632.895(8)(a)1.
1. "Direction" means verbal or written instructions, standing orders or protocols.
632.895(8)(a)2.
2. "Low-dose mammography" means the X-ray examination of a breast using equipment dedicated specifically for mammography, including the X-ray tube, filter, compression device, screens, films and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with 2 views for each breast.
632.895(8)(a)3.
3. "Nurse practitioner" means an individual who is licensed as a registered nurse under
ch. 441 or the laws of another state and who satisfies any of the following:
632.895(8)(a)3.a.
a. Is certified as a primary care nurse practitioner or clinical nurse specialist by the American nurses' association or by the national board of pediatric nurse practitioners and associates.
632.895(8)(a)3.am.
am. Holds a master's degree in nursing from an accredited school of nursing.
632.895(8)(a)3.b.
b. Before July 1, 1990, has successfully completed a formal one-year academic program that prepares registered nurses to perform an expanded role in the delivery of primary care, includes at least 4 months of classroom instruction and a component of supervised clinical practice, and awards a degree, diploma or certificate to individuals who successfully complete the program.
632.895(8)(a)3.c.
c. Has successfully completed a formal education program that is intended to prepare registered nurses to perform an expanded role in the delivery of primary care but that does not meet the requirements of
subd. 3. b., and has performed an expanded role in the delivery of primary care for a total of 12 months during the 18-month period immediately before July 1, 1978.
632.895(8)(b)1.1. Except as provided in
subd. 2. and
par. (f), every disability insurance policy that provides coverage for a woman age 45 to 49 shall provide coverage for that woman of 2 examinations by low-dose mammography performed when the woman is age 45 to 49, if all of the following are satisfied:
632.895(8)(b)1.a.
a. Each examination by low-dose mammography is performed at the direction of a licensed physician or a nurse practitioner, except as provided in
par. (e).
632.895(8)(b)1.b.
b. The woman has not had an examination by low-dose mammography within 2 years before each examination is performed.
632.895(8)(b)2.
2. A disability insurance policy need not provide coverage under
subd. 1. to the extent that the woman had obtained one or more examinations by low-dose mammography while between the ages of 45 and 49 and before obtaining coverage under the disability insurance policy.
632.895(8)(c)
(c) Except as provided in
par. (f), every disability insurance policy that provides coverage for a woman age 50 or older shall provide coverage for that woman of an annual examination by low-dose mammography to screen for the presence of breast cancer, if the examination is performed at the direction of a licensed physician or a nurse practitioner or if
par. (e) applies.
632.895(8)(d)
(d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in
pars. (b),
(c) and
(e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy.
632.895(8)(e)
(e) A disability insurance policy shall cover an examination by low-dose mammography that is not performed at the direction of a licensed physician or a nurse practitioner but that is otherwise required to be covered under
par. (b) or
(c), if all of the following are satisfied:
632.895(8)(e)1.
1. The woman does not have an assigned or regular physician or nurse practitioner when the examination is performed.
632.895(8)(e)2.
2. The woman designates a physician to receive the results of the examination.
632.895(8)(e)3.
3. Any examination by low-dose mammography previously obtained by the woman was at the direction of a licensed physician or a nurse practitioner.
632.895(8)(f)
(f) This subsection does not apply to any of the following:
632.895(8)(f)1.
1. A disability insurance policy that only provides coverage of certain specified diseases.
632.895(8)(f)3.
3. A medicare replacement policy, a medicare supplement policy or a long-term care insurance policy.
632.895(9)
(9) Drugs for treatment of HIV infection. 632.895(9)(a)(a) In this subsection, "HIV infection" means the pathological state produced by a human body in response to the presence of HIV, as defined in
s. 631.90 (1).
632.895(9)(b)
(b) Except as provided in
par. (d), every disability insurance policy that is issued or renewed on or after April 28, 1990, and that provides coverage of prescription medication shall provide coverage for each drug that satisfies all of the following:
632.895(9)(b)1.
1. Is prescribed by the insured's physician for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection.
632.895(9)(b)2.
2. Is approved by the federal food and drug administration for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection, including each investigational new drug that is approved under
21 CFR 312.34 to
312.36 for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection and that is in, or has completed, a phase 3 clinical investigation performed in accordance with
21 CFR 312.20 to
312.33.
632.895(9)(b)3.
3. If the drug is an investigational new drug described in
subd. 2., is prescribed and administered in accordance with the treatment protocol approved for the investigational new drug under
21 CFR 312.34 to
312.36.
632.895(9)(c)
(c) Coverage of a drug under
par. (b) may be subject to any copayments and deductibles that the disability insurance policy applies generally to other prescription medication covered by the disability insurance policy.
