632.72
632.72
Medical benefits or assistance; assignment. 632.72(1g)(a)
(a) "Department or contract provider" means the department of health and family services, the county providing the medical benefits or assistance or a health maintenance organization that has contracted with the department of health and family services to provide the medical benefits or assistance.
632.72(1g)(b)
(b) "Medical benefits or assistance" means health care services funded by a relief block grant under
ch. 49; medical assistance, as defined under
s. 49.43 (8); or maternal and child health services under
s. 253.05.
632.72(1r)
(1r) The providing of medical benefits or assistance constitutes an assignment to the department or contract provider. The assignment shall be, to the extent of the medical benefits or assistance provided, for benefits to which the recipient would be entitled under any policy of health and disability insurance.
632.72(2)
(2) An insurer may not impose on the department or contract provider, as assignee of a person who is covered under the policy of health and disability insurance and who is eligible for medical benefits or assistance, requirements that are different from those imposed on any other agent or assignee of a person who is covered under the policy of health and disability insurance.
632.725
632.725
Standardization of health care billing and insurance claim forms. 632.725(1)
(1)
Definition. In this section, "health care provider" has the meaning given in
s. 146.81 (1).
632.725(2)
(2) Rules for standardization of forms. The commissioner, in consultation with the department of health and family services, shall, by rule, do all of the following:
632.725(2)(a)
(a) Establish a standardized billing format for health care services and require that a health care provider that provides health care services in this state use, by July 1, 1993, the standardized format for all printed billing forms.
632.725(2)(b)
(b) Establish a standardized claim format for health care insurance benefits and require that an insurer that provides health care coverage to one or more residents of this state use, by July 1, 1993, the standardized format for all printed claim forms.
632.725(2)(c)
(c) Establish a standardized explanation of benefits format for health care insurance benefits and require that an insurer that provides health care coverage to one or more residents of this state use, by July 1, 1993, the standardized format for all printed forms that contain an explanation of benefits. The rule shall also require that benefits be explained in easily understood language.
632.725(2)(d)
(d) Establish a uniform statewide patient identification system in which each individual who receives health care services in this state is assigned an identification number. The standardized billing format established under
par. (a) and the standardized claim format established under
par. (b) shall provide for the designation of an individual's patient identification number.
632.725(3)
(3) Proposals for legislation. The commissioner shall develop proposals for legislation for the use of the patient identification system established under
sub. (2) (d) and for the implementation of the proposed uses, including any proposals for safeguarding patient confidentiality.
632.725 History
History: 1991 a. 250;
1995 a. 27 s.
9126 (19).
632.73
632.73
Right to return policy. 632.73(1)
(1)
Right of return. A policyholder may return an individual or franchise disability policy within 10 days after receipt. If the policyholder does so, the contract is void, and all payments made under it shall be refunded. This subsection does not apply to medicare supplement policies, medicare replacement policies or long-term care insurance policies subject to
sub. (2m).
632.73(2)
(2) Notification. Subsection (1) shall in substance be conspicuously printed on the first page of each such policy or conspicuously attached thereto.
632.73(2m)
(2m) Medicare supplement policies, medicare replacement policies and long-term care insurance policies. Medicare supplement policies, medicare replacement policies and long-term care insurance policies shall have a notice that complies with this subsection prominently printed on the first page of the policy or certificate, or attached thereto. The notice shall state that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery to the policyholder or certificate holder and to have the premium refunded to the person who paid the premium if, after examination of the policy or certificate, the policyholder or certificate holder is not satisfied for any reason. The commissioner may by rule exempt from this subsection certain classes of medicare supplement policies, medicare replacement policies and long-term care insurance policies, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.
632.73(3)(a)(a)
Specified. This section does not apply to single premium nonrenewable policies issued for terms not greater than 6 months or covering accidents only or accidental bodily injuries only.
632.73(3)(b)
(b)
By rule. The commissioner may by rule permit exemptions from
subs. (1) and
(2) for additional classes or parts of classes of insurance where the right to return the policy would be impracticable or is not necessary to protect the policyholder's interests.
