SB466: Bill Text

SB466, s. 34 Section 34. 632.835 (1) (c) of the statutes is amended to read:

SB466,13,19 632.835 (1) (c) "Health benefit plan" has the meaning given in s. 632.745 (11), except that "health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10. and a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3.

SB466, s. 35 Section 35. 632.835 (1) (cg) of the statutes is created to read:

SB466,13,22 632.835 (1) (cg) "Insured" includes a person who participates in a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3.

SB466, s. 36 Section 36. 632.835 (1) (ck) of the statutes is created to read:

SB466,14,3 632.835 (1) (ck) "Insurer" includes a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan.

SB466, s. 37 Section 37. 632.845 (2) of the statutes, as created by 2009 Wisconsin Act 28, is amended to read:

SB466,14,10 632.845 (2) An A self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3. or an insurer that provides coverage under a health care plan may not refuse to cover health care services that are provided to an insured under the plan and for which there is coverage under the plan on the basis that there may be coverage for the services under a liability insurance policy.

SB466, s. 38 Section 38. 632.85 (1) (c) of the statutes is renumbered 632.85 (1) (c) (intro.) and amended to read:

SB466,14,14 632.85 (1) (c) "Self-insured health plan" means a self-insured health plan of the any of the following:

SB466,14,15 1. The state or a .

SB466,14,16 2. A county, city, village, or town or.

SB466,14,17 3. A school district.

SB466, s. 39 Section 39. 632.857 of the statutes is amended to read:

SB466,15,2 632.857 Explanation required for restriction or termination of coverage. If an insurer or a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., restricts or terminates an insured's or a health plan participant's coverage for the treatment of a condition or complaint and, as a result, the insured or health plan participant becomes liable for payment for all of his or her treatment for the condition or complaint, the insurer or self-insured health plan shall provide on the explanation of benefits form 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 or self-insured health plan's restriction or termination of coverage.

SB466, s. 40 Section 40. 632.86 (2) (intro.) of the statutes is amended to read:

SB466,15,7 632.86 (2) No group or blanket disability insurance policy or self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., that provides coverage of prescribed drugs or devices through a pharmaceutical mail order plan may do any of the following:

SB466, s. 41 Section 41. 632.87 (1) of the statutes is renumbered 632.87 (1r).

SB466, s. 42 Section 42. 632.87 (1g) of the statutes is created to read:

SB466,15,10 632.87 (1g) In this section, unless the context requires otherwise:

SB466,15,12 (a) "Insured" includes a person who participates in a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3.

SB466,15,14 (b) "Insurer" includes a city, town, village, county, or school district that provides a self-insured health plan, with respect to that self-insured health plan.

SB466,15,16 (c) "Plan" includes a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3.

SB466, s. 43 Section 43. 632.875 (1) (bg) of the statutes is created to read:

SB466,15,20 632.875 (1) (bg) "Insurer" includes a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan.

SB466, s. 44 Section 44. 632.875 (1) (cg) of the statutes is created to read:

SB466,15,23 632.875 (1) (cg) "Plan" includes a self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3.

SB466, s. 45 Section 45. 632.88 (1) (intro.) of the statutes is amended to read:

SB466,16,7 632.88 (1) Termination of coverage. (intro.) Every hospital or medical expense insurance policy or contract or self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., that provides that coverage of a dependent child of a person insured under the policy or covered under the plan shall terminate upon attainment of a limiting age for dependent children specified in the policy or plan 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:

SB466, s. 46 Section 46. 632.88 (2) of the statutes is amended to read:

SB466,16,15 632.88 (2) Proof of incapacity. The insurer or self-insured health plan, as defined in s. 632.85 (1) (c) 2. and 3., may require that proof of the incapacity and dependency be furnished by the person insured under the policy or participating in the self-insured health plan within 31 days of the date the child attains the limiting age, and at any time thereafter except that the insurer or self-insured health plan may not require proof more frequently than annually after the 2-year period immediately following attainment of the limiting age by the child.

SB466, s. 47 Section 47. 632.89 (1) (bm) of the statutes is created to read:

SB466,16,18 632.89 (1) (bm) "Group or blanket disability insurance policy" includes a self-insured health plan, as defined in 632.85 (1) (c) 2. and 3.

SB466, s. 48 Section 48. 632.89 (1) (dg) of the statutes is created to read:

SB466,16,22 632.89 (1) (dg) "Insurer" includes a city, town, village, county, or school district that provides a self-insured health plan, with respect to the self-insured health plan.

SB466, s. 49 Section 49. 632.895 (1) (e) of the statutes is created to read:

SB466,16,25 632.895 (1) (e) "Insured" includes a person who participates in a self-insured health plan.

SB466, s. 50 Section 50. 632.895 (1) (f) of the statutes is created to read:

SB466,17,4 632.895 (1) (f) "Insurer" includes a city, town, village, county, or school district that provides a self-insured health plan, with respect to that self-insured health plan.

