632.87(6)(a)1.1. Except as provided in
subd. 2., in this subsection, "routine patient care" means all of the following:
632.87(6)(a)1.a.
a. All health care services, items, and drugs for the treatment of cancer.
632.87(6)(a)1.b.
b. All health care services, items, and drugs that are typically provided in health care; including health care services, items, and drugs provided to a patient during the course of treatment in a cancer clinical trial for a condition or any of its complications; and that are consistent with the usual and customary standard of care, including the type and frequency of any diagnostic modality.
632.87(6)(a)2.
2. "Routine patient care" does not include the health care service, item, or investigational drug that is the subject of the cancer clinical trial; any health care service, item, or drug provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient; an investigational drug or device that has not been approved for market by the federal food and drug administration; transportation, lodging, food, or other expenses for the patient or a family member or companion of the patient that are associated with travel to or from a facility providing the cancer clinical trial; any services, items, or drugs provided by the cancer clinical trial sponsors free of charge for any patient; or any services, items, or drugs that are eligible for reimbursement by a person other than the insurer, including the sponsor of the cancer clinical trial.
632.87(6)(b)
(b) No policy, plan, or contract may exclude coverage for the cost of any routine patient care that is administered to an insured in a cancer clinical trial satisfying the criteria under
par. (c) and that would be covered under the policy, plan, or contract if the insured were not enrolled in a cancer clinical trial.
632.87(6)(c)
(c) A cancer clinical trial under
par. (b) must satisfy all of the following criteria:
632.87(6)(c)1.
1. A purpose of the trial is to test whether the intervention potentially improves the trial participant's health outcomes.
632.87(6)(c)2.
2. The treatment provided as part of the trial is given with the intention of improving the trial participant's health outcomes.
632.87(6)(c)3.
3. The trial has therapeutic intent and is not designed exclusively to test toxicity or disease pathophysiology.
632.87(6)(c)4.a.
a. Tests how to administer a health care service, item, or drug for the treatment of cancer.
632.87(6)(c)4.b.
b. Tests responses to a health care service, item, or drug for the treatment of cancer.
632.87(6)(c)4.c.
c. Compares the effectiveness of health care services, items, or drugs for the treatment of cancer with that of other health care services, items, or drugs for the treatment of cancer.
632.87(6)(c)4.d.
d. Studies new uses of health care services, items, or drugs for the treatment of cancer.
632.87(6)(c)5.a.
a. A National Institute of Health, or one of its cooperative groups or centers, under the federal department of health and human services.
632.87(6)(d)1.1. The coverage that may not be excluded under this subsection shall apply to all phases of a cancer clinical trial.
632.87(6)(d)2.
2. The coverage that may not be excluded under this subsection is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to any other coverage under the policy, plan, or contract, including the treatment under the policy, plan, or contract of services performed by participating and nonparticipating providers.
632.87(6)(e)1.1. Nothing in the subsection requires a policy, plan, or contract to offer; or prohibits a policy, plan, or contract from offering; cancer clinical trial services by a participating provider.
632.87(6)(e)2.
2. Nothing in this subsection requires services that are performed in a cancer clinical trial by a nonparticipating provider of a policy, plan, or contract to be reimbursed at the same rate as a participating provider of the policy, plan, or contract.
632.87 Annotation
Legislative Council Note, 1975: This [sub. (1)] continues (and expands the scope of) s. 207.04 (1) (k) [repealed by this act], which does not deal with an unfair marketing practice but an unduly restrictive interpretation of an insurance contract. Presently it applies only to podiatrists but the same principles apply to all health care professionals. Since the legislature has licensed podiatrists (s. 448.10 et. seq.), as well as other health care professionals who are not physicians, applicable insurance contracts should provide benefits for their services or payment to them, as well as for those of physicians, unless they are specifically and clearly excluded by a policy which has been approved by the commissioner. But general principles of freedom of contract should be operative if the contract is clear enough. Parties negotiating for insurance coverage should be free to decide what kind of health care services they want and are willing to pay for. [Bill 16-S]
632.875
632.875
Independent evaluations relating to chiropractic treatment. 632.875(1)(a)
(a) "Chiropractor" means a person licensed to practice chiropractic under
ch. 446.
632.875(1)(b)
(b) "Independent evaluation" means an examination or evaluation by or recommendation of a chiropractor or a peer review committee under
s. 632.87 (3) (b) 1.
632.875(1)(c)
(c) "Patient" means a person whose treatment by a chiropractor is the subject of an independent evaluation.
632.875(1)(d)
(d) "Treating chiropractor" means a chiropractor who is treating a patient and whose treatment of the patient is the subject of an independent evaluation.
632.875(2)
(2) If, on the basis of an independent evaluation, an insurer restricts or terminates a patient's coverage for the treatment of a condition or complaint by a chiropractor acting within the scope of his or her license and the restriction or termination of coverage results in the patient becoming liable for payment for his or her treatment, the insurer shall, within the time required under
s. 628.46 (2m), provide to the patient and to the treating chiropractor a written statement that contains all of the following:
632.875(2)(d)
(d) A description of the insurer's internal appeal process that is available to the patient.
