Chapter 632

632.873 632.873 Restrictions relating to fees for dental services.

632.873(1) (1) Definitions. In this section, unless the context requires otherwise:

632.873(1)(a) (a) “Covered service” means, with respect to dental or related services specified in a policy or plan that provides coverage for those services, a service provided by a dentist or at the direction of a dentist to an insured under the policy or an enrollee of the plan for which the policy or plan makes payment, administered consistently with policies traditionally governing covered services, or for which the policy or plan would make payment but for the application of contractual limitations of deductibles, copayments, coinsurance, waiting periods, annual maximums, lifetime maximums applicable to the same course of treatment, frequency limitations, or alternative benefit payments.

632.873(1)(b) (b) “Policy” means a policy, certificate, or contract of insurance that provides only limited-scope dental benefits.

632.873(1)(c) (c) “Related service” means a service that is commonly provided, by a dentist or at the direction of a dentist, in conjunction with a dental service.

632.873(2) (2) Prohibitions on setting fees.

632.873(2)(a) (a)

632.873(2)(a)1. 1. A contract between an insurer offering a policy that provides coverage for dental and related services and a dentist for the provision of dental and related services to an insured under the policy may not require the dentist to provide a service to an insured under the policy at a fee set by the insurer unless the service is a covered service under the policy.

632.873(2)(a)2. 2. A policy that provides coverage for dental and related services may not provide nominal or de minimis coverage for a dental or related service for the sole purpose of avoiding the requirements under subd. 1.

632.873(2)(b) (b) An administrator providing 3rd-party administration services or a provider network for a plan that provides coverage for dental and related services may not require any dentist in the administrator’s provider network that is eligible to provide services under the plan to charge set fees for dental or related services provided to enrollees of the plan that are not covered services under the plan.

632.873(3) (3) Prohibition on charges. A dentist who, under a contract with an insurer offering a policy that provides coverage for dental and related services, provides dental or related services to an insured under the policy may not charge the insured more than the dentist’s usual nondiscounted fee for a dental or related service that is not a covered service under the policy.

632.873 History History: 2013 a. 26.

632.875 632.875 Independent evaluations relating to chiropractic treatment.

632.875(1) (1) In this section:

632.875(1)(a) (a) “Chiropractor” means a person licensed to practice chiropractic under ch. 446.

632.875(1)(b) (b) “Independent evaluation” means an examination or evaluation by or recommendation of a chiropractor or a peer review committee under s. 632.87 (3) (b) 1.

632.875(1)(c) (c) “Patient” means a person whose treatment by a chiropractor is the subject of an independent evaluation.

632.875(1)(d) (d) “Treating chiropractor” means a chiropractor who is treating a patient and whose treatment of the patient is the subject of an independent evaluation.

632.875(2) (2) If, on the basis of an independent evaluation, an insurer restricts or terminates a patient’s coverage for the treatment of a condition or complaint by a chiropractor acting within the scope of his or her license and the restriction or termination of coverage results in the patient becoming liable for payment for his or her treatment, the insurer shall, within the time required under s. 628.46 (2m), provide to the patient and to the treating chiropractor a written statement that contains all of the following:

632.875(2)(a) (a) A statement that an independent evaluation has been conducted under s. 632.87 (3) (b) 1.

632.875(2)(b) (b) The name of the treating chiropractor.

632.875(2)(c) (c) The name of the patient.

632.875(2)(d) (d) A description of the insurer’s internal appeal process that is available to the patient.

632.875(2)(e) (e) A statement indicating that the patient may, no later than 30 days after receiving the statement required under this subsection, request an internal appeal of the insurer’s restriction or termination of coverage.

632.875(2)(f) (f) The address to which the patient should send the request for an appeal.

632.875(2)(g) (g) A detailed explanation of the clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer’s restriction or termination of coverage.

632.875(2)(h) (h) A list of records and documents reviewed as part of the independent evaluation.

632.875(3) (3) 

632.875(3)(a) (a) In this subsection, “claim” means a patient’s claim for coverage, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, the restriction or termination of which coverage is the subject of an independent evaluation.

632.875(3)(b) (b) A chiropractor who conducts an independent evaluation may not be compensated by an insurer based on a percentage of the dollar amount by which a claim is reduced as a result of the independent evaluation.

632.875(4) (4) Subject to sub. (2) (e), an insurer shall make available to a patient an internal procedure by which the patient may appeal an insurer’s decision to restrict or terminate coverage.

