632.875(2)(e)
(e) A statement indicating that the patient may, no later than 30 days after receiving the statement required under this subsection, request an internal appeal of the insurer's restriction or termination of coverage.
632.875(2)(f)
(f) The address to which the patient should send the request for an appeal.
632.875(2)(g)
(g) A reasonable explanation of the factual basis and of the basis in the policy, plan or contract or in applicable law for the insurer's restriction or termination of coverage.
632.875(2)(h)
(h) A list of records and documents reviewed as part of the independent evaluation.
632.875(3)(a)(a) In this subsection, "claim" means a patient's claim for coverage, 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, the restriction or termination of which coverage is the subject of an independent evaluation.
632.875(3)(b)
(b) A chiropractor who conducts an independent evaluation may not be compensated by an insurer based on a percentage of the dollar amount by which a claim is reduced as a result of the independent evaluation.
632.875(4)
(4) Subject to
sub. (2) (e), an insurer shall make available to a patient an internal procedure by which the patient may appeal an insurer's decision to restrict or terminate coverage.
632.875(5)
(5) This section does not apply to any of the following:
632.875(5)(b)
(b) Any line of property and casualty insurance except disability insurance. In this paragraph, "disability insurance" does not include uninsured motorist coverage, underinsured motorist coverage or medical payment coverage.
632.875 History
History: 1995 a. 94.
632.88
632.88
Policy extension for handicapped children. 632.88(1)(1)
Termination of coverage.. Every hospital or medical expense insurance policy or contract that provides that coverage of a dependent child of a person insured under the policy shall terminate upon attainment of a limiting age for dependent children specified in the policy shall also provide that the age limitation may not operate to terminate the coverage of a dependent child while the child is and continues to be both:
632.88(1)(a)
(a) Incapable of self-sustaining employment because of mental retardation or physical handicap; and
632.88(1)(b)
(b) Chiefly dependent upon the person insured under the policy for support and maintenance.
632.88(2)
(2) Proof of incapacity. The insurer may require that proof of the incapacity and dependency be furnished by the person insured under the policy within 31 days of the date the child attains the limiting age, and at any time thereafter except that the insurer may not require proof more frequently than annually after the 2-year period immediately following attainment of the limiting age by the child.
632.88 History
History: 1975 c. 375.
632.89
632.89
Required coverage of alcoholism and other diseases. 632.89(1)(d)
(d) "Inpatient hospital services" means services for the treatment of nervous and mental disorders or alcoholism and other drug abuse problems that are provided in a hospital to a bed patient in the hospital.
632.89(1)(e)
(e) "Outpatient services" means nonresidential services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems provided to an insured and, if for the purpose of enhancing the treatment of the insured, a collateral by any of the following:
632.89(1)(e)1.
1. A program in an outpatient treatment facility, if both are approved by the department of health and family services, the program is established and maintained according to rules promulgated under
s. 51.42 (7) (b) and the facility is certified under
s. 51.04.
632.89(1)(e)2.
2. A licensed physician who has completed a residency in psychiatry, in an outpatient treatment facility or the physician's office.
632.89(1)(e)3.
3. A licensed psychologist who is listed in the national register of health service providers in psychology or who is certified by the American board of professional psychology.
632.89(1)(em)
(em) "Policy year" means any period of time as defined by the group or blanket disability insurance policy that does not exceed 12 consecutive months.
632.89(1)(f)
(f) "Transitional treatment arrangements" means services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems that are provided to an insured in a less restrictive manner than are inpatient hospital services but in a more intensive manner than are outpatient services, and that are specified by the commissioner by rule under
sub. (4).
632.89(2)(a)1.1. A group or blanket disability insurance policy issued by an insurer shall provide coverage of nervous and mental disorders and alcoholism and other drug abuse problems if required by and as provided in
pars. (b) to
(e).
632.89(2)(a)2.
2. Except as provided in
pars. (b) to
(e), coverage of conditions under
subd. 1. by a policy may not be subject to exclusions or limitations that are not generally applicable to other conditions covered under the policy.
632.89(2)(b)
(b)
Minimum coverage of inpatient hospital, outpatient and transitional treatment arrangements. 632.89(2)(b)1.1. Except as provided in
subd. 2., if a group or blanket disability insurance policy issued by an insurer provides coverage of inpatient hospital treatment or outpatient treatment or both, the policy shall provide coverage in every policy year as provided in
pars. (c) to
(dm), as appropriate, except that the total coverage under the policy for a policy year need not exceed $7,000 or, if the coverage is provided by a health maintenance organization, as defined in
s. 609.01 (2), the equivalent benefits measured in services rendered.
632.89(2)(b)2.
2. The amount under
subd. 1. may be reduced if the policy is written in combination with major medical coverage to the extent that results in combined coverage complying with
subd. 1.
632.89(2)(c)
(c)
Minimum coverage of inpatient hospital services. 632.89(2)(c)1.1. If a group or blanket disability insurance policy issued by an insurer provides coverage of any inpatient hospital treatment, the policy shall provide coverage for inpatient hospital services for the treatment of conditions under
par. (a) 1. as provided in
subd. 2.