632.875(2)(e)
(e) A statement indicating that the patient may, no later than 30 days after receiving the statement required under this subsection, request an internal appeal of the insurer's restriction or termination of coverage.
632.875(2)(f)
(f) The address to which the patient should send the request for an appeal.
632.875(2)(g)
(g) A detailed explanation of the clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer's restriction or termination of coverage.
632.875(2)(h)
(h) A list of records and documents reviewed as part of the independent evaluation.
632.875(3)(a)(a) In this subsection, "claim" means a patient's claim for coverage, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license, the restriction or termination of which coverage is the subject of an independent evaluation.
632.875(3)(b)
(b) A chiropractor who conducts an independent evaluation may not be compensated by an insurer based on a percentage of the dollar amount by which a claim is reduced as a result of the independent evaluation.
632.875(4)
(4) Subject to
sub. (2) (e), an insurer shall make available to a patient an internal procedure by which the patient may appeal an insurer's decision to restrict or terminate coverage.
632.875(5)
(5) This section does not apply to any of the following:
632.875(5)(b)
(b) Any line of property and casualty insurance except disability insurance. In this paragraph, "disability insurance" does not include uninsured motorist coverage, underinsured motorist coverage or medical payment coverage.
632.875 History
History: 1995 a. 94;
2001 a. 16;
2007 a. 20.
632.88
632.88
Policy extension for handicapped children. 632.88(1)(1)
Termination of coverage. Every hospital or medical expense insurance policy or contract that provides that coverage of a dependent child of a person insured under the policy shall terminate upon attainment of a limiting age for dependent children specified in the policy shall also provide that the age limitation may not operate to terminate the coverage of a dependent child while the child is and continues to be both:
632.88(1)(a)
(a) Incapable of self-sustaining employment because of mental retardation or physical handicap; and
632.88(1)(b)
(b) Chiefly dependent upon the person insured under the policy for support and maintenance.
632.88(2)
(2) Proof of incapacity. The insurer may require that proof of the incapacity and dependency be furnished by the person insured under the policy within 31 days of the date the child attains the limiting age, and at any time thereafter except that the insurer may not require proof more frequently than annually after the 2-year period immediately following attainment of the limiting age by the child.
632.88 History
History: 1975 c. 375.
632.89
632.89
Required coverage of alcoholism and other diseases. 632.89(1)(b)
(b) "Diagnostic testing" means procedures used to exclude the existence of conditions other than nervous or mental disorders or alcoholism or other drug abuse problems.
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)(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 licensed psychologist who is listed in the national register of health service providers in psychology or who is certified by the American board of professional psychology.
632.89(1)(em)
(em) "Policy year" means any period of time as defined by the group or blanket disability insurance policy that does not exceed 12 consecutive months.
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)(a)1.1. A group or blanket disability insurance policy issued by an insurer shall provide coverage of nervous and mental disorders and alcoholism and other drug abuse problems if required by and as provided in
pars. (b) to
(e).
632.89(2)(a)2.
2. Except as provided in
pars. (b) to
(e), coverage of conditions under
subd. 1. by a policy may be subject to exclusions or limitations, including deductibles and copayments, that are generally applicable to other conditions covered under the policy.
632.89(2)(b)
(b)
Minimum coverage of inpatient hospital, outpatient and transitional treatment arrangements. 632.89(2)(b)1.1. Except as provided in
subd. 2., if a group or blanket disability insurance policy issued by an insurer provides coverage of inpatient hospital treatment or outpatient treatment or both, the policy shall provide coverage in every policy year as provided in
pars. (c) to
(dm), as appropriate, except that the total coverage under the policy for a policy year need not exceed $7,000 or the equivalent benefits measured in services rendered.
632.89(2)(b)2.
2. The amount under
subd. 1. may be reduced if the policy is written in combination with major medical coverage to the extent that results in combined coverage complying with
subd. 1.
632.89(2)(c)
(c)
Minimum coverage of inpatient hospital services. 632.89(2)(c)1.1. If a group or blanket disability insurance policy issued by an insurer provides coverage of any inpatient hospital treatment, the policy shall provide coverage for inpatient hospital services for the treatment of conditions under
par. (a) 1. as provided in
subd. 2.
632.89(2)(c)2.
2. Except as provided in
par. (b), a policy under
subd. 1. shall provide coverage in every policy year for not less than the lesser of the following:
632.89(2)(c)2.b.
b. Seven thousand dollars minus any applicable cost sharing at the level charged under the policy for inpatient hospital services or the equivalent benefits measured in services rendered or, if the policy does not use cost sharing, $6,300 in equivalent benefits measured in services rendered.
632.89(2)(d)1.1. If a group or blanket disability insurance policy issued by an insurer provides coverage of any outpatient treatment, the policy shall provide coverage for outpatient services for the treatment of conditions under
par. (a) 1. as provided in
subd. 2.
632.89(2)(d)2.
2. Except as provided in
par. (b), a policy under
subd. 1. shall provide coverage in every policy year for not less than $2,000 minus any applicable cost sharing at the level charged under the policy for outpatient services or the equivalent benefits measured in services rendered or, if the policy does not use cost sharing, $1,800 in equivalent benefits measured in services rendered.
632.89(2)(dm)
(dm)
Minimum coverage of transitional treatment arrangements.