632.875(5) (5) This section does not apply to any of the following:

632.875(5)(a) (a) Worker’s compensation insurance.

632.875(5)(b) (b) Any line of property and casualty insurance except disability insurance. In this paragraph, “disability insurance” does not include uninsured motorist coverage, underinsured motorist coverage or medical payment coverage.

632.875 History History: 1995 a. 94; 2001 a. 16; 2007 a. 20.

632.88 632.88 Policy extension for handicapped children.

632.88(1) (1) Termination of coverage. Every hospital or medical expense insurance policy or contract that provides that coverage of a dependent child of a person insured under the policy shall terminate upon attainment of a limiting age for dependent children specified in the policy shall also provide that the age limitation may not operate to terminate the coverage of a dependent child while the child is and continues to be both:

632.88(1)(a) (a) Incapable of self-sustaining employment because of intellectual disability or physical handicap; and

632.88(1)(b) (b) Chiefly dependent upon the person insured under the policy for support and maintenance.

632.88(2) (2) Proof of incapacity. The insurer may require that proof of the incapacity and dependency be furnished by the person insured under the policy within 31 days of the date the child attains the limiting age, and at any time thereafter except that the insurer may not require proof more frequently than annually after the 2-year period immediately following attainment of the limiting age by the child.

632.88 History History: 1975 c. 375; 2011 a. 126.

632.885 632.885 Coverage of dependents.

632.885(1) (1) Definitions. In this section:

632.885(1)(af) (af) “Eligible employer-sponsored plan” has the meaning given in 26 USC 5000A (f) (2).

632.885(1)(ar) (ar) “Grandfathered health plan” has the meaning given under section 1251 of the Patient Protection and Affordable Care Act (P.L. 111-148).

632.885(1)(at) (at) “Health insurance coverage” has the meaning given in 42 USC 300gg-91 (b) (1).

632.885(1)(b) (b) “Insured” includes an enrollee.

632.885(1)(c) (c) “Self-insured health plan” has the meaning given in s. 632.745 (24).

632.885(2) (2) Requirement to offer dependent coverage.

632.885(2)(a) (a) Subject to ss. 632.88 and 632.895 (5), and except as provided in pars. (b) and (c), every insurer that offers health insurance coverage that provides dependent coverage of children, and every self-insured health plan that provides dependent coverage of children, shall provide coverage for any child of an applicant or insured as a dependent of the applicant or insured if the child is under the age of 26.

632.885(2)(b) (b) Except as provided in par. (c), the coverage requirement under this section applies to an adult child who satisfies all of the following criteria:

632.885(2)(b)1. 1. The child is a full-time student, regardless of age.

632.885(2)(b)3. 3. The child was called to federal active duty in the national guard or in a reserve component of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher education.

632.885(2)(b)4. 4. The child was under the age of 27 years when called to federal active duty under subd. 3.

632.885(2)(c) (c) For any policy year or plan year beginning before January 1, 2014, health insurance coverage or a self-insured health plan described in par. (a) that is a grandfathered health plan is required to provide dependent coverage for an adult child described in par. (a) or (b) only if the child is not eligible for coverage under an eligible employer-sponsored plan other than the health insurance coverage or self-insured health plan.

632.885(3m) (3m) Defining dependent; uniform terms. An insurer or self-insured health plan described in sub. (2) may not do any of the following:

632.885(3m)(a) (a) Define “dependent” for purposes of eligibility for dependent coverage of children other than in terms of the relationship between a child and an applicant or insured.

632.885(3m)(b) (b) Vary the terms of coverage under the health insurance coverage or self-insured health plan on the basis of age except for children 26 years of age or older.

632.885 History History: 2009 a. 28; 2011 a. 32.

632.885 Cross-reference Cross-reference: See also s. Ins 3.34, Wis. adm. code.

632.89 632.89 Coverage of mental disorders, alcoholism, and other diseases.

632.89(1) (1) Definitions. In this section:

632.89(1)(a) (a) “Collateral” means a member of an insured’s immediate family, as defined in s. 632.895 (1).

632.89(1)(at) (at) “Group health benefit plan” has the meaning given in s. 632.745 (9).

632.89(1)(b) (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

632.89(1)(c) (c) “Hospital” means any of the following:

632.89(1)(c)1. 1. A hospital licensed under s. 50.35.

632.89(1)(c)2. 2. An approved private treatment facility as defined in s. 51.45 (2) (b).

632.89(1)(c)3. 3. An approved public treatment facility as defined in s. 51.45 (2) (c).

