632.79 History
History: 1975 c. 352; Stats. 1975 s. 204.324;
1975 c. 422 s.
106; Stats. 1975 s. 632.79;
1979 c. 32,
221.
632.793
632.793
Notice of loss of primary insurance coverage due to age. 632.793(1)(1)
Notice to insured and employer. If an individual who is covered under a group disability insurance policy, as defined in
s. 632.895 (1) (a), that is purchased by or on behalf of an employer to provide coverage for employes will lose primary coverage under the policy upon reaching age 65, the insurer issuing the policy shall provide written notice of the change in coverage status by regular mail to the individual and shall send a copy of the notice by regular mail to the employer. The insurer shall provide the notice not less than 30 nor more than 60 days before the individual becomes 65 years of age. The notice shall specify the date on which the insurance coverage will no longer be primary and shall inform the individual that he or she will be eligible for coverage under the federal medicare program at age 65.
632.793(2)
(2) Applicability. Subsection (1) does not apply if the employer has at least 20 employes for each working day in at least 20 calendar weeks in the current year or the preceding year.
632.793 History
History: 1993 a. 108.
632.795
632.795
Open enrollment upon liquidation. 632.795(1)
(1)
Definition. In this section, "liquidated insurer" means an insurer ordered liquidated under
ch. 645 or under similar laws of another jurisdiction.
632.795(2)
(2) Coverage for group members. Except as provided in
sub. (5) and unless otherwise provided by rule or order of the commissioner, an insurer described in
sub. (3) shall permit insureds or enrolled participants of a liquidated insurer's group health care policy or plan to obtain coverage under a comprehensive group health care policy or plan offered by the insurer in the manner and under the terms required by
sub. (4).
632.795(3)
(3) Participating insurers. Subsection (2) applies to an insurer that participated in the most recent enrollment period in which the group members were able to choose among coverage offered by the liquidated insurer and coverage offered by one or more other insurers, if all of the following are satisfied:
632.795(3)(a)
(a) Coverage under a comprehensive group health care policy or plan offered by the insurer was selected by one or more members of the group in the most recent enrollment period.
632.795(3)(b)
(b) The most recent enrollment period occurred on or after July 1, 1989.
632.795(4)(a)(a) An insurer subject to
sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.
632.795(4)(b)
(b) An insurer subject to
sub. (2) shall offer coverage to the group members, and the policyholder shall provide group members with the opportunity to obtain coverage, in the manner and within the time limits required by the commissioner by rule or order.
632.795(5)
(5) Medical assistance enrollees. This section does not apply to persons enrolled in a health care plan offered by a liquidated insurer if the persons are enrolled in that plan under a contract between the department of health and family services and the liquidated insurer under
s. 49.45 (2) (b) 2.
632.795 History
History: 1989 a. 23;
1995 a. 27 s.
9126 (19).
632.797
632.797
Disclosure of group health claims experience. 632.797(1)(a)(a) Except as provided in
subs. (2) and
(3), an insurer shall provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employes through a multiple-employer trust, with the policyholder's or the employer's aggregate group health claims experience for the current policy period, and for up to 2 policy periods immediately preceding the current policy period if the insurer provided coverage during those periods, upon request from the policyholder or employer.
632.797(1)(b)
(b) The insurer shall provide the information under
par. (a) no later than 30 days after receiving a request for that information from the policyholder or employer.
632.797(1)(c)
(c) The insurer may not charge the policyholder or the employer for providing the information under
par. (a) one time in a 12-month period.
632.797(2)
(2) An insurer is not required to provide the information under
sub. (1) unless the policyholder or employer requesting the information provides coverage under the policy for at least 50 individuals, exclusive of individuals who have coverage under the policy as a dependent of another individual.
632.797(3)
(3) Notwithstanding
sub. (1), an insurer is not required to provide health claims experience under
sub. (1) for any period of time that is before 18 months before the date on which the information is requested.
632.797(4)
(4) Subsection (1) does not require that an insurer provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employes through a multiple-employer trust, with the health claims experience of an individual employe or insured.
632.797(5)
(5) An insurer is not required under
sub. (1) to provide information that identifies an individual or that is confidential under
s. 146.82.
