Ins 3.53 History
History: Cr.
Register, May, 1987, No. 377, eff. 6-1-87; r. and recr.
Register, April, 1991, No. 424, eff. 5-1-91; am. (1), (3) (b) and (5) (b) 1., r. (3) (c), (d) and (4) (f), renum. (3) (e) to (i) and (4) (g) and (h) to be (3) (c) to (g) and (4) (f) and (g) and am. (3) (f) and (g), (4) (f) and (g), r. and recr. (4) (e),
Register, May, 1998, No. 509, eff. 6-1-98; correction in (4) (b) 2. made under s.
13.92 (4) (b) 7., Stats.,
Register October 2008 No. 634.
Ins 3.53 APPENDIX A
[Insurer name and address]
WISCONSIN NOTICE AND CONSENT FOR HUMAN IMMUNODEFICIENCY TESTING
REQUEST FOR CONSENT FOR TESTING
To evaluate your insurability, ( insurer name ) (Insurer) requests that you be tested to determine the presence of human immunodeficiency virus (HIV) antibody or antigens. By signing and dating this form, you agree that this test may be done and that underwriting decisions may be based on the test results. A licensed laboratory will perform one or more tests approved by the Wisconsin Commissioner of Insurance.
PRETESTING CONSIDERATION
Many public health organizations recommend that, if you have any reason to believe you may have been exposed to HIV, you become informed about the implications of the test before being tested. You may obtain information about HIV and counseling from a private health care provider, a public health clinic, or one of the AIDS service organizations on the attached list. You may also wish to obtain an HIV test from an anonymous counseling and testing site before signing this consent form. The Insurer is prohibited from asking you whether you have been tested at an anonymous counseling and testing site and from obtaining the results of such a test. For further information on these options, contact the Wisconsin AIDSline at 1-800-334-2437.
MEANING OF POSITIVE TEST RESULTS
This is not a test for AIDS. It is a test for HIV and shows whether you have been infected by the virus. A positive test result may have an effect on your ability to obtain insurance. A positive test result does not mean that you have AIDS, but it does mean that you are at a seriously increased risk of developing problems with your immune system. HIV tests are very sensitive and specific. Errors are rare but they can occur. If your test result is positive, you may wish to consider further independent testing from your physician, a public health clinic, or an anonymous counseling and testing site.
HIV testing may be arranged by calling the Wisconsin AIDSline at 1-800-334-2437.
NOTIFICATION OF TEST RESULTS
If your HIV test result is negative, no routine notification will be sent to you. If your HIV test result is other than normal, the Insurer will contact you and ask for the name of a physician or other health care provider to whom you may authorize disclosure and with whom you may wish to discuss the test results.
DISCLOSURE OF TEST RESULTS
All test results will be treated confidentially. The laboratory that does the testing will report the result to the Insurer. If necessary to process your application, the Insurer may disclose your test result to another entity such as a contractor, affiliate, or reinsurer. If your HIV test is positive, the Insurer may report it to the Medical Information Bureau (MIB, Inc.), as described in the notice given to you at the time of application. If your HIV test is negative, no report about it will be made to the MIB, Inc. The organizations described in this paragraph may maintain the test results in a file or data bank. These organizations may not disclose the fact that the test has been done or the result of the test except as permitted by law or authorized in writing by you.
CONSENT
I have read and I understand this notice and consent for HIV testing. I voluntarily consent to this testing and the disclosure of the test result as described above. A photocopy or facsimile of this form will be as valid as the original.
_______________________________/____________
Signature of Proposed Insured or Parent,
Guardian, or Health Care Agent/Date
___________________________________________
Name of Proposed Insured (Print)
___________________________________________
Date of Birth
___________________________________________
Address
___________________________________________
City, State, and Zip Code
Ins 3.54
Ins 3.54 Home health care benefits under disability insurance policies. Ins 3.54(1)(1)
Purpose. This section implements and interprets ss.
628.34 (1) and
(12),
631.20 and
632.895 (1) and
(2), Stats., for the purpose of facilitating the administration of claims for coverage of home health care under disability insurance policies and the review of policy forms. The commissioner of insurance shall disapprove a policy under s.
631.20, Stats., if that policy does not meet the minimum requirements specified in this section.
Ins 3.54(2)
(2)
Scope. This section applies to disability insurance policies.
Ins 3.54(3)(a)
(a) “Disability insurance policy" means a disability insurance policy as defined under s.
632.895 (1) (a), Stats., which provides coverage of expenses incurred for in-patient hospital care.
Ins 3.54(3)(b)
(b) “Home health aide services" means nonmedical services performed by a home health aide which:
Ins 3.54(3)(b)1.
