Chapter Ins 3

Ins 3.34(3)(a) (a) “Adult child” means a child of the applicant, enrollee or insured who meets the eligibility requirements of s. 632.885 (2), Stats., as applicable.

Ins 3.34(3)(b) (b) “Premium contribution” means the amount the adult child is required to pay for coverage under the adult child’s employer-sponsored group health benefit plan or self-insured health plan.

Ins 3.34(3)(c) (c) “Premium amount” means the additional amount the applicant or insured is required to pay for inclusion of the adult child under the applicant’s or insured’s health insurance policy or self-insured plan.

Ins 3.34(4) (4) Premium Determination. To determine whether an adult child meets the eligibility standard in s. 632.885 (2) (a) 3., Stats., the insurer or self-insured health plan must use only the following:

Ins 3.34 Note Note: 2011 Wis. Act 32 repealed s. 632.885 (2) (a) 1. to 3., Stats. See s. 632.885 (2) (a), Stats.

Ins 3.34(4)(a) (a) The amount of the adult child’s premium contribution.

Ins 3.34(4)(b) (b) The amount of the applicant’s or insured’s premium amount.

Ins 3.34(5) (5) Offer of coverage.

Ins 3.34(5)(a) (a) On or after January 1, 2010, an insurer and self-insured health plan shall offer coverage to an adult child of an applicant or insured as a new entrant when the applicant or insured requests enrollment of the adult child no later than 30 days after the date the adult child first becomes eligible according to this section. It is solely the applicant’s or insured’s decision whether or not to add eligible adult children to the plan to the extent permitted by law.

Ins 3.34(5)(b) (b) Insurers and self-insured health plans may not limit or otherwise restrict the offer of coverage to an eligible adult child by requiring any of the following:

Ins 3.34(5)(b)1. 1. The eligible adult child to have been previously covered as a dependent.

Ins 3.34(5)(b)2. 2. The eligible adult child to reside in this state.

Ins 3.34(5)(b)3. 3. The eligible adult child to demonstrate that he or she had previous creditable coverage.

Ins 3.34(5)(b)4. 4. The insured or applicant to have requested coverage for an eligible adult child the first time the child was eligible for coverage.

Ins 3.34(5)(c) (c) Insurers offering individual disability insurance may individually rate the eligible adult child and apply preexisting condition waiting periods consistent with s. 632.76 (2) (ac) 2., Stats., and may apply elimination riders to the eligible adult child, but may not do either of the following:

Ins 3.34(5)(c)1. 1. Deny coverage to an eligible adult child when the applicant or insured requests coverage.

Ins 3.34(5)(c)2. 2. Otherwise limit coverage if such limitation results in coverage that is illusory.

Ins 3.34(5)(d) (d) Insurers offering group disability insurance policies and self-insured health plans shall comply with all of the following:

Ins 3.34(5)(d)1. 1. May not deny coverage of an eligible adult child when coverage is requested by the applicant or insured.

Ins 3.34(5)(d)2. 2. Shall apply portability rights to an eligible adult child so long as the adult child has not had a break in creditable coverage longer than 62 days.

Ins 3.34(5)(d)3. 3. Shall comply with s. 632.746, Stats., as applicable.

Ins 3.34(5)(d)4. 4. May request documentation of the adult child’s creditable coverage for determining portability. The pre-existing condition waiting period applicable to the eligible adult child shall be applied to the adult child in the same manner as applied to any other applicant or eligible dependent.

Ins 3.34(6) (6) Eligible adult child.

Ins 3.34(6)(a) (a) For purposes of this section and implementation of s. 632.885 (2), Stats., an adult child is eligible for coverage as a dependent if either of the following is met:

Ins 3.34(6)(a)1. 1. For an adult child who has not been called to federal active duty in the national guard or in a reserve component of the U.S. armed forces, either of the following:

Ins 3.34(6)(a)1.a. a. An adult child who meets s. 632.885 (2) (a) 1., 2., and 3., Stats.

Ins 3.34 Note Note: 2011 Wis. Act 32 repealed s. 632.885 (2) (a) 1. to 3., Stats. See s. 632.885 (2) (a), Stats.

Ins 3.34(6)(a)1.b. b. An adult child who meets s. 632.885 (2) (a) 1. and 2., Stats., and who is not eligible for his or her employer sponsored coverage or whose employer does not offer health insurance to its employees is an eligible adult child.