SB466, s. 51 Section 51. 632.895 (1) (g) of the statutes is created to read:

SB466,17,7 632.895 (1) (g) "Self-insured health plan" means a self-insured health plan of any of the following:

SB466,17,8 1. The state.

SB466,17,9 2. A county, city, village, or town.

SB466,17,10 3. A school district.

SB466, s. 52 Section 52. 632.895 (2) (a), (d) and (e) of the statutes are amended to read:

SB466,17,20 632.895 (2) (a) Every disability insurance policy or self-insured health plan under sub. (1) (g) 2. and 3. 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 or self-insured health plan 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.

SB466,18,2 (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 or self-insured health plan under sub. (1) (g) 2. and 3. 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 or self-insured health plan. Up to 4 consecutive hours in a 24-hour period of home health service shall be considered as one home care visit.

SB466,18,8 (e) Every disability insurance policy or self-insured health plan under sub. (1) (g) 2. and 3. 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 plan or policy year.

SB466, s. 53 Section 53. 632.895 (3) of the statutes is amended to read:

SB466,19,9 632.895 (3) Skilled nursing care. Every disability insurance policy filed after November 29, 1979, which and every self-insured health plan under sub. (1) (g) 2. and 3. that 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 or self-insured health plan, 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 or self-insured health plan 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 or self-insured health plan governed by this subsection may be subject to a deductible that applies to the hospital care coverage provided by the policy or plan. 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.

SB466, s. 54 Section 54. 632.895 (4) (a) of the statutes is amended to read:

SB466,19,16 632.895 (4) (a) Every disability insurance policy which and every self-insured health plan under sub. (1) (g) 2. and 3. that 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).

SB466, s. 55 Section 55. 632.895 (4) (c) of the statutes is amended to read:

SB466,19,20 632.895 (4) (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 or plan.

SB466, s. 56 Section 56. 632.895 (5) (a), (b), (c) and (d) of the statutes are amended to read:

SB466,19,24 632.895 (5) (a) Every disability insurance policy and every self-insured health plan under sub. (1) (g) 2. and 3. shall provide coverage for a newly born child of the insured from the moment of birth.

SB466,20,6 (b) Coverage for newly born children required under this subsection shall consider congenital defects and birth abnormalities as an injury or sickness under the policy or self-insured health plan under sub. (1) (g) 2. and 3. and shall cover functional repair or restoration of any body part when necessary to achieve normal body functioning, but shall not cover cosmetic surgery performed only to improve appearance.

SB466,20,14 (c) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or self-insured health plan under sub. (1) (g) 2. and 3. may require that notification of the birth of a child and payment of the required premium or fees shall be furnished to the insurer within 60 days after the date of birth. The insurer may refuse to continue coverage beyond the 60-day period if such notification is not received, unless within one year after the birth of the child the insured makes all past-due payments and in addition pays interest on such payments at the rate of 5 1/2% per year.

SB466,20,18 (d) If payment of a specific premium or subscription fee is not required to provide coverage for a child, the policy, self-insured health plan under sub. (1) (g) 2. and 3., or contract may request notification of the birth of a child but may not deny or refuse to continue coverage if such notification is not furnished.

SB466, s. 57 Section 57. 632.895 (5m) of the statutes is amended to read:

SB466,20,23 632.895 (5m) Coverage of grandchildren. Every disability insurance policy issued or renewed on or after May 7, 1986, and every self-insured health plan under sub. (1) (g) 2. and 3. that provides coverage for any child of the insured shall provide the same coverage for all children of that child until that child is 18 years of age.

SB466, s. 58 Section 58. 632.895 (6) and (7) of the statutes are amended to read:

SB466,21,12 632.895 (6) Equipment and supplies for treatment of diabetes. Every disability insurance policy and every self-insured health plan under sub. (1) (g) 2. and 3. which provides coverage of expenses incurred for treatment of diabetes shall provide coverage for expenses incurred by the installation and use of an insulin infusion pump, coverage for all other equipment and supplies, including insulin or any other prescription medication, used in the treatment of diabetes, and coverage of diabetic self-management education programs. Coverage required under this subsection shall be subject to the same exclusions, limitations, deductibles, and coinsurance provisions of the policy or self-insured health plan as other covered expenses, except that insulin infusion pump coverage may be limited to the purchase of one pump per year and the insurer may require the insured to use a pump for 30 days before purchase.

SB466,21,18 (7) Maternity coverage. Every group disability insurance policy which and every self-insured health plan under sub. (1) (g) 2. and 3. that provides maternity coverage shall provide maternity coverage for all persons covered under the policy. Coverage required under this subsection may not be subject to exclusions or limitations which are not applied to other maternity coverage under the policy or self-insured health plan.

