632.855(2)(a)
(a) Who is authorized to make a determination on the limitation.
632.855(2)(b)
(b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.
632.855(3)(am)(am) A health care plan or a self-insured health plan that receives a request for prior authorization of an experimental procedure that includes all of the required information upon which to make a decision shall, within 5 working days after receiving the request, issue a coverage decision. If the health care plan or self-insured health plan denies coverage of an experimental treatment, procedure, drug or device for an insured who has a terminal condition or illness, the health care plan or self-insured health plan shall, as part of its coverage decision, provide the insured with a denial letter that includes all of the following:
632.855(3)(am)1.
1. A statement setting forth the specific medical and scientific reasons for denying coverage.
632.855(3)(am)2.
2. Notice of the insured's right to appeal and a description of the appeal procedure.
632.855(3)(bm)
(bm) A health care plan or a self-insured health plan may not deny coverage under
par. (am) of an experimental treatment, procedure, drug, or device for an insured if the denial violates
s. 632.87 (6).
632.855 History
History: 1997 a. 237;
2005 a. 194.
632.857
632.857
Explanation required for restriction or termination of coverage. If an insurer restricts or terminates an insured's coverage for the treatment of a condition or complaint and, as a result, the insured becomes liable for payment for all of his or her treatment for the condition or complaint, the insurer 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 restriction or termination of coverage.
632.857 History
History: 2007 a. 20.
632.86
632.86
Restrictions on pharmaceutical services. 632.86(1)(a)
(a) "Disability insurance policy" has the meaning given in
s. 632.895 (1) (a), except that the term does not include coverage under a health maintenance organization, as defined in
s. 609.01 (2), a limited service health organization, as defined in
s. 609.01 (3), a preferred provider plan, as defined in
s. 609.01 (4), or a health care plan operated by a cooperative association organized under
s. 185.981.
632.86(1)(b)
(b) "Pharmaceutical mail order plan" means a plan under which prescribed drugs or devices are dispensed through the mail.
632.86(2)
(2) No group or blanket disability insurance policy that provides coverage of prescribed drugs or devices through a pharmaceutical mail order plan may do any of the following:
632.86(2)(a)
(a) Exclude coverage, expressly or by implication, of any prescribed drug or device provided by a pharmacist or pharmacy selected by a covered individual if the pharmacist or pharmacy provides or agrees to provide prescribed drugs or devices under the terms of the policy and at the same cost to the insurer issuing the policy as a pharmaceutical mail order plan.
632.86(2)(b)
(b) Contain coverage, deductible or copayment provisions for prescribed drugs or devices provided by a pharmacist or pharmacy selected by a covered individual that are different from the coverage, deductible or copayment provisions for prescribed drugs or devices provided by a pharmaceutical mail order plan.
632.86 History
History: 1991 a. 70;
2009 a. 165.
632.867
632.867
Oral and injected chemotherapy. 632.867(1)(a)
(a) "Chemotherapy" means drugs and biologics that kill cancer cells directly, including antineoplastics, biologic response modifiers, hormone therapy, and monoclonal antibodies, and that are used to do any of the following:
632.867(1)(a)4.
4. Destroy microscopic cancer cells that may be present after a tumor is removed by surgery to prevent a cancer recurrence.
632.867(2)
(2) Copayment, deductible, or coinsurance requirements; limitations. 632.867(2)(a)(a) Except as provided in
par. (am), a disability insurance policy that covers injected or intravenous chemotherapy and oral chemotherapy, or a self-insured health plan that covers injected or intravenous chemotherapy and oral chemotherapy, may not require a higher copayment, deductible, or coinsurance amount for oral chemotherapy than it requires for injected or intravenous chemotherapy, regardless of the formulation or benefit category determination by the policy or plan.
632.867(2)(am)
(am) A disability insurance policy or self-insured health plan that limits copayments paid by a covered individual to no more than $100 for a 30-day supply of oral chemotherapy medication is considered to comply with this section. On January 1, 2016, and on each January 1 annually thereafter, a disability insurance policy or self-insured health plan may adjust the $100 limit under this paragraph by an amount that does not exceed the percentage increase in the U.S. consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.
632.867(2)(b)
(b) A disability insurance policy or a self-insured health plan may not comply with
par. (a) by increasing the copayment, deductible, or coinsurance amount required for injected or intravenous chemotherapy that is covered under the policy or plan.
632.867(2)(c)
(c) Notwithstanding
par. (a), for a disability insurance policy, or self-insured health plan, that is a high deductible health plan, as defined in
26 USC 223 (c) (2),
par. (a) applies only after the plan enrollee's deductible has been satisfied for the year.
632.867 History
History: 2013 a. 186.
632.87
632.87
Restrictions on health care services. 632.87(1)
(1) No insurer may refuse to provide or pay for benefits for health care services provided by a licensed health care professional on the ground that the services were not rendered by a physician as defined in
s. 990.01 (28), unless the contract clearly excludes services by such practitioners, but no contract or plan may exclude services in violation of
sub. (2),
(2m),
(3),
(4),
(5), or
(6).