Ins 3.34 Note Note: 2011 Wis. Act 32 repealed s. 632.885 (2) (a) 1. to 3., Stats. See s. 632.885 (2) (a), Stats.

Ins 3.34(6)(a)2. 2. For an adult child who has been called to federal active duty in the national guard or in a reserve component of the U.S. armed forces and who meet s. 632.885 (2) (b) 1., 3., and 4., Stats., all of the following:

Ins 3.34(6)(a)2.a. a. The adult child must apply to an institution of higher education as a full-time student within 12 months from the date the adult child has fulfilled his or her active duty obligation.

Ins 3.34(6)(a)2.b. b. When an adult child is called to active duty more than once within a four-year period of time, the insurer and self-insured health plan must use the adult child’s age when first called to active duty for determining eligibility under this section.

Ins 3.34 History History: EmR0930: emerg. cr. eff. 10-31-09; CR 09-076: cr. Register May 2010 No. 653, eff. 6-1-10; corrections in (title) and (6) (a) 1. b. made under s. 13.92 (4) (b) 2. and 7., Stats., Register May 2010 No. 653; correction in (6) (a) 2. made under s. 13.92 (4) (b) 7., Stats., Register March 2017 No. 735.

Ins 3.35 Ins 3.35 Colorectal cancer screening coverage.

Ins 3.35(1) (1) Applicability.

Ins 3.35(1)(a) (a) This section applies to disability insurance policies as defined at s. 632.895 (1) (a), Stats., unless otherwise excepted in s. 632.895 (16m) (c), Stats., that are issued or renewed on or after December 1, 2010. This section applies to Medicare supplement and cost plans but does not include limited –scope plans including vision and dental, hospital indemnity, income continuation, accident-only benefits, and long-term care policies. This section also applies to self-insured health plans as defined at s. 632.745 (24), Stats.

Ins 3.35(1)(b) (b) For a disability insurance policy and a self-insured health plan covering employees who are affected by a collective bargaining agreement the coverage under this section first applies as follows:

Ins 3.35(1)(b)1. 1. If the collective bargaining agreement contains provisions consistent with s. 632.895 (16m), Stats., coverage under this section first applies the earliest of any of the following: the date the disability insurance policy is issued or renewed on or after December 1, 2010, or the date the self-insured health plan is established, modified, extended or renewed on or after December 1, 2010.

Ins 3.35(1)(b)2. 2. If the collective bargaining agreement contains provisions inconsistent with s. 632.895 (16m), Stats., the coverage under this section first applies on the date the health benefit plan is first issued or renewed or a self-insured health plan is first established, modified, extended, or renewed on or after the earlier of the date the collectively bargained agreement expires, or the date the collectively bargained agreement is modified, extended, or renewed on or after December 1, 2010.

Ins 3.35(2) (2) Definitions. In addition to the definitions contained in s. 632.895 (1), Stats., for purposes of this section all the following apply:

Ins 3.35(2)(a) (a) “Designated guideline” means the recommendations of the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society regarding colorectal cancer screening guidelines identified by the insurer or self-insured health plan for compliance.

Ins 3.35(2)(b) (b) “Enrollee” means an insured or enrollee of a health plan subject to s. 632.895 (16m), Stats.

Ins 3.35(2)(c) (c) “Self-insured health plan” means a self-insured governmental health plan offered by the state, county, city, village, town, or school district that provides coverage of any diagnostic or surgical procedure.

Ins 3.35(3) (3) Colorectal cancer screening guidelines and updates.

Ins 3.35(3)(a) (a) Insurers may utilize one or more of the most current colorectal cancer screening guidelines issued by the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society as the basis for the coverage offered for preventive colorectal cancer screening tests and procedures. If an insurer or self-insured health plan elects to designate more than one guideline, the insurer or self-insured health plan shall specify the guideline that will be primary in the event of a conflict between the designated guidelines. Insurers shall provide notice of the selected guideline or guidelines and which guideline is primary in a prominent location within the plan summary and in the notice provided to insureds when a benefit is denied based upon the primary guideline.

Ins 3.35(3)(b) (b) Insurers and self-insured health plans shall at least annually review the designated guidelines and incorporate modifications to be effective the first day of the subsequent plan year.

Ins 3.35(4) (4) Covered screening. Insurers offering disability insurance and self-insured health plans shall offer as a covered benefit the screening for colorectal cancer that may be subject to limitations, exclusions and cost-sharing provisions that generally apply under the plan and comply with all of the following:

Ins 3.35(4)(a) (a) Insurers and self-insured health plans shall cover evidence-based, recommended preventive colorectal cancer screening tests or procedures contained in the most current version of the designated guideline.

