632.895(5)(d)
(d) If payment of a specific premium or subscription fee is not required to provide coverage for a child, the policy or contract may request notification of the birth of a child but may not deny or refuse to continue coverage if such notification is not furnished.
632.895(5)(e)
(e) This subsection applies to all policies issued or renewed after May 5, 1976, and to all policies in existence on June 1, 1976. All policies issued or renewed after June 1, 1976, shall be amended to comply with the requirements of this subsection.
632.895(5m)
(5m) Coverage of grandchildren. Every disability insurance policy issued or renewed on or after May 7, 1986, that provides coverage for any child of the insured shall provide the same coverage for all children of that child until that child is 18 years of age.
632.895(6)
(6) Equipment and supplies for treatment of diabetes. Every disability insurance policy which provides coverage of expenses incurred for treatment of diabetes shall provide coverage for expenses incurred by the installation and use of an insulin infusion pump, coverage for all other equipment and supplies, including insulin, used in the treatment of diabetes and coverage of diabetic self-management education programs. Coverage required under this subsection shall be subject to the same deductible and coinsurance provisions of the policy as other covered expenses, except that insulin infusion pump coverage may be limited to the purchase of one pump per year and the insurer may require the insured to use a pump for 30 days before purchase.
632.895(7)
(7) Maternity coverage. Every group disability insurance policy which provides maternity coverage shall provide maternity coverage for all persons covered under the policy. Coverage required under this subsection may not be subject to exclusions or limitations which are not applied to other maternity coverage under the policy.
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 March 31, 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(11)
(11) Treatment for the correction of temporomandibular disorders. 632.895(11)(a)(a) Except as provided in
par. (e), every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, that provides coverage of any diagnostic or surgical procedure involving a bone, joint, muscle or tissue shall provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders if all of the following apply:
632.895(11)(a)1.
1. The condition is caused by congenital, developmental or acquired deformity, disease or injury.
632.895(11)(a)2.
2. Under the accepted standards of the profession of the health care provider rendering the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of the condition.
632.895(11)(a)3.
3. The purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction.
632.895(11)(b)1.1. The coverage required under this subsection for nonsurgical treatment includes coverage for prescribed intraoral splint therapy devices.
632.895(11)(b)2.
2. The coverage required under this subsection does not include coverage for cosmetic or elective orthodontic care, periodontic care or general dental care.
632.895(11)(c)1.1. The coverage required under this subsection may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan.
632.895(11)(c)2.
2. Notwithstanding
subd. 1., the coverage required under this subsection for diagnostic procedures and medically necessary nonsurgical treatment for the correction of temporomandibular disorders may not exceed $1,250 annually.
632.895(11)(d)
(d) Notwithstanding
par. (c) 1., an insurer or a self-insured health plan of the state or a county, city, village, town or school district may require that an insured obtain prior authorization for any medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders.
632.895(11)(e)
(e) This subsection does not apply to any of the following:
632.895(12)
(12) Hospital and ambulatory surgery center charges and anesthetics for dental care. 632.895(12)(a)(a) In this subsection, "ambulatory surgery center" has the meaning given in
s. 49.45 (6r) (a) 1[., 1995 stats.].
632.895 Note
NOTE: Section 49.45 (6r) was repealed by
1997 Wis. Act 252. Corrective legislation is pending. The repealed s. 49.45 (6r) (a) 1. read: In this subsection, "ambulatory surgery center" has the meaning given under s. 42 CFR 416.2.
632.895(12)(b)
(b) Except as provided in
par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, shall cover hospital or ambulatory surgery center charges incurred, and anesthetics provided, in conjunction with dental care that is provided to a covered individual in a hospital or ambulatory surgery center, if any of the following applies:
632.895(12)(b)3.
3. The individual has a medical condition that requires hospitalization or general anesthesia for dental care.
632.895(12)(c)
(c) The coverage required under this subsection may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the disability insurance policy or self-insured plan.
632.895(12)(d)
(d) This subsection does not apply to a disability insurance policy that covers only dental care.
632.895(13)(a)(a) Every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town or school district, that provides coverage of the surgical procedure known as a mastectomy shall provide coverage of breast reconstruction of the affected tissue incident to a mastectomy.
632.895(13)(b)
(b) The coverage required under
par. (a) may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan.
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;
1997 a. 27,
35,
75,
175,
237; s. 13.93 (2) (c).
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).