1. Are not required to be performed by a registered nurse or licensed practical nurse; and
Ins 3.54(3)(b)2.
2. Primarily aid the patient in performing normal activities of daily living.
Ins 3.54(3)(c)
(c) “Home care visits" means the period of a visit to provide home care, without limit on the duration of the visit, except each consecutive 4 hours in a 24-hour period of home health aide services is one visit.
Ins 3.54(3)(d)
(d) “Medically necessary" means that the service or supply is:
Ins 3.54(3)(d)1.
1. Required to diagnose or treat an injury or sickness and shall be performed or prescribed by the physician;
Ins 3.54(3)(d)2.
2. Consistent with the diagnosis and treatment of the sickness or injury;
Ins 3.54(3)(d)3.
3. In accordance with generally accepted standards of medical practice; and
Ins 3.54(3)(d)4.
4. Not solely for the convenience of the insured or the physician.
Ins 3.54(4)(a)(a) All disability insurance policies including, but not limited to, medicare supplement or replacement policies, shall provide a minimum of 40 home care visits in a consecutive 12-month period for each person covered under the policy and shall make available coverage for supplemental home care visits as required by s.
632.895 (2) (e), Stats.
Ins 3.54(4)(b)
(b) An insurer shall review each home care claim under a disability insurance policy and may not deny coverage of a home care claim based solely on Medicare's denial of benefits.
Ins 3.54(4)(c)
(c) An insurer may deny coverage of all or a portion of a home health aide service visit because the visit is not medically necessary, not appropriately included in the home care plan or not necessary to prevent or postpone confinement in a hospital or skilled nursing facility only if:
Ins 3.54(4)(c)1.
1. The insurer has a reasonable, and documented factual basis for the determination; and
Ins 3.54(4)(c)2.
2. The basis for the determination is communicated to the insured in writing.
Ins 3.54(4)(d)
(d) In determining whether a home care claim, including a claim for home health aide services, is reimbursable under a disability insurance policy, an insurer may apply claim review criteria to determine that home is an appropriate treatment setting for the patient and that it is not reasonable to expect the patient to obtain medically necessary services or supplies on an outpatient basis, subject to the requirements of s.
632.895 (2) (g), Stats.
Ins 3.54(4)(e)
(e) An insurer shall disclose and clearly define the home care benefits and limitations in a disability insurance policy, certificate and outline of coverage. An insurer may not use the terms “homebound" or “custodial" in the sections of a policy describing home care benefits, exclusions, limitations, or reductions.
Ins 3.54(4)(f)
(f) In determining whether a home care claim under a disability insurance policy involves medically necessary part-time or intermittent care, an insurer shall give due consideration to the circumstances of each claimant and may not make arbitrary decisions concerning the number of home care visits within a given period which the insurer will reimburse. An insurer may not deny a claim for home care visits without properly reviewing and giving due consideration to the plan of care established by the attending physician under s.
632.895 (1) (b), Stats. An insurer may use claim review criteria based on the number of home care visits in a period for the purpose of determining whether a more thorough review of a home care claim or plan is conducted.
Ins 3.54(4)(g)
(g) An insurer may use claim review criteria under par.
(d) or
(f) only if the criteria and review process do not violate s.
Ins 6.11. An insurer shall comply with s.
628.34 (1), Stats., when communicating claim review criteria to applicants, insureds, providers or the public.
Ins 3.54 History
History: Cr.
Register, April, 1976, No. 376, eff. 6-1-87.
Ins 3.55
Ins 3.55
Benefit appeals under long-term care policies, life insurance-long-term care coverage. Ins 3.55(1)(1)
Purpose. This section implements and interprets s.
632.84, Stats., for the purpose of establishing minimum requirements for the internal procedure for benefit appeals that insurers shall provide in long-term care policies, life insurance-long-term care coverage. This section also facilitates the review by the commissioner of these policy forms.
Ins 3.55(2)
(2)
Scope. This section applies to individual and group nursing home insurance policies issued or renewed on or after August 1, 1988, and to long-term care policies and life insurance-long-term care coverage issued or renewed on and after June 1, 1991, except for polices or coverage exempt under s.
Ins 3.455 (2) (b). This section does not apply to health maintenance organizations, limited service health organization or preferred provider plan, as those are defined in s.
609.01, Stats.
Ins 3.55(3)(a)
(a) “Benefit appeal" means a request for further consideration of actions involving the denial of a benefit.
Ins 3.55(3)(b)
(b) “Denial of a benefit" means any denial of a claim, the application of a limitation or exclusion provision, and any refusal to continue coverage.