Ins 3.35(4)(b) (b) In accordance with the most current recommendations from the designated guideline for frequency of testing, insurers and self-insured health plans shall provide as a covered benefit, colorectal cancer screening tests or procedures for enrollees who are 50 years of age or older other than as provided for in sub. (5) (b). Medically appropriate or medically necessary covered screening tests or procedures shall at least include 3 of the following:

Ins 3.35(4)(b)1. 1. Fecal occult blood test.

Ins 3.35(4)(b)2. 2. Flexible sigmoidoscopy.

Ins 3.35(4)(b)3. 3. Colonoscopy.

Ins 3.35(4)(b)4. 4. Computerized tomographic colonography.

Ins 3.35(4)(c) (c) Insurers and self-insured health plans may require the enrollee’s health care provider or the enrollee’s primary care provider to obtain prior authorization for screening tests or procedures when the screening test or procedure is not contained in the most current version of guideline recommendations designated by the insurer or self-insured health plan.

Ins 3.35(4)(d) (d) Disputes regarding coverage of medically appropriate or medically necessary evidence-based screening tests or procedures are subject to internal grievance and independent review as provided by ch. Ins 18.

Ins 3.35(5) (5) Factors for high risk.

Ins 3.35(5)(a) (a) In accordance with recommended factors for identifying persons at high risk for colorectal cancer developed by the American Cancer Society, insurers and self-insured health plans shall provide as a covered benefit evidence-based colorectal cancer screening tests and procedures at recommended ages and intervals for enrollees determined to be at high risk for developing colorectal cancer. Insurers and self-insured health plans that designated either the U.S. Preventive Services Task Force or the National Cancer Institute as the designated guideline may include additional high risk factors when the guidelines identify factors for persons at high risk for colorectal cancer. All insurers and self-insured health plans shall at a minimum consider all of the following factors, as appropriate, when determining whether an enrollee is at high risk for colorectal cancer:

Ins 3.35(5)(a)1. 1. Personal history of colorectal cancer, polyps or chronic inflammatory bowel disease.

Ins 3.35(5)(a)2. 2. Strong family history in a first-degree relative or two or more second-degree relatives of colorectal cancer or polyps.

Ins 3.35(5)(a)3. 3. Personal history or family history in a first or second-degree relative of hereditary colorectal cancer syndromes.

Ins 3.35(5)(a)4. 4. Other conditions, symptoms or diseases that are recognized as elevating one’s risk for colorectal cancer as determined by the U.S. Preventive Services Task Force, the National Cancer Institute or the American Cancer Society.

Ins 3.35(5)(b) (b) Notwithstanding sub. (4) (b), insurers and self-insured health plans shall provide as a covered benefit evidence-based, recommended colorectal cancer screening tests or procedures for high risk enrollees no later than the earliest recommended age determined to be medically appropriate or medically necessary.

Ins 3.35(5)(c) (c) Disputes regarding an enrollee’s status as being at high risk or factors to be considered as high risk for colon cancer are subject to internal grievance and independent review as provided by ch. Ins 18.

Ins 3.35(6) (6) Preventive services compliance. Notwithstanding s. 632.895 (16m), Stats., insurers and self-insured health plans shall comply with P.L. 111-148 and 45 CFR 147.130 relating to cost-sharing provisions of preventive services including colon cancer screening.

Ins 3.35 History History: EmR1042: emerg. cr. eff. 11-29-10; CR 10-150: cr. Register June 2011 No. 666, eff. 7-1-11.

Ins 3.36 Ins 3.36 Coverage of autism spectrum disorders.

Ins 3.36(1) (1) Applicability.

Ins 3.36(1)(a) (a) This section applies to disability insurance policies as defined in s. 632.895 (1) (a), Stats., except as provided in s. 632.895 (12m) (e), Stats., and self-insured health plans sponsored by the state, county, city, town, village, or school district.

Ins 3.36(1)(b) (b) For a disability insurance policy covering employees who are affected by a collective bargaining agreement the coverage under this section first applies as follows:

Ins 3.36(1)(b)1. 1. If the collective bargaining agreement contains provisions consistent with s. 632.895 (12m), Stats., coverage under this section first applies the earliest of any of the following: the date the disability insurance policy is issued or renewed on or after November 1, 2009, or the date the self-insured health plan is established, modified, extended or renewed on or after November 1, 2009.

