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(16t)
(16t)
Prescription eye drops. 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 prescription eye drops shall cover a refill of the prescription eye drops that satisfies all of the following:
632.895(16t)(a)
(a) The refill is requested by the insured or plan participant when 75 percent or more of the days have elapsed from the later of the original date the prescription was distributed to the insured or plan participant or the date on which the most recent refill was distributed to the insured or plan participant.
632.895(16t)(b)
(b) The prescription allows for a refill of the prescription eye drops.
632.895(16t)(c)
(c) The requested refill does not exceed the number of refills allowed by the prescription.
632.895(16v)
(16v)
Prohibiting coverage limitations on prescription drugs. 632.895(16v)(a)(a) During the period covered by the state of emergency related to public health declared by the governor on March 12, 2020, by executive order 72, an insurer offering a disability insurance policy that covers prescription drugs, a self-insured health plan of the state or of a county, city, town, village, or school district that covers prescription drugs, or a pharmacy benefit manager acting on behalf of a policy or plan may not do any of the following in order to maintain coverage of a prescription drug:
632.895(16v)(a)1.
1. Require prior authorization for early refills of a prescription drug or otherwise restrict the period of time in which a prescription drug may be refilled.
632.895(16v)(a)2.
2. Impose a limit on the quantity of prescription drugs that may be obtained if the quantity is no more than a 90-day supply.
632.895(16v)(b)
(b) This subsection does not apply to a prescription drug that is a controlled substance, as defined in s.
961.01 (4).
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;
2015 a. 55;
2017 a. 305;
2019 a. 185.
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,
328 Wis. 2d 110,
786 N.W.2d 785,
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 percent 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;