Ins 3.55(3)(c)
(c) “Internal procedure" means the insurer's written procedure for handling benefit appeals.
Ins 3.55(4)(a)(a) Pursuant to s.
632.84 (2), Stats., an insurer shall include an internal procedure for benefit appeals in any long-term care policy or life insurance-long-term care coverage.
Ins 3.55(4)(b)
(b) The insurer shall provide the policyholder and insured with a written description of the benefit appeals internal procedure at the time the insurer gives notice of the denial of a benefit. The written description shall include the name, address, and phone number of the individual designated by the insurer to be responsible for administering the benefit appeals internal procedure.
Ins 3.55(4)(c)
(c) An insurer shall describe the benefit appeals internal procedure in every policy, group certificate, and outline of coverage. The description shall include a statement on the following:
Ins 3.55(4)(c)1.
1. The insured's right to submit a written request in any form, including supporting material, for review by the insurer of the denial of a benefit under the policy; and
Ins 3.55(4)(c)2.
2. The insured's right to receive notification of the disposition of the review within 30 days of the insurer's receipt of the benefit appeal.
Ins 3.55(4)(d)
(d) An insurer shall retain records pertaining to a benefit appeal filed and the disposition of this appeal for at least 3 years from the date that the insurer files with the commissioner under sub.
(5) the annual report in which information concerning the appeal is reported.
Ins 3.55(4)(e)
(e) No insurer may impose a time limit for filing a benefit appeal that is less than 3 years from the date the insurer gives notice of the denial of a benefit.
Ins 3.55(4)(f)
(f) An insurer shall make any internal procedure established pursuant to s.
632.84, Stats., available to the commissioner upon request and in as much detail as the commissioner requests.
Ins 3.55(5)
(5)
Reports to the commissioner. An insurer offering a long-term care insurance policy or rider shall report to the commissioner by March 31 of each year a summary of all benefit appeals filed during the previous calendar year and the disposition of these appeals, including:
Ins 3.55(5)(a)
(a) The name of the individual designated by the insurer to be responsible for administering the benefit appeals internal procedure;
Ins 3.55(5)(b)
(b) Changes made in the administration of claims as a result of the review of benefit appeals;
Ins 3.55(5)(d)
(d) The date each benefit appeal was filed and, if within the calendar year, subsequently resolved;
Ins 3.55(5)(e)
(e) The date each benefit appeal carried over from the previous calendar year was resolved;
Ins 3.55(6)
(6)
Policy disapproval. The commissioner shall disapprove a policy under s.
631.20, Stats., if that policy does not meet the minimum requirements specified in this section.
Ins 3.55 History
History: Cr.
Register, May, 1989, No. 401, eff. 1-1-90; am. (1), (2) and (4) (a), r. (3) (f), cr. (3) (cg) and (cm),
Register, April, 1991, No. 424, eff. 6-1-91;
EmR0817: emerg. am. (3) (cg) and (cm), eff. 6-3-08;
CR 08-032: am. (3) (cg) and (cm)
Register October 2008 No. 634, eff. 11-1-08;
CR 19-036: am. (title), (1), (2), r. (3) (d), (e), am. (4) (a), (5) (intro.)
Register December 2019 No. 768, eff. 1-1-20.
Ins 3.55 Note
Note:
CR 08-032 first applies to policies or certificates issued on or after January 1, 2009 or on the first renewal date on or after January 1, 2009, but no later than January 1, 2010 for collectively bargained policies or certificates.
Ins 3.60
Ins 3.60
Disclosure of information on health care claim settlements. Ins 3.60(1)(1)
Purpose. This section implements and interprets s.
628.34 (1) (a) and
(12), Stats., for the purpose of allowing insureds and providers access to information on the methodology health insurers use to determine the eligible amount of a health insurance claim and permitting insureds to obtain estimates of amounts that their insurers will pay for specific health care procedures and services.
Ins 3.60(2)(a)
(a) “C.D.T." means the American dental association's current dental terminology.
Ins 3.60(2)(b)
(b) “C.P.T." means the American medical association's current procedural terminology.
Ins 3.60(2)(c)
(c) “Provider" means a licensed health care professional.
Ins 3.60(3)(a)(a) This section applies to an individual or group health insurance contract or certificate of individual coverage issued in this state that provides for settlement of claims based on a specific methodology, including but not limited to, usual, customary and reasonable charges or prevailing rate in the community, by which the insurer determines the eligible amount of a provider's charge.
Ins 3.60(3)(b)
(b) This section applies to a health maintenance organization to the extent that it makes claim settlement determinations for out-of-plan services as described in par.
(a).