632.74
632.74
Reinstatement of individual or franchise disability insurance policies. 632.74(1)
(1)
Conditions of reinstatement. If an insurer, after termination of an individual or franchise disability insurance policy for nonpayment of premium, within one year after the termination accepts without reservation a premium payment, the policy is reinstated as of the date of the acceptance. There is no acceptance without reservation if the insurer delivers or mails a written statement of reservations within 45 days after receipt of the payment.
632.74(2)
(2) Consequences of reinstatement. If a policy is reinstated under
sub. (1) or if the insurer within one year after the termination issues to the policyholder a reinstatement policy, any losses resulting from accidents occurring or sickness beginning between the termination and the effective date of the reinstatement or the new policy are not covered, and no premium is payable for that period, except to the extent that the premium is applied to a reserve for future losses. The insurer may also charge a reinstatement fee in accordance with a schedule that has been filed with and expressly approved by the commissioner as not excessive and not unreasonably discriminatory. In all other respects, the reinstated or renewed contract shall be treated as an uninterrupted contract subject to any provisions which are endorsed on or attached to the contract in connection with the reinstatement and which are fully and prominently disclosed to the policyholder.
632.745
632.745
Coverage requirements for group health benefit plans. 632.745(1)(a)1.1. Except as provided in
subd. 2., "eligible employe" means an employe who works on a permanent basis and has a normal work week of 30 or more hours. The term includes a sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership and a member of a limited liability company if the sole proprietor, business owner, partner or member is included as an employe under a health benefit plan of an employer, but the term does not include an employe who works on a temporary or substitute basis.
632.745(1)(a)2.
2. For purposes of a group health benefit plan, or a self-insured health plan, that is offered by the state under
s. 40.51 (6) or by the group insurance board under
s. 40.51 (7), "eligible employe" has the meaning given in
s. 40.02 (25).
632.745(1)(b)1.
1. An individual, firm, corporation, partnership, limited liability company or association that is actively engaged in a business enterprise in this state, including a farm business.
632.745(1)(c)
(c) "Group health benefit plan" means a health benefit plan that is issued by an insurer to an employer on behalf of a group consisting of eligible employes of the employer. The term includes individual health benefit plans covering eligible employes when 3 or more are sold to an employer.
632.745(1)(d)
(d) "Health benefit plan" means any hospital or medical policy or certificate. "Health benefit plan" does not include accident-only, credit accident or health, dental, vision, medicare supplement, medicare replacement, long-term care, disability income or short-term insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, automobile medical payment insurance, individual conversion policies, specified disease policies, hospital indemnity policies, as defined in
s. 632.895 (1) (c), policies or certificates issued under the health insurance risk-sharing plan or an alternative plan under
subch. II of ch. 619 or other insurance exempted by rule of the commissioner.
632.745(1)(e)
(e) "Insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers group health benefit plans covering eligible employes of one or more employers in this state. The term includes a health maintenance organization, as defined in
s. 609.01 (2), a preferred provider plan, as defined in
s. 609.01 (4), an insurer operating as a cooperative association organized under
ss. 185.981 to
185.985 and a limited service health organization, as defined in
s. 609.01 (3).
632.745(1)(f)1.1. "Qualifying coverage" means benefits or coverage provided under any of the following:
632.745(1)(f)1.b.
b. A group health benefit plan or an employer-based health benefit arrangement that provides benefits similar to or exceeding benefits provided under a basic health benefit plan under
subch. II of ch. 635.
632.745(1)(f)1.c.
c. An individual health benefit plan that provides benefits similar to or exceeding benefits provided under a basic health benefit plan under
subch. II of ch. 635, if the individual health benefit plan has been in effect for at least one year.
632.745(1)(f)2.
