632.79(1)(1)
Scope. This section shall apply to every group hospital, surgical or medical expense insurance policy or service plan purchased by or on behalf of an employer to provide coverage for employees and issued under
s. 185.981 or by any insurer authorized under
chs. 600 to
646 which has been delivered, renewed or is otherwise in force on or after June 12, 1976.
632.79(2)
(2) Notice to policyholder or party responsible for payment of premiums. 632.79(2)(a)(a) Prior to termination of any group policy, plan or coverage subject to this section due to a cessation of business or default in payment of premiums by the policyholder, trust, association or other party responsible for such payment, the insurer or organization issuing the policy, contract, booklet or other evidence of insurance shall notify in writing the policyholder, trust, association or other party responsible for payment of premiums of the date as of which the policy or plan will be terminated or discontinued. At such time, the insurer or organization shall additionally furnish to the policyholder, trust, association or other party a notice form in sufficient number to be distributed to covered employees or members indicating what rights, if any, are available to them upon termination.
632.79(2)(b)
(b) For purpose of notice and distribution to covered employees and members under
par. (a), the administrator responsible for determining the persons covered and the premiums payable to the insurer or organization under any group policy or plan of disability insurance is responsible for providing such notices.
632.79(3)
(3) Liability of insurer or service organization for payment of claims. Under any group policy or plan subject to this section, the insurer or organization shall be liable for all valid claims for covered losses prior to the expiration of any grace period specified in the group policy or plan.
632.79(5)
(5) Notice exception. The notice requirements of this section shall not apply if a group policy or plan providing coverage to employees or members is terminated and immediately replaced by another policy or plan providing similar coverage to such employees or members.
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.
632.79 Cross-reference
Cross Reference: See also s.
Ins 6.51, Wis. adm. code.
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 employees 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 employees 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 employees 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 employees through a multiple-employer trust, with the health claims experience of an individual employee 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.
632.81 Cross-reference
Cross Reference: See also s.
Ins 3.39, Wis. adm. code.
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.
632.83
632.83
Internal grievance procedure. 632.83(1)
(1) In this section, "health benefit plan" has the meaning given in
s. 632.745 (11), except that "health benefit plan" includes the coverage specified in
s. 632.745 (11) (b) 10. and includes a policy, certificate or contract under
s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.
632.83(2)
(2) Every insurer that issues a health benefit plan shall do all of the following:
632.83(2)(a)
(a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with
sub. (3) for the resolution of insureds' grievances with the health benefit plan.
632.83(2)(b)
(b) Provide insureds with complete and understandable information describing the internal grievance procedure under
par. (a).
632.83(2)(c)
(c) Submit an annual report to the commissioner describing the internal grievance procedure under
par. (a) and summarizing the experience under the procedure for the year.
632.83(3)
(3) The internal grievance procedure established under
sub. (2) (a) shall include all of the following elements:
632.83(3)(a)
(a) The opportunity for an insured to submit a written grievance in any form.
632.83(3)(b)
(b) Establishment of a grievance panel for the investigation of each grievance submitted under
par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one insured other than the grievant, if an insured is available to serve on the grievance panel.
632.83(3)(c)
(c) Prompt investigation of each grievance submitted under
par. (a).
632.83(3)(d)
(d) Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.
632.83(3)(e)
(e) Retention of records pertaining to each grievance for at least 3 years after the date of notification under
par. (d).
632.83 History
History: 1999 a. 155 ss.
8 to
17; Stats. 1999 s. 632.83.
632.835
632.835
Independent review of adverse and experimental treatment determinations. 632.835(1)(a)
(a) "Adverse determination" means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:
632.835(1)(a)1.
1. An admission to a health care facility, the availability of care, the continued stay or other treatment that is a covered benefit has been reviewed.
632.835(1)(a)2.
2. Based on the information provided, the treatment under
subd. 1. does not meet the health benefit plan's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness.
632.835(1)(a)3.
3. Based on the information provided, the insurer that issued the health benefit plan reduced, denied or terminated the treatment under
subd. 1. or payment for the treatment under
subd. 1.
632.835(1)(a)4.
4. Subject to
sub. (5) (c), the amount of the reduction or the cost or expected cost of the denied or terminated treatment or payment exceeds, or will exceed during the course of the treatment, $250.
632.835(1)(b)
(b) "Experimental treatment determination" means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:
632.835(1)(b)2.
2. Based on the information provided, the treatment under
subd. 1. is determined to be experimental under the terms of the health benefit plan.
632.835(1)(b)3.
3. Based on the information provided, the insurer that issued the health benefit plan denied the treatment under
subd. 1. or payment for the treatment under
subd. 1.
632.835(1)(b)4.
4. Subject to
sub. (5) (c), the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, $250.
632.835(1)(d)
(d) "Treatment" means a medical service, diagnosis, procedure, therapy, drug or device.
632.835(2)
(2) Review requirements; who may conduct. 632.835(2)(a)(a) Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of an adverse determination or an experimental treatment determination made with respect to the insured.
632.835(2)(b)
(b) If an adverse determination or an experimental treatment determination is made, the insurer involved in the determination shall provide notice to the insured of the insured's right to obtain the independent review required under this section, how to request the review, and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under
sub. (4). An independent review under this section may be conducted only by an independent review organization certified under
sub. (4) and selected by the insured.
632.835(2)(bg)
(bg) Notwithstanding
par. (b), an insurer is not required to provide the notice under
par. (b) to an insured until the insurer sends notice of the disposition of the internal grievance if all of the following apply:
632.835(2)(bg)1.
1. The health benefit plan issued by the insurer contains a description of the independent review procedure under this section, including an explanation of the insured's rights under
par. (d), how to request the review, the time within which the review must be requested, and how to obtain a current listing of independent review organizations certified under
sub. (4).
632.835(2)(bg)2.
2. The insurer includes on its explanation of benefits form a statement that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited independent review with respect to an urgent matter. The statement shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under
subd. 1. The statement shall provide a toll-free telephone number and website, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.
632.835(2)(bg)3.
3. For any adverse determination or experimental treatment determination for which an explanation of benefits is not provided to the insured, the insurer provides a notice that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited, independent review with respect to an urgent matter. The notice shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under
subd. 1. The notice shall provide a toll-free telephone number and website, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.
632.835(2)(c)
(c) Except as provided in
par. (d), an insured must exhaust the internal grievance procedure under
s. 632.83 before the insured may request an independent review under this section. Except as provided in
sub. (9), an insured who uses the internal grievance procedure must request an independent review as provided in
sub. (3) (a) within 4 months after the insured receives notice of the disposition of his or her grievance under
s. 632.83 (3) (d).
632.835(2)(d)
(d) An insured is not required to exhaust the internal grievance procedure under
s. 632.83 before requesting an independent review if any of the following apply:
632.835(2)(d)1.
1. The insured and the insurer agree that the matter may proceed directly to independent review under
sub. (3).
