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)(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(14)(a)1.
1. "Appropriate and necessary immunizations" means the administration of vaccine that meets the standards approved by the U.S. public health service for such biological products against at least all of the following:
632.895(14)(a)2.
2. "Dependent" means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.
632.895(14)(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, town, village or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for a dependent who is a child of the insured.
632.895(14)(c)
(c) The coverage required under
par. (b) may not be subject to any deductibles, copayments or coinsurance under the policy or plan. This paragraph applies to a managed care plan, as defined in
s. 609.01 (3c), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in
s. 609.01 (3m), in the plan.
632.895(14)(d)
(d) This subsection does not apply to any of the following:
632.895(14)(d)1.
1. A disability insurance policy that covers only certain specified diseases.
632.895(14)(d)2.
2. A disability insurance policy that covers only hospital and surgical charges.
632.895(14)(d)3.
3. A health care plan offered by a limited service health organization, as defined in
s. 609.01 (3), or by a preferred provider plan, as defined in
s. 609.01 (4), that is not a managed care plan, as defined in
s. 609.01 (3c).
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;
1999 a. 32,
115;
1999 a. 150 s.
672.
632.895 Annotation
The commissioner can reasonably construe sub. (3) to require an insurer to pay a facility's charge for care up to the maximum department of health and social services rate. Mutual Benefit v. Insurance Commissioner,
151 Wis. 2d 411,
444 N.W.2d 450 (Ct. App. 1989).
632.895 Annotation
Sub. (2) (g) does not prohibit an insurer from contracting away the right to review medical necessity. The provision does not apply until the insurer has shown that its own determination is relevant to a insurance contract. Schroeder v. Blue Cross & Blue Shield,
153 Wis. 2d 165,
450 N.W.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. 632.746 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).
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.