SB466, s. 59 Section 59. 632.895 (8) (b) 1. (intro.) and 2., (c), (d) and (e) (intro.) of the statutes are amended to read:

SB466,21,25 632.895 (8) (b) 1. (intro.) Except as provided in subd. 2. and par. (f), every disability insurance policy and every self-insured health plan under sub. (1) (g) 2. and 3. that provides coverage for a woman age 45 to 49 shall provide coverage for that woman of 2 examinations by low-dose mammography performed when the woman is age 45 to 49, if all of the following are satisfied:

SB466,22,5 2. A disability insurance policy or self-insured health plan under sub. (1) (g) 2. and 3. need not provide coverage under subd. 1. to the extent that the woman had obtained one or more examinations by low-dose mammography while between the ages of 45 and 49 and before obtaining coverage under the disability insurance policy or self-insured health plan.

SB466,22,11 (c) Except as provided in par. (f), every disability insurance policy and every self-insured health plan under sub. (1) (g) 2. and 3. that provides coverage for a woman age 50 or older shall provide coverage for that woman of an annual examination by low-dose mammography to screen for the presence of breast cancer, if the examination is performed at the direction of a licensed physician or a nurse practitioner or if par. (e) applies.

SB466,22,17 (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c) and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy or self-insured health plan under sub. (1) (g) 2. and 3.

SB466,22,22 (e) (intro.) A disability insurance policy or self-insured health plan under sub. (1) (g) 2. and 3. shall cover an examination by low-dose mammography that is not performed at the direction of a licensed physician or a nurse practitioner but that is otherwise required to be covered under par. (b) or (c), if all of the following are satisfied:

SB466, s. 60 Section 60. 632.895 (9) (b) (intro.) of the statutes is amended to read:

SB466,23,2 632.895 (9) (b) (intro.) Except as provided in par. (d), every disability insurance policy that is issued or renewed on or after April 28, 1990, and every self-insured health plan under sub. (1) (g) 2. and 3. that provides coverage of prescription medication shall provide coverage for each drug that satisfies all of the following:

SB466, s. 61 Section 61. 632.895 (9) (c) of the statutes is amended to read:

SB466,23,7 632.895 (9) (c) Coverage of a drug under par. (b) may be subject to any copayments and deductibles that the disability insurance policy or self-insured health plan under sub. (1) (g) 2. and 3. applies generally to other prescription medication covered by the disability insurance policy or self-insured health plan.

SB466, s. 62 Section 62. 632.895 (10) (a) of the statutes is amended to read:

SB466,23,17 632.895 (10) (a) Except as provided in par. (b), every disability insurance policy and every health care benefits plan provided on a self-insured basis by a county board under s. 59.52 (11), by a city or village under s. 66.0137 (4), by a political subdivision under s. 66.0137 (4m), by a town under s. 60.23 (25), or by a school district under s. 120.13 (2) self-insured health plan under sub. (1) (g) 2. and 3. shall provide coverage for blood lead tests for children under 6 years of age, which shall be conducted in accordance with any recommended lead screening methods and intervals contained in any rules promulgated by the department of health services under s. 254.158.

SB466, s. 63 Section 63. 632.895 (11) (a) (intro.) and (d) of the statutes are amended to read:

SB466,23,24 632.895 (11) (a) (intro.) Except as provided in par. (e), every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, that provides coverage of any diagnostic or surgical procedure involving a bone, joint, muscle or tissue shall provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders if all of the following apply:

SB466,24,4 (d) Notwithstanding par. (c) 1., an insurer or a self-insured health plan of the state or a county, city, village, town or school district may require that an insured obtain prior authorization for any medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders.

SB466, s. 64 Section 64. 632.895 (12) (b) (intro.) of the statutes is amended to read:

SB466,24,11 632.895 (12) (b) (intro.) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, shall cover hospital or ambulatory surgery center charges incurred, and anesthetics provided, in conjunction with dental care that is provided to a covered individual in a hospital or ambulatory surgery center, if any of the following applies:

SB466, s. 65 Section 65. 632.895 (12) (c) of the statutes is amended to read:

SB466,24,15 632.895 (12) (c) The coverage required under this subsection may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan.

SB466, s. 66 Section 66. 632.895 (13) (a) of the statutes is amended to read:

SB466,24,20 632.895 (13) (a) Every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, that provides coverage of the surgical procedure known as a mastectomy shall provide coverage of breast reconstruction of the affected tissue incident to a mastectomy.

SB466, s. 67 Section 67. 632.895 (14) (b) of the statutes is amended to read:

SB466,25,2 632.895 (14) (b) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for a dependent who is a child of the insured.

SB466, s. 68 Section 68. 632.895 (15) (a) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

SB466,25,10 632.895 (15) (a) Subject to pars. (b) and (c), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a person as a dependent of the insured because the person is a full-time student, including the coverage under s. 632.885 (2) (b), shall continue to provide dependent coverage for the person if, due to a medically necessary leave of absence, he or she ceases to be a full-time student.