2. Notwithstanding
subd. 1. b. and
c., "qualifying coverage" does not include a high cost-share health plan, as defined in
s. 632.898 (1) (c), that is linked to a medical savings account, as described in
s. 632.898, if the employer that provides the individual's new coverage offers its eligible employes a choice of health benefit plan options that includes a high cost-share health plan, as defined in
s. 632.898 (1) (c), and the individual's new coverage is not a high cost-share health plan.
Effective date note
NOTE: Subd. 2. is created eff. 5-1-97 by
1995 Wis. Act 453. Subd. 2. is repealed by
1995 Wis. Act 453 effective on the 31st day after the day on which the commissioner of insurance certifies to the revisor of statutes under s. 632.898 (7) that subd. 2. is not necessary for the purpose for which it was intended.
632.745(1)(g)
(g) "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.
632.745(2)(a)(a) A group health benefit plan, or a self-insured health plan, may not deny, exclude or limit benefits for a covered individual for losses incurred more than 12 months after the effective date of the individual's coverage due to a preexisting condition.
632.745(2)(b)
(b) Except as provided in
par. (c), a group health benefit plan, or a self-insured health plan, may not define a preexisting condition more restrictively than any of the following:
632.745(2)(b)1.
1. A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 6 months immediately preceding the effective date of coverage and for which the individual did not seek medical advice, diagnosis, care or treatment.
632.745(2)(b)2.
2. A condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of coverage.
632.745(2)(c)
(c) Notwithstanding
par. (b) 1. and
2., a group health benefit plan, or a self-insured health plan, shall exclude pregnancy from the definition of a preexisting condition for the purpose of coverage of expenses related to prenatal and postnatal care, delivery and any complications of pregnancy.
632.745(3)(a)(a) A group health benefit plan, or a self-insured health plan, shall waive any period applicable to a preexisting condition exclusion or limitation period with respect to particular services for the period that an individual was previously covered by qualifying coverage that was not sponsored by the employer sponsoring the group health benefit plan or the self-insured health plan and that provided benefits with respect to such services, if the qualifying coverage terminated not more than 60 days before the effective date of the new coverage.
632.745(3)(b)
(b) Paragraph (a) does not prohibit the application of a waiting period to all new enrollees under a group health benefit plan or a self-insured health plan; however, a waiting period may not be applied when determining whether the qualifying coverage terminated not more than 60 days before the effective date of the new coverage.
632.745(4)(a)(a) Except as provided in
par. (d), requirements used by an insurer in determining whether to provide coverage under a group health benefit plan to an employer, including requirements for minimum participation of eligible employes and minimum employer contributions, shall be applied uniformly among all employers that apply for or receive coverage from the insurer.
632.745(4)(b)
(b) An insurer may vary its minimum participation requirements and minimum employer contribution requirements only by the size of the employer group based on the number of eligible employes.
632.745(4)(c)
(c) In applying minimum participation requirements with respect to an employer, an insurer may not count eligible employes who have other coverage that is qualifying coverage in determining whether the applicable percentage of participation is met, except that an insurer may count eligible employes who have coverage under another health benefit plan that is sponsored by that employer and that is qualifying coverage.
632.745(4)(d)
(d) An insurer may not increase a requirement for minimum employe participation or a requirement for minimum employer contribution that applies to an employer after the employer has been accepted for coverage.
632.745(4)(e)
(e) This subsection does not apply to a group health benefit plan offered by the state under
s. 40.51 (6) or by the group insurance board under
s. 40.51 (7).
632.745(5)(a)1.1. Except as provided in rules promulgated under
subd. 3., if an insurer offers a group health benefit plan to an employer, the insurer shall offer coverage to all of the eligible employes of the employer and their dependents. Except as provided in rules promulgated under
subd. 3., an insurer may not offer coverage to only certain individuals in an employer group or to only part of the group, except for an eligible employe who has not yet satisfied an applicable waiting period, if any.
632.745(5)(a)2.