632.895(9)(d)
(d) This subsection does not apply to any of the following:
632.895(9)(d)1.
1. A disability insurance policy that covers only certain specified diseases.
632.895(9)(d)3.
3. A medicare replacement policy or a medicare supplement policy.
632.895(10)(a)(a) Except as provided in
par. (b), every disability insurance policy and every health care benefits plan provided on a self-insured basis by a county board under
s. 59.52 (11), by a city or village under
s. 66.184 or by a school district under
s. 120.13 (2) shall provide coverage for blood lead tests for children under 6 years of age, which shall be conducted in accordance with any recommended lead screening methods and intervals contained in any rules promulgated by the department of health and family services under
s. 254.158.
632.895(10)(b)
(b) This subsection does not apply to any of the following:
632.895(10)(b)1.
1. A disability insurance policy that covers only certain specified diseases.
632.895 History
History: 1981 c. 39 ss.
4 to
12,
18,
20;
1981 c. 85,
99;
1981 c. 314 ss.
122,
123,
125;
1983 a. 36,
429;
1985 a. 29,
56,
311;
1987 a. 195,
327,
403;
1989 a. 129,
201,
229,
316,
332,
359;
1991 a. 32,
45,
123;
1993 a. 443,
450;
1995 a. 27 ss.
7048,
9126 (19);
1995 a. 201,
225.
632.895 Annotation
Commissioner can reasonably construe (3) to require insurer to pay facility's charge for care up to the maximum department of health and social services rate. Mutual Benefit v. Ins. Comr. 151 W (2d) 411, 444 NW (2d) 450 (Ct. App. 1989).
632.895 Annotation
Sub. (2) (g) does not prohibit insurer from contracting away right to review medical necessity; provision does not apply until insurer has shown that its own determination is relevant to insurance contract. Schroeder v. Blue Cross & Blue Shield, 153 W (2d) 165, 450 NW (2d) 470 (Ct. App. 1989).
632.896
632.896
Mandatory coverage of adopted children. 632.896(1)(a)
(a) "Department" means the department of health and family services.
632.896(1)(c)
(c) "Placed for adoption" means any of the following:
632.896(1)(c)1.
1. The department, a county department under
s. 48.57 (1) (e) or
(hm) or a child welfare agency licensed under
s. 48.60 places a child in the insured's home for adoption and enters into an agreement under
s. 48.833 with the insured.
632.896(1)(c)3.
3. A sending agency, as defined in
s. 48.988 (2) (d), places a child in the insured's home under
s. 48.988 for adoption, and the insured takes physical custody of the child at any location within the United States.
632.896(1)(c)4.
4. The person bringing the child into this state has complied with
s. 48.98, and the insured takes physical custody of the child at any location within the United States.
632.896(1)(c)5.
5. A court of a foreign jurisdiction appoints the insured as guardian of a child who is a citizen of that jurisdiction, and the child arrives in the insured's home for the purpose of adoption by the insured under
s. 48.839.
632.896(2)
(2) Adopted or placed for adoption. Every disability insurance policy that is issued or renewed on or after March 1, 1991, and that provides coverage for dependent children of the insured, as defined in the disability insurance policy, shall cover adopted children of the insured and children placed for adoption with the insured, on the same terms and conditions, including exclusions, limitations, deductibles and copayments, as other dependent children, except as provided in
subs. (3) to
(6).
632.896(3)(a)1.1. Coverage of a child under this section shall begin on the date that a court makes a final order granting adoption of the child by the insured or on the date that the child is placed for adoption with the insured, whichever occurs first.
632.896(3)(a)2.
2. Subdivision 1. does not require coverage to begin before coverage is available under the disability insurance policy for other dependent children.
632.896(3)(b)
(b) Coverage of a child placed for adoption with the insured is required under this section despite whether a court ultimately makes a final order granting adoption of the child by the insured. If adoption of a child who is placed for adoption with the insured is not finalized, the insurer may terminate coverage of the child when the child's adoptive placement with the insured terminates.
632.896(4)
(4) Preexisting conditions. Notwithstanding
ss. 632.745 (2) and
632.76 (2) (a), a disability insurance policy that is subject to
sub. (2) and that is in effect when a court makes a final order granting adoption or when the child is placed for adoption may not exclude or limit coverage of a disease or physical condition of the child on the ground that the disease or physical condition existed before coverage is required to begin under
sub. (3).
