632.895(12m)(f)1.1. The commissioner shall by rule further define "intensive-level services" and "nonintensive-level services" and define "paraprofessional" for purposes of
par. (b) 4. and "qualified" for purposes of providing services under this subsection. The commissioner may promulgate rules governing the interpretation or administration of this subsection.
632.895(12m)(f)2.
2. Using the procedure under
s. 227.24, the commissioner may promulgate the rules under
subd. 1. for the period before the effective date of the permanent rules promulgated under
subd. 1., but not to exceed the period authorized under
s. 227.24 (1) (c) and
(2). Notwithstanding
s. 227.24 (1) (a),
(2) (b), and
(3), the commissioner is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.
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 defined network plan, as defined in
s. 609.01 (1b), 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 defined network plan, as defined in
s. 609.01 (1b).
632.895(15)(a)(a) Subject to
pars. (b) and
(c), 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 person as a dependent of the insured because the person is a full-time student, including the coverage under
s. 632.885 (2) (b), shall continue to provide dependent coverage for the person if, due to a medically necessary leave of absence, he or she ceases to be a full-time student.
632.895(15)(b)
(b) A policy or plan is not required to continue coverage under
par. (a) unless the person submits documentation and certification of the medical necessity of the leave of absence from the person's attending physician. The date on which the person ceases to be a full-time student due to the medically necessary leave of absence shall be the date on which the coverage continuation under
par. (a) begins.
632.895(15)(c)
(c) A policy or plan is required to continue coverage under
par. (a) only until any of the following occurs:
632.895(15)(c)1.
1. The person advises the policy or plan that he or she does not intend to return to school full time.
632.895(15)(c)4.
4. The person marries and is eligible for coverage under his or her spouse's health care coverage.
632.895(15)(c)5.
5. Except for a person who has coverage as a dependent under
s. 632.885 (2) (b), the person reaches the age at which coverage as a dependent who is a full-time student would otherwise end under the terms and conditions of the policy or plan.
632.895(15)(c)6.
6. Coverage of the insured through whom the person has dependent coverage under the policy or plan is discontinued or not renewed.
632.895(15)(c)7.
7. One year has elapsed since the person's coverage continuation under
par. (a) began and the person has not returned to school full time.
632.895(16)
(16) Hearing aids, cochlear implants, and related treatment for infants and children. 632.895(16)(a)1.
1. "Cochlear implant" includes any implantable instrument or device that is designed to enhance hearing.
632.895(16)(a)2.
2. "Hearing aid" means any externally wearable instrument or device designed for or offered for the purpose of aiding or compensating for impaired human hearing and any parts, attachments, or accessories of such an instrument or device, except batteries and cords.
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 Cross-reference
Cross-reference: See also s.
Ins 3.35, Wis. adm. code.
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;
2011 a. 260 s.
80.
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).
