable to the patient for services provided at any other inpatient health care facility or community-based residential facility.
632.89(5) (5)Exclusions.
632.89(5)(a)(a) Medicare. No insurer or other organization subject to this section is required to duplicate coverage available under the federal medicare program.
632.89(5)(b) (b) Certain health care plans. This section does not apply to a health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).
632.89(5)(c) (c) Coverage of autism treatment. This section does not apply to coverage of treatment for autism spectrum disorder, as defined in s. 632.895 (12m) (a) 1., to which s. 632.895 (12m) applies.
632.89 Cross-reference Cross-reference: See also ss. Ins 3.37 and 3.375, Wis. adm. code.
632.895 632.895 Mandatory coverage.
632.895(1)(1) Definitions. In this section:
632.895(1)(a) (a) "Disability insurance policy" means surgical, medical, hospital, major medical or other health service coverage but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.
632.895(1)(b) (b) "Home care" means care and treatment of an insured under a plan of care established, approved in writing and reviewed at least every 2 months by the attending physician, unless the attending physician determines that a longer interval between reviews is sufficient, and consisting of one or more of the following:
632.895(1)(b)1. 1. Part-time or intermittent home nursing care by or under the supervision of a registered nurse.
632.895(1)(b)2. 2. Part-time or intermittent home health services that are medically necessary as part of the home care plan, under the supervision of a registered nurse or medical social worker, which consist solely of caring for the patient.
632.895(1)(b)3. 3. Physical or occupational therapy or speech-language pathology or respiratory care.
632.895(1)(b)4. 4. Medical supplies, drugs and medications prescribed by a physician and laboratory services by or on behalf of a hospital, if necessary under the home care plan, to the extent such items would be covered under the policy if the insured had been hospitalized.
632.895(1)(b)5. 5. Nutrition counseling provided by or under the supervision of one of the following, where such services are medically necessary as part of the home care plan:
632.895(1)(b)5.a. a. A registered dietitian.
632.895(1)(b)5.b. b. A dietitian certified under subch. V of ch. 448, if the nutrition counseling is provided on or after July 1, 1995.
632.895(1)(b)6. 6. The evaluation of the need for and development of a plan, by a registered nurse, physician extender or medical social worker, for home care when approved or requested by the attending physician.
632.895(1)(c) (c) "Hospital indemnity policies" means policies which provide benefits in a stated amount for confinement in a hospital, regardless of the hospital expenses actually incurred by the insured, due to such confinement.
632.895(1)(d) (d) "Immediate family" means the spouse, children, parents, grandparents, brothers and sisters of the insured and their spouses.
632.895(2) (2)Home care.
632.895(2)(a)(a) Every disability insurance policy which provides coverage of expenses incurred for inpatient hospital care shall provide coverage for the usual and customary fees for home care. Such coverage shall be subject to the same deductible and coinsurance provisions of the policy as other covered services. The maximum weekly benefit for such coverage need not exceed the usual and customary weekly cost for care in a skilled nursing facility. If an insurer provides disability insurance, or if 2 or more insurers jointly provide disability insurance, to an insured under 2 or more policies, home care coverage is required under only one of the policies.
632.895(2)(b) (b) Home care shall not be reimbursed unless the attending physician certifies that:
632.895(2)(b)1. 1. Hospitalization or confinement in a skilled nursing facility would otherwise be required if home care was not provided.
632.895(2)(b)2. 2. Necessary care and treatment are not available from members of the insured's immediate family or other persons residing with the insured without causing undue hardship.
632.895(2)(b)3. 3. The home care services shall be provided or coordinated by a state-licensed or medicare-certified home health agency or certified rehabilitation agency.
632.895(2)(c) (c) If the insured was hospitalized immediately prior to the commencement of home care, the home care plan shall also be initially approved by the physician who was the primary provider of services during the hospitalization.
632.895(2)(d) (d) Each visit by a person providing services under a home care plan or evaluating the need for or developing a plan shall be considered as one home care visit. The policy may contain a limit on the number of home care visits, but not less than 40 visits in any 12-month period, for each person covered under the policy. Up to 4 consecutive hours in a 24-hour period of home health service shall be considered as one home care visit.
632.895(2)(e) (e) Every disability insurance policy which purports to provide coverage supplementing parts A and B of Title XVIII of the social security act shall make available and if requested by the insured provide coverage of supplemental home care visits beyond those provided by parts A and B, sufficient to produce an aggregate coverage of 365 home care visits per policy year.
632.895(2)(f) (f) This subsection does not require coverage for any services provided by members of the insured's immediate family or any other person residing with the insured.
632.895(2)(g) (g) Insurers reviewing the certified statements of physicians as to the appropriateness and medical necessity of the services certified by the physician under this subsection may apply the same review criteria and standards which are utilized by the insurer for all other business.
632.895(3) (3)Skilled nursing care. Every disability insurance policy filed after November 29, 1979, which provides coverage for hospital care shall provide coverage for at least 30 days for skilled nursing care to patients who enter a licensed skilled nursing care facility. A disability insurance policy, other than a medicare supplement policy or medicare replacement policy, may limit coverage under this subsection to patients who enter a licensed skilled nursing care facility within 24 hours after discharge from a general hospital. The daily rate payable under this subsection to a licensed skilled nursing care facility shall be no less than the maximum daily rate established for skilled nursing care in that facility by the department of health services for purposes of reimbursement under the medical assistance program under subch. IV of ch. 49. The coverage under this subsection shall apply only to skilled nursing care which is certified as medically necessary by the attending physician and is recertified as medically necessary every 7 days. If the disability insurance policy is other than a medicare supplement policy or medicare replacement policy, coverage under this subsection shall apply only to the continued treatment for the same medical or surgical condition for which the insured had been treated at the hospital prior to entry into the skilled nursing care facility. Coverage under any disability insurance policy governed by this subsection may be subject to a deductible that applies to the hospital care coverage provided by the policy. The coverage under this subsection shall not apply to care which is essentially domiciliary or custodial, or to care which is available to the insured without charge or under a governmental health care program, other than a program provided under ch. 49.
632.895(4) (4)Kidney disease treatment.
632.895(4)(a)(a) Every disability insurance policy which provides hospital treatment coverage on an expense incurred basis shall provide coverage for hospital inpatient and outpatient kidney disease treatment, which may be limited to dialysis, transplantation and donor-related services, in an amount not less than $30,000 annually, as defined by the department of health services under par. (d).
632.895(4)(b) (b) No insurer is required to duplicate coverage available under the federal medicare program, nor duplicate any other insurance coverage the insured may have. Other insurance coverage does not include public assistance under ch. 49.
632.895(4)(c) (c) Coverage under this subsection may not be subject to exclusions or limitations, including deductibles and coinsurance factors, which are not generally applicable to other conditions covered under the policy.
632.895(4)(d) (d) The department of health services may by rule impose reasonable standards for the treatment of kidney diseases required to be covered under this subsection, which shall not be inconsistent with or less stringent than applicable federal standards.
632.895(5) (5)Coverage of newborn infants.
632.895(5)(a)(a) Every disability insurance policy shall provide coverage for a newly born child of the insured from the moment of birth.
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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)