632.87(2)
(2) No insurer may, under a contract or plan covering vision care services or procedures, refuse to provide coverage for vision care services or procedures provided by an optometrist licensed under
ch. 449 within the scope of the practice of optometry, as defined in
s. 449.01 (1), if the contract or plan includes coverage for the same services or procedures when provided by another health care provider.
632.87(2m)(a)(a) No health maintenance organization or preferred provider plan that provides vision care services or procedures within the scope of the practice of optometry, as defined in
s. 449.01 (1), may do any of the following:
632.87(2m)(a)1.
1. Fail to provide to persons covered by the health maintenance organization or preferred provider plan, at the time of enrollment and annually thereafter, a listing of then participating vision care providers, including participating optometrists, setting forth the names of the vision care providers in alphabetical order by last name and their respective business addresses and telephone numbers, with the listing of participating vision care providers to be incorporated in any listing of all participating health care providers that includes the same information regarding all providers, if such listing is provided at the time of enrollment and annually thereafter, or with the listing of participating vision care providers otherwise to be provided separately.
632.87(2m)(a)2.
2. Fail to provide to persons covered by the health maintenance organization or preferred provider plan, at the time vision care services or procedures are needed, the opportunity to choose optometrists from the listing under
subd. 1. from whom the persons may obtain covered vision care services and procedures within the scope of the practice of optometry, as defined in
s. 449.01 (1).
632.87(2m)(a)3.
3. Fail to include as participating providers in the health maintenance organization or preferred provider plan optometrists licensed under
ch. 449 in sufficient numbers to meet the demand of persons covered by the health maintenance organization or preferred provider plan for optometric services.
632.87(2m)(a)4.
4. When vision care services or procedures are deemed appropriate by the health maintenance organization or preferred provider plan, restrict or discourage a person covered by the health maintenance organization or preferred provider plan from obtaining covered vision care services or procedures, within the scope of the practice of optometry as defined in
s. 449.01 (1), from participating optometrists solely on the basis that the providers are optometrists.
632.87(3)(a)(a) No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by a licensed physician or osteopath, even if different nomenclature is used to describe the condition or complaint. Examination by or referral from a physician shall not be a condition precedent for receipt of chiropractic care under this paragraph. This paragraph does not:
632.87(3)(a)1.
1. Prohibit the application of deductibles or coinsurance provisions to chiropractic and physician charges on an equal basis.
632.87(3)(a)2.
2. Prohibit the application of cost containment or quality assurance measures to chiropractic services in a manner that is consistent with cost containment or quality assurance measures generally applicable to physician services and that is consistent with this section.
632.87(3)(b)
(b) No insurer, 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, may do any of the following:
632.87(3)(b)1.
1. Restrict or terminate coverage for the treatment of a condition or a complaint by a licensed chiropractor within the scope of the chiropractor's professional license on the basis of other than an examination or evaluation by or a recommendation of a licensed chiropractor or a peer review committee that includes a licensed chiropractor.
632.87(3)(b)2.
2. Refuse to provide coverage to an individual because that individual has been treated by a chiropractor.
632.87(3)(b)3.
3. Establish underwriting standards that are more restrictive for chiropractic care than for care provided by other health care providers.
632.87(3)(b)4.
4. Exclude or restrict health care coverage of a health condition solely because the condition may be treated by a chiropractor.
632.87(3)(c)
(c) An exclusion or a restriction that violates
par. (b) is void in its entirety.
632.87(4)
(4) No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed dentist within the scope of the dentist's license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by another health care provider, as defined in
s. 146.81 (1) (a) to
(p).
632.87(5)
(5) No insurer or self-insured school district, city or village may, under a policy, plan or contract covering gynecological services or procedures, exclude or refuse to provide coverage for Papanicolaou tests, pelvic examinations or associated laboratory fees when the test or examination is performed by a licensed nurse practitioner, as defined in
s. 632.895 (8) (a) 3., within the scope of the nurse practitioner's professional license, if the policy, plan or contract includes coverage for Papanicolaou tests, pelvic examinations or associated laboratory fees when the test or examination is performed by a physician.
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]
632.873
632.873
Restrictions relating to fees for dental services. 632.873(1)(1)
Definitions. In this section, unless the context requires otherwise:
632.873(1)(a)
(a) "Covered service" means, with respect to dental or related services specified in a policy or plan that provides coverage for those services, a service provided by a dentist or at the direction of a dentist to an insured under the policy or an enrollee of the plan for which the policy or plan makes payment, administered consistently with policies traditionally governing covered services, or for which the policy or plan would make payment but for the application of contractual limitations of deductibles, copayments, coinsurance, waiting periods, annual maximums, lifetime maximums applicable to the same course of treatment, frequency limitations, or alternative benefit payments.
632.873(1)(b)
(b) "Policy" means a policy, certificate, or contract of insurance that provides only limited-scope dental benefits.
632.873(1)(c)
(c) "Related service" means a service that is commonly provided, by a dentist or at the direction of a dentist, in conjunction with a dental service.
