632.895(16)(a)4.
4. "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town, or school district.
632.895(16)(a)5.
5. "Treatment" means services, diagnoses, procedures, surgery, and therapy provided by a health care professional.
632.895(16)(b)1.1. Except as provided in
par. (c), every disability insurance policy and every self-insured health plan shall provide the following coverages:
632.895(16)(b)1.a.
a. Coverage of the cost of hearing aids and cochlear implants that are prescribed by a physician, or by an audiologist licensed under
subch. II of ch. 459, in accordance with accepted professional medical or audiological standards, for a child covered under the policy or plan who is under 18 years of age and who is certified as deaf or hearing impaired by a physician or by an audiologist licensed under
subch. II of ch. 459.
632.895(16)(b)1.b.
b. Coverage of the cost of treatment related to hearing aids and cochlear implants, including procedures for the implantation of cochlear devices, for a child specified in
subd. 1. a.
632.895(16)(b)2.
2. Coverage of the cost of hearing aids under this subsection is not required to exceed the cost of one hearing aid per ear per child more often than once every 3 years.
632.895(16)(b)3.
3. The coverage required under this subsection may be subject to any cost-sharing provisions, limitations, or exclusions, other than a preexisting condition exclusion, that apply generally under the disability insurance policy or self-insured health plan.
632.895(16)(c)
(c) This subsection does not apply to any of the following:
632.895(16)(c)1.
1. A disability insurance policy that covers only certain specified diseases.
632.895(16)(c)2.
2. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.
632.895(16)(c)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 defined network plan, as defined in
s. 609.01 (1b).
632.895(16)(c)5.
5. A medicare replacement policy or a medicare supplement policy.
632.895(16)(c)5m.
5m. An individual health benefit plan that is not renewable and that has a specified termination date that, including any extensions that the policyholder may elect without the insurer's consent, is less than 12 months after the original effective date.
632.895(16m)(a)(a) Except as provided in
par. (c), 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 procedures shall provide coverage of colorectal cancer examinations and laboratory tests, in accordance with guidelines specified by the commissioner by rule under
par. (d) 1. and
3., for all of the following:
632.895(16m)(a)2.
2. An insured or enrollee who is under 50 years of age and at high risk for colorectal cancer, as specified by the commissioner by rule under
par. (d) 2. and
3.
632.895(16m)(b)
(b) 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(16m)(c)
(c) This subsection does not apply to any of the following:
632.895(16m)(c)1.
1. A disability insurance policy that covers only certain specified diseases.
632.895(16m)(c)2.
2. 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 defined network plan, as defined in
s. 609.01 (1b).
632.895(16m)(c)3.
3. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.
632.895(16m)(d)
(d) The commissioner, in consultation with the secretary of health services and after considering nationally validated guidelines, including guidelines issued by the American Cancer Society for colorectal cancer screening, shall promulgate rules that do all of the following:
632.895(16m)(d)1.
1. Specify guidelines for the colorectal cancer screening that must be covered under this subsection.
632.895(16m)(d)2.
2. Specify the factors for determining whether an individual is at high risk for colorectal cancer.
632.895(16m)(d)3.
3. Periodically update the guidelines under
subd. 1. and the factors under
subd. 2., as medically appropriate.
632.895 Note
NOTE: Sub. (16m) was created as sub. (16) by
2009 Wis. Act 346 and renumbered to sub. (16m) by the legislative reference bureau under s. 13.92 (1) (bm) 2.
632.895(17)(a)(a) In this subsection, "contraceptives" means drugs or devices approved by the federal food and drug administration to prevent pregnancy.
632.895(17)(b)
(b) Every disability insurance policy, and every self-insured health plan of the state or of a county, city, town, village, or school district, that provides coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices shall provide coverage for all of the following:
632.895(17)(b)2.
2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan.
632.895(17)(c)
(c) Coverage under
par. (b) may be subject only to the exclusions, limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan.
632.895(17)(d)
(d) This subsection does not apply to any of the following:
632.895(17)(d)1.
1. A disability insurance policy that covers only certain specified diseases.
632.895(17)(d)2.
2. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.
632.895(17)(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 defined network plan, as defined in
s. 609.01 (1b).
632.895(17)(d)5.
5. A Medicare replacement policy or a Medicare supplement policy.
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;
2001 a. 16,
82;
2007 a. 20 s.
9121 (6) (a);
2007 a. 36,
153;
2009 a. 14,
28,
282,
346; s. 13.92 (1) (bm) 2.
632.895 Cross-reference
Cross-reference: See also ss.
Ins 3.38 and
3.54, Wis. adm. code.
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).
632.895 Annotation
Sub. (7) permits an insurer to exclude or limit certain services and procedures, as long as the exclusion or limitation applies to all policies. However, an insurer may not make routine maternity services that are generally covered under the policy unavailable to a specific subgroup of insureds, surrogate mothers, based solely on the insured's reasons for becoming pregnant or the method used to achieve pregnancy. Mercycare Ins. Co. v. Wisconsin Commissioner of Insurance, 2010 WI 87, ___ Wis. 2d___, ___ N.W.2d ___,
08-2937.
632.896
632.896
Mandatory coverage of adopted children. 632.896(1)(a)
(a) "Department" means the department of health services.
632.896(1)(c)
(c) "Placed for adoption" means any of the following:
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, or a public child placing agency, as defined in
s. 48.99 (2) (r), or a private child placing agency, as defined in
s. 48.99 (2) (p), of a sending state, as defined in
s. 48.99 (2) (w), places a child in the insured's home under
s. 48.99 as a preliminary step to a possible 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.
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.
632.897(2)(d)
(d) If the employer is notified to terminate the coverage for any of the reasons provided under
par. (b), the employer shall provide the terminated insured written notification of the right to continue group coverage or convert to individual coverage and the payment amounts required for either continued or converted coverage including the manner, place and time in which the payments shall be made. This notice shall be given not more than 5 days after the employer receives notice to terminate coverage. The payment amount for continued group coverage may not exceed the group rate in effect for a group member, including an employer's contribution, if any, for a group policy as defined in
sub. (1) (c) 1. or
1m. or the equivalent value of the monthly contribution of a group member to a group policy as defined in
sub. (1) (c) 2. or the equivalent value of the monthly premium for franchise insurance as defined in
sub. (1) (c) 3. The premium for converted coverage shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risks of each person to be covered under that policy and to the type and amount of coverage provided. The notice may be sent to the terminated insured's home address as shown on the records of the employer.