Ins 3.36(1)(b)2. 2. If the collective bargaining agreement contains provisions inconsistent with s. 632.895 (12m), Stats., the coverage under this section first applies on the date the health benefit plan is first issued or renewed or a self-insured health plan is first established, modified, extended, or renewed on or after the earlier of the date the collectively bargained agreement expires, or the date the collectively bargained agreement is modified, extended or renewed.

Ins 3.36(2) (2) Definitions. In addition to the definitions in s. 632.895 (12m) (a), Stats., in this section:

Ins 3.36(2)(a) (a) “Behavior analyst” means a person certified by the Behavior Analyst Certification Board, Inc., or successor organization as a board-certified behavior analyst and has been granted a license under s. 440.312, Stats., to engage in the practice of behavior analysis.

Ins 3.36(2)(b) (b) “Behavioral” means interactive therapies that target observable behaviors to build needed skills and to reduce problem behaviors using well-established principles of learning utilized to change socially important behaviors with the goal of building a range of communication, social and learning skills, as well as reducing challenging behaviors.

Ins 3.36(2)(c) (c) “Department” means the Wisconsin department of health services.

Ins 3.36(2)(d) (d) “Efficacious treatment” or “efficacious strategy” means treatment or strategies designed to address cognitive, social or behavioral conditions associated with autism spectrum disorders; to sustain and maximize gains made during intensive-level services; or to improve an individual with autism spectrum disorder’s condition.

Ins 3.36(2)(e) (e) “Evidence-based therapy” means therapy, service and treatment that is based upon medical and scientific evidence as described at s. 632.835 (3m) (b) 1., 2. (intro.) and a., Stats., and s. Ins 18.10 (4), is determined to be an efficacious treatment or strategy and is prescribed to improve the insured’s condition or to achieve social, cognitive, communicative, self-care or behavioral goals that are clearly defined within the insured’s treatment plan.

Ins 3.36(2)(f) (f) “Intensive-level service” means evidence-based behavioral therapies that are directly based on, and related to, an insured’s therapeutic goals and skills as prescribed by a physician familiar with the insured. Intensive-level service may include evidence-based speech therapy and occupational therapy provided by a qualified therapist when such therapy is based on, or related to, an insured’s therapeutic goals and skills, and is concomitant with evidence-based behavioral therapy.

Ins 3.36(2)(g) (g) “Qualified intensive-level professional” means an individual working under the supervision of an outpatient mental health clinic who is a licensed treatment professional as defined in s. DHS 35.03 (9g), and who has completed at least 2080 hours of training, education and experience including all of the following:

Ins 3.36(2)(g)1. 1. Fifteen hundred hours supervised training involving direct one-on-one work with individuals with autism spectrum disorders using evidence-based, efficacious therapy models.

Ins 3.36(2)(g)2. 2. Supervised experience with all of the following:

Ins 3.36(2)(g)2.a. a. Working with families as part of a treatment team and ensuring treatment compliance.

Ins 3.36(2)(g)2.b. b. Treating individuals with autism spectrum disorders who function at a variety of cognitive levels and exhibit a variety of skill deficits and strengths.

Ins 3.36(2)(g)2.c. c. Treating individuals with autism spectrum disorders with a variety of behavioral challenges.

Ins 3.36(2)(g)2.d. d. Treating individuals with autism spectrum disorders who have shown improvement to the average range in cognitive functioning, language ability, adaptive and social interaction skills.

Ins 3.36(2)(g)2.e. e. Designing and implementing progressive treatment programs for individuals with autism spectrum disorders.

Ins 3.36(2)(g)3. 3. Academic coursework from a regionally-accredited higher education institution with demonstrated coursework in the application of evidence-based therapy models consistent with best practice and research on effectiveness for individuals with autism spectrum disorders.

Ins 3.36(2)(h) (h) “Qualified intensive-level provider” means an individual identified in s. 632.895 (12m) (b) 1. to 4., Stats., acting within the scope of a currently valid state-issued license for psychiatry, psychology or behavior analyst, or a social worker acting within the scope of a currently valid state-issued certificate or license to practice psychotherapy, who provides evidence-based behavioral therapy in accordance with this section and s. 632.895 (12m) (a) 3., Stats., and who has completed at least 2080 hours of training, education and experience which includes all of the following:

Ins 3.36(2)(h)1. 1. Fifteen hundred hours supervised training involving direct one-on-one work with individuals with autism spectrum disorders using evidence-based, efficacious therapy models.