632.89(2)(c)2.
2. Except as provided in
par. (b), a policy under
subd. 1. shall provide coverage in every policy year for not less than the lesser of the following:
632.89(2)(c)2.a.
a. The expenses of the first 30 days as an inpatient in a hospital.
632.89(2)(c)2.b.
b. The first $7,000 minus a copayment of up to 10% for inpatient hospital services or, if the coverage is provided by a health maintenance organization, as defined in
s. 609.01 (2), the first $6,300 or the equivalent benefits measured in services rendered.
632.89(2)(d)1.1. If a group or blanket disability insurance policy issued by an insurer provides coverage of any outpatient treatment, the policy shall provide coverage for outpatient services for the treatment of conditions under
par. (a) 1. as provided in
subd. 2.
632.89(2)(d)2.
2. Except as provided in
par. (b), a policy under
subd. 1. shall provide coverage in every policy year for not less than the first $2,000 minus a copayment of up to 10% for outpatient services or, if the coverage is provided by a health maintenance organization, as defined in
s. 609.01 (2), the first $1,800 or the equivalent benefits measured in services rendered.
632.89(2)(dm)
(dm)
Minimum coverage of transitional treatment arrangements. 632.89(2)(dm)1.1. If a group or blanket disability insurance policy issued by an insurer provides coverage of any inpatient hospital treatment or any outpatient treatment, the policy shall provide coverage for transitional treatment arrangements for the treatment of conditions under
par. (a) 1. as provided in
subd. 2.
632.89(2)(dm)2.
2. Except as provided in
par. (b), a policy under
subd. 1. shall provide coverage in every policy year for not less than the first $3,000 minus a copayment of up to 10% for transitional treatment arrangements or, if the coverage is provided by a health maintenance organization, as defined in
s. 609.01 (2), the first $2,700 or the equivalent benefits measured in services rendered.
632.89(2)(e)
(e)
Exclusion. This subsection does not apply to a health care plan offered by a limited service health organization, as defined in
s. 609.01 (3).
632.89(2m)
(2m) Liability to the state or county. For any insurance policy issued on or after January 1, 1981, any insurer providing hospital treatment coverage is liable to the state or county for any costs incurred for services an inpatient health care facility, as defined in
s. 50.135 (1), or community-based residential facility, as defined in
s. 50.01 (1g), owned or operated by a state or county, provides to a patient regardless of the patient's liability for the services, to the extent that the insurer is liable to the patient for services provided at any other inpatient health care facility or community-based residential facility.
632.89(3m)
(3m) Issuance of policy. Every group or blanket disability insurance policy subject to
sub. (2) shall include a definition of "policy year".
632.89(4)
(4) Specify transitional treatment arrangements by rule. The commissioner shall specify by rule the services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems, including but not limited to day hospitalization, that are covered under
sub. (2) (dm).
632.89(5)
(5) Medicare exclusion. No insurer or other organization subject to this section is required to duplicate coverage available under the federal medicare program.
632.89 History
History: 1975 c. 223,
224,
375;
1977 c. 203 s.
106;
1979 c. 175,
221;
1981 c. 20 s.
2202 (20) (q);
1981 c. 39 ss.
14,
15,
22;
1981 c. 314;
1983 a. 27;
1983 a. 189 s.
329 (5);
1985 a. 29,
176;
1987 a. 195,
403;
1991 a. 39,
250;
1993 a. 27,
270;
1995 a. 27 ss.
7047,
9126 (19).
632.895
632.895
Mandatory coverage. 632.895(1)(a)
(a) "Disability insurance policy" means surgical, medical, hospital, major medical or other health service coverage but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.
632.895(1)(b)
(b) "Home care" means care and treatment of an insured under a plan of care established, approved in writing and reviewed at least every 2 months by the attending physician, unless the attending physician determines that a longer interval between reviews is sufficient, and consisting of one or more of the following:
632.895(1)(b)1.
1. Part-time or intermittent home nursing care by or under the supervision of a registered nurse.
632.895(1)(b)2.
2. Part-time or intermittent home health aide services which are medically necessary as part of the home care plan, under the supervision of a registered nurse or medical social worker, which consist solely of caring for the patient.
632.895(1)(b)3.
3. Physical or occupational therapy or speech-language pathology or respiratory care.
632.895(1)(b)4.
4. Medical supplies, drugs and medications prescribed by a physician and laboratory services by or on behalf of a hospital, if necessary under the home care plan, to the extent such items would be covered under the policy if the insured had been hospitalized.
632.895(1)(b)5.
5. Nutrition counseling provided by or under the supervision of one of the following, where such services are medically necessary as part of the home care plan:
632.895(1)(b)5.b.
b. A dietitian certified under
subch. IV of ch. 448, if the nutrition counseling is provided on or after July 1, 1995, and no later than June 30, 1999.
632.895(1)(b)6.