Effective date note
NOTE: Sub. (4) is shown as amended eff. 5-1-97 by
1995 Wis. Act 289. Prior to 5-1-97 it reads:
Effective date text
(4) Preexisting conditions. Notwithstanding s. 632.76 (2) (a), a disability insurance policy that is subject to sub. (2) and that is in effect when a court makes a final order granting adoption or when the child is placed for adoption may not exclude or limit coverage of a disease or physical condition of the child on the ground that the disease or physical condition existed before coverage is required to begin under sub. (3).
632.896(6)
(6) Notice to insurer. The disability insurance policy may require the insured to notify the insurer that a child is adopted or placed for adoption and to pay the insurer any premium or fees required to provide coverage for the child, within 60 days after coverage is required to begin under
sub. (3). If the insured fails to give notice or make payment within 60 days as required by the disability insurance policy in accordance with this subsection, the disability insurance policy shall treat the adopted child or child placed for adoption no less favorably than it treats other dependents, other than newborn children, who seek coverage at a time other than when the dependent was first eligible to apply for coverage.
632.897
632.897
Hospital and medical coverage for persons insured under individual and group policies. 632.897(1)(ac)
(ac) "Custodial parent" means the parent of a child who has been awarded physical placement with the child for more than 50% of the time.
632.897(1)(am)
(am) "Dependent" means a person who is or would be covered as a dependent of a group member under the terms of the group policy including, but not limited to, age limits, if the group member continues or had continued as a member of the group.
632.897(1)(b)
(b) "Employer" means the policyholder in the case of a group policy as defined in
par. (c) 1. or
1m. and the sponsor in the case of a group policy as defined in
par. (c) 2. or
3.
632.897(1)(c)1.
1. An insurance policy issued by an insurer to a policyholder on behalf of a group whose members thereby receive hospital or medical coverage on either an expense incurred or service basis, other than for specified diseases or for accidental injuries;
632.897(1)(c)1m.
1m. A long-term care insurance policy issued by an insurer to a policyholder on behalf of a group;
632.897(1)(c)2.
2. An uninsured plan or program whereby a health maintenance organization, limited service health organization, preferred provider plan, labor union, religious community or other sponsor contracts to provide hospital or medical coverage to members of a group on either an expense incurred or service basis, other than for specified diseases or for accidental injuries; or
632.897(1)(c)3.
3. A plan or program whereby a sponsor arranges for the mass marketing of franchise insurance to members of a group related to one another through their relationship with the sponsor.
632.897(1)(cm)
(cm) "Individual policy" means an insurance policy whereby an insured receives hospital or medical coverage on either an expense incurred or service basis, other than for specified diseases or for accidental injuries, and a long-term care insurance policy.
632.897(1)(d)
(d) "Insurer" means the insurer in the case of a group policy as defined in
par. (c) 1.,
1m. or
3. and the sponsor in the case of a group policy as defined in
par. (c) 2.
632.897(1)(e)
(e) "Medicare" means coverage under both part A and part B of Title XVIII of the federal social security act,
42 USC 1395 et seq., as amended.
632.897(1)(f)
(f) "Terminated insured" means a person entitled to elect continued or conversion coverage under
sub. (2) (b) or
(9).
632.897(1m)
(1m) Except as provided in
sub. (10), this section applies to any group policy which would otherwise be exempt under
s. 600.01 (1) (b) 3. if at least 150 of the certificate holders or insureds are residents of this state.
632.897(2)(a)(a) No group policy which provides coverage to the spouse of the group member may contain a provision for termination of coverage for the spouse solely as a result of a break in their marital relationship except by reason of the entry of a judgment of divorce or annulment of their marriage.
632.897(2)(b)
(b) An insurer issuing or renewing a group policy on or after May 14, 1980 and every insurer on and after the date which is 2 years after May 14, 1980 shall permit the following persons who have been continuously covered under a group policy for at least 3 months to elect to continue group policy coverage under
sub. (3) or to convert to individual coverage under
sub. (4):
632.897(2)(b)1.
1. The former spouse of a group member who otherwise would terminate coverage because of divorce or annulment.
632.897(2)(b)2.
2. A group member who would otherwise terminate eligibility for coverage under the group policy other than a group member who terminates eligibility for coverage due to discharge for misconduct shown in connection with his or her employment.
632.897(2)(b)3.
3. The spouse or dependent of a group member if the group member dies while covered by the group policy and the spouse or dependent was also covered.
632.897(2)(c)
(c) Group policy coverage of a terminated insured who is entitled under
par. (b) to elect continued group policy coverage or conversion to individual coverage and coverage of the spouse and dependents of the terminated insured provided for in the group policy continues until the terminated insured is notified under
par. (d) of the right to elect continued or conversion coverage if the premium for the coverage continues to be paid.