2. Except as provided in rules promulgated under
subd. 3., if the state or a county, city, village, town or school district offers coverage under a self-insured health plan, it shall offer coverage to all of its eligible employes and their dependents. Except as provided in rules promulgated under
subd. 3., the state or a county, city, village, town or school district may not offer coverage to only certain individuals in the employer group or to only part of the group, except for an eligible employe who has not yet satisfied an applicable waiting period, if any.
632.745(5)(a)3.
3. The secretary of employe trust funds, with the approval of the group insurance board, shall promulgate rules related to offering coverage to eligible employes under a group health benefit plan, or a self-insured health plan, offered by the state under
s. 40.51 (6) or by the group insurance board under
s. 40.51 (7). The rules shall conform to the intent of
subds. 1. and
2. and may not allow the state or the group insurance board to refuse to offer coverage to an eligible employe or dependent for reasons related to health condition.
632.745(5)(b)1.1. An insurer may not modify a group health benefit plan with respect to an employer or an eligible employe or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the group health benefit plan.
632.745(5)(b)2.
2. The state or a county, city, village, town or school district may not modify a self-insured health plan with respect to an eligible employe or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the self-insured health plan.
632.745(5)(b)3.
3. Nothing in this paragraph limits the authority of the group insurance board to fulfill its obligations as trustee under
s. 40.03 (6) (d) or to design or modify procedures or provisions pertaining to enrollment, premium transmitted or coverage of eligible employes for health care benefits under
s. 40.51 (1).
632.745 History
History: 1995 a. 289,
453.
632.747
632.747
Guaranteed acceptance. 632.747(1)
(1)
Employe becomes eligible after commencement of coverage. If an insurer provides coverage under a group health benefit plan, the insurer shall provide coverage under the group health benefit plan to an eligible employe who becomes eligible for coverage after the commencement of the employer's coverage, and to the eligible employe's dependents, regardless of health condition or claims experience, if all of the following apply:
632.747(1)(a)
(a) The employe has satisfied any applicable waiting period.
632.747(1)(b)
(b) The employer agrees to pay the premium required for coverage of the employe under the group health benefit plan.
632.747(2)
(2) Employe waived coverage previously. If an insurer provides coverage under a group health benefit plan, the insurer shall provide coverage under the group health benefit plan to an eligible employe who waived coverage during an enrollment period during which the employe was entitled to enroll in the group health benefit plan, regardless of health condition or claims experience, if all of the following apply:
632.747(2)(a)
(a) The eligible employe was covered as a dependent under qualifying coverage when he or she waived coverage under the group health benefit plan.
632.747(2)(b)
(b) The eligible employe's coverage under the qualifying coverage has terminated or will terminate due to a divorce from the insured under the qualifying coverage, the death of the insured under the qualifying coverage, loss of employment by the insured under the qualifying coverage or involuntary loss of coverage under the qualifying coverage by the insured under the qualifying coverage.
632.747(2)(c)
(c) The eligible employe applies for coverage under the group health benefit plan not more than 30 days after termination of his or her coverage under the qualifying coverage.
632.747(2)(d)
(d) The employer agrees to pay the premium required for coverage of the employe under the group health benefit plan.
632.747(3)
(3) State or municipal self-insured plans. If the state or a county, city, village, town or school district provides coverage under a self-insured health plan, it shall provide coverage under the self-insured health plan to an eligible employe who waived coverage during an enrollment period during which the employe was entitled to enroll in the self-insured health plan, regardless of health condition or claims experience, if all of the following apply:
632.747(3)(a)
(a) The eligible employe was covered as a dependent under qualifying coverage when he or she waived coverage under the self-insured health plan.
632.747(3)(b)
(b) The eligible employe's coverage under the qualifying coverage has terminated or will terminate due to a divorce from the insured under the qualifying coverage, the death of the insured under the qualifying coverage, loss of employment by the insured under the qualifying coverage or involuntary loss of coverage under the qualifying coverage by the insured under the qualifying coverage.
632.747(3)(c)
(c) The eligible employe applies for coverage under the self-insured health plan not more than 30 days after termination of his or her coverage under the qualifying coverage.
632.747 History
History: 1995 a. 289.