6. The evaluation of the need for and development of a plan, by a registered nurse, physician extender or medical social worker, for home care when approved or requested by the attending physician.
632.895(1)(c)
(c) "Hospital indemnity policies" means policies which provide benefits in a stated amount for confinement in a hospital, regardless of the hospital expenses actually incurred by the insured, due to such confinement.
632.895(1)(d)
(d) "Immediate family" means the spouse, children, parents, grandparents, brothers and sisters of the insured and their spouses.
632.895(2)(a)(a) Every disability insurance policy which provides coverage of expenses incurred for inpatient hospital care shall provide coverage for the usual and customary fees for home care. Such coverage shall be subject to the same deductible and coinsurance provisions of the policy as other covered services. The maximum weekly benefit for such coverage need not exceed the usual and customary weekly cost for care in a skilled nursing facility. If an insurer provides disability insurance, or if 2 or more insurers jointly provide disability insurance, to an insured under 2 or more policies, home care coverage is required under only one of the policies.
632.895(2)(b)
(b) Home care shall not be reimbursed unless the attending physician certifies that:
632.895(2)(b)1.
1. Hospitalization or confinement in a skilled nursing facility would otherwise be required if home care was not provided.
632.895(2)(b)2.
2. Necessary care and treatment are not available from members of the insured's immediate family or other persons residing with the insured without causing undue hardship.
632.895(2)(b)3.
3. The home care services shall be provided or coordinated by a state-licensed or medicare-certified home health agency or certified rehabilitation agency.
632.895(2)(c)
(c) If the insured was hospitalized immediately prior to the commencement of home care, the home care plan shall also be initially approved by the physician who was the primary provider of services during the hospitalization.
632.895(2)(d)
(d) Each visit by a person providing services under a home care plan or evaluating the need for or developing a plan shall be considered as one home care visit. The policy may contain a limit on the number of home care visits, but not less than 40 visits in any 12-month period, for each person covered under the policy. Up to 4 consecutive hours in a 24-hour period of home health aide service shall be considered as one home care visit.
632.895(2)(e)
(e) Every disability insurance policy which purports to provide coverage supplementing parts A and B of Title XVIII of the social security act shall make available and if requested by the insured provide coverage of supplemental home care visits beyond those provided by parts A and B, sufficient to produce an aggregate coverage of 365 home care visits per policy year.
632.895(2)(f)
(f) This subsection does not require coverage for any services provided by members of the insured's immediate family or any other person residing with the insured.
632.895(2)(g)
(g) Insurers reviewing the certified statements of physicians as to the appropriateness and medical necessity of the services certified by the physician under this subsection may apply the same review criteria and standards which are utilized by the insurer for all other business.
632.895(3)
(3) Skilled nursing care. Every disability insurance policy filed after November 29, 1979, which provides coverage for hospital care shall provide coverage for at least 30 days for skilled nursing care to patients who enter a licensed skilled nursing care facility. A disability insurance policy, other than a medicare supplement policy or medicare replacement policy, may limit coverage under this subsection to patients who enter a licensed skilled nursing care facility within 24 hours after discharge from a general hospital. The daily rate payable under this subsection to a licensed skilled nursing care facility shall be no less than the maximum daily rate established for skilled nursing care in that facility by the department of health and family services for purposes of reimbursement under the medical assistance program under
subch. IV of ch. 49. The coverage under this subsection shall apply only to skilled nursing care which is certified as medically necessary by the attending physician and is recertified as medically necessary every 7 days. If the disability insurance policy is other than a medicare supplement policy or medicare replacement policy, coverage under this subsection shall apply only to the continued treatment for the same medical or surgical condition for which the insured had been treated at the hospital prior to entry into the skilled nursing care facility. Coverage under any disability insurance policy governed by this subsection may be subject to a deductible that applies to the hospital care coverage provided by the policy. The coverage under this subsection shall not apply to care which is essentially domiciliary or custodial, or to care which is available to the insured without charge or under a governmental health care program, other than a program provided under
ch. 49.
632.895(4)(a)(a) Every disability insurance policy which provides hospital treatment coverage on an expense incurred basis shall provide coverage for hospital inpatient and outpatient kidney disease treatment, which may be limited to dialysis, transplantation and donor-related services, in an amount not less than $30,000 annually, as defined by the department of health and family services under
par. (d).
632.895(4)(b)
(b) No insurer is required to duplicate coverage available under the federal medicare program, nor duplicate any other insurance coverage the insured may have. Other insurance coverage does not include public assistance under
ch. 49.
632.895(4)(c)
(c) Coverage under this subsection may not be subject to exclusions or limitations, including deductibles and coinsurance factors, which are not generally applicable to other conditions covered under the policy.
632.895(4)(d)
(d) The department of health and family services may by rule impose reasonable standards for the treatment of kidney diseases required to be covered under this subsection, which shall not be inconsistent with or less stringent than applicable federal standards.
632.895(5)(a)(a) Every disability insurance policy shall provide coverage for a newly born child of the insured from the moment of birth.