632.797(6)
(6) An insurer that provides aggregate health claims experience information in compliance with this section is immune from civil liability for its acts or omissions in providing such information.
632.797 History
History: 1993 a. 448.
632.80
632.80
Restrictions on medical payments insurance. The provisions of this subchapter do not apply to medical payments insurance when it is a part of or supplemental to liability, steam boiler, elevator, automobile or other insurance covering loss of or damage to property, provided the loss, damage or expense arises out of a hazard directly related to such other insurance.
632.80 History
History: 1975 c. 375.
632.81
632.81
Minimum standards for certain disability policies. The commissioner may by rule establish minimum standards for benefits, claims payments, marketing practices, compensation arrangements and reporting practices for medicare supplement policies, medicare replacement policies and long-term care insurance policies. The commissioner may by rule exempt from the minimum standards certain types of coverage, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.
632.82
632.82
Renewability of long-term care insurance policies. Notwithstanding
s. 631.36 (2) to
(5), the commissioner shall, by rule, require long-term care insurance policies that are issued on an individual basis to include a provision restricting the insurer's ability to terminate or alter the long-term care insurance policy except for nonpayment of premium. The rule may specify exceptions to the restriction, including exceptions that allow insurers to do any of the following:
632.82(1)
(1) Change the rates charged on a long-term care insurance policy if the rate change is made on a class basis.
632.82(2)
(2) Refuse to renew a long-term care insurance policy if conditions specified in the rule are satisfied. The conditions shall, at a minimum, require all of the following:
632.82(2)(a)
(a) That the nonrenewal be on other than an individual basis.
632.82(2)(b)
(b) That the insurer demonstrate to the commissioner that renewal will affect the insurer's solvency or loss experience as specified in the rule.
632.82 History
History: 1989 a. 31.
632.825
632.825
Midterm termination of long-term care insurance policy by insured. 632.825(1)(a)(a) No insurer that provides coverage under a long-term care insurance policy may prohibit the insured under the policy from canceling the policy before the expiration of the agreed term.
632.825(1)(b)
(b) If an insured under a long-term care insurance policy cancels the policy before the expiration of the agreed term, the insurer shall issue a prorated premium refund to the insured.
632.825(1)(c)
(c) If an insured under a long-term care insurance policy dies during the term of the policy, the insurer shall issue a prorated premium refund to the insured's estate.
632.825(2)
(2) Policy provision. Every long-term care insurance policy shall contain a provision that apprises the insured of the insured's right to cancel and the insurer's premium refund responsibilities under
sub. (1).
632.825 History
History: 1993 a. 207.
632.84
632.84
Benefit appeals under certain policies. 632.84(1)(b)
(b) "Nursing home insurance policy" means an individual or group insurance policy which provides coverage primarily for confinement or care in a nursing home.
632.84(2)(a)(a) Except as provided in
sub. (3), an insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall establish an internal procedure by which the policyholder or the certificate holder or a representative of the policyholder or the certificate holder may appeal the denial of any benefits under the medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy. The procedure established under this paragraph shall include all of the following:
632.84(2)(a)1.
1. The opportunity for the policyholder or certificate holder or a representative of the policyholder or certificate holder to submit a written request, which may be in any form and which may include supporting material, for review by the insurer of the denial of any benefits under the policy.
632.84(2)(a)2.
2. Within 30 days after receiving the request under
subd. 1., disposition of the review and notification to the person submitting the request of the results of the review.
632.84(2)(b)
(b) An insurer shall describe the procedure established under
par. (a) in every policy, group certificate and outline of coverage issued in connection with a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy.
632.84(2)(c)
(c) If an insurer denies any benefits under a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy, the insurer shall, at the time the insurer gives notice of the denial of any benefits, provide the policyholder and certificate holder with a written description of the appeal process established under
par. (a).
632.84(2)(d)
(d) An insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall annually report to the commissioner a summary of all appeals filed under this section and the disposition of those appeals.
632.84(3)
(3) Exceptions. This section does not apply to a health maintenance organization, limited service health organization or preferred provider plan, as defined in
s. 609.01.
632.84 History
History: 1987 a. 156,
403;
1989 a. 31.
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 sickness care plan operated by a cooperative association organized under
ss. 185.981 to
185.985.
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.
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) or
(5).
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).
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 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]