632.89(1)(d) (d) “Inpatient hospital services” means services for the treatment of nervous and mental disorders or alcoholism and other drug abuse problems that are provided in a hospital to a bed patient in the hospital.

632.89(1)(dm) (dm) “Licensed mental health professional” means a clinical social worker who is licensed under subch. I of ch. 457, a marriage and family therapist who is licensed under s. 457.10, or a professional counselor who is licensed under s. 457.12 or who is exercising the professional counselor privilege to practice, as defined in s. 457.50 (2) (s), in this state.

632.89(1)(e) (e) “Outpatient services” means nonresidential services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems provided to an insured and, if for the purpose of enhancing the treatment of the insured, a collateral by any of the following:

632.89(1)(e)1. 1. A program in an outpatient treatment facility, if both are approved by the department of health services, the program is established and maintained according to rules promulgated under s. 51.42 (7) (b) and the facility is certified under s. 51.04.

632.89(1)(e)2. 2. A licensed physician who has completed a residency in psychiatry, in an outpatient treatment facility or the physician’s office.

632.89(1)(e)3. 3. A psychologist.

632.89(1)(e)4. 4. A licensed mental health professional practicing within the scope of his or her credential under subch. I of ch. 457 and applicable rules.

632.89(1)(em) (em) “Self-insured health plan” has the meaning given in s. 632.745 (24).

632.89(1)(f) (f) “Transitional treatment arrangements” means services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems that are provided to an insured in a less restrictive manner than are inpatient hospital services but in a more intensive manner than are outpatient services, and that are specified by the commissioner by rule under sub. (4).

632.89(2) (2) Required coverage for group plans.

632.89(2)(a) (a) Conditions covered. A group health benefit plan and a self-insured health plan shall provide coverage of nervous and mental disorders and alcoholism and other drug abuse problems if required by pars. (c) to (dm) and as provided in pars. (c) to (dm) and subs. (3) to (3f).

632.89(2)(c) (c) Coverage of inpatient hospital services. If a group health benefit plan or a self-insured health plan provides coverage of any inpatient hospital treatment, the plan shall provide coverage for inpatient hospital services for the treatment of conditions under par. (a).

632.89(2)(d) (d) Coverage of outpatient services. If a group health benefit plan or a self-insured health plan provides coverage of any outpatient treatment, the plan shall provide coverage for outpatient services for the treatment of conditions under par. (a).

632.89(2)(dm) (dm) Coverage of transitional treatment arrangements. If a group health benefit plan or a self-insured health plan provides coverage of any inpatient hospital treatment or any outpatient treatment, the plan shall provide coverage for transitional treatment arrangements for the treatment of conditions under par. (a).

632.89(3) (3) Limitations. For a group health benefit plan and a self-insured health plan that provide coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems, and for an individual health benefit plan that provides coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems, the exclusions and limitations; deductibles; copayments; coinsurance; annual and lifetime payment limitations; out-of-pocket limits; out-of-network charges; day, visit, or appointment limits; limitations regarding referrals to nonphysician providers and treatment programs; and duration or frequency of coverage limits under the plan may be no more restrictive for coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems than the most common or frequent type of treatment limitations applied to substantially all other coverage under the plan. The plan shall include in any overall deductible amount or annual or lifetime limit or out-of-pocket limit for the plan, expenses incurred for the treatment of nervous and mental disorders or alcoholism and other drug abuse problems.

632.89(3c) (3c) Exemption for cost increase.

632.89(3c)(a) (a) Notwithstanding sub. (3), an employer that provides health care coverage for its employees through a group health benefit plan or a self-insured health plan that provides coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems may elect for the employer’s plan to be exempt from the requirements under sub. (3) during the plan year following any plan year in which, as a result of the requirements under sub. (3), there is an increase under the plan in the employer’s total cost of coverage for the treatment of physical conditions and nervous and mental disorders and alcoholism and other drug abuse problems by a percentage that exceeds either of the following:

632.89(3c)(a)1. 1. Two percent in the first plan year in which the requirements apply.

632.89(3c)(a)2. 2. One percent in any plan year after the first plan year in which the requirements apply.

632.89(3c)(b) (b) A cost increase specified under par. (a) may not be determined until the employer’s group health benefit plan or self-insured health plan has complied with the requirements under sub. (3) for at least the first 6 months of the plan year for which the increase is to be determined. The cost increase shall be determined, and certified, by a qualified actuary, as defined in s. 623.06 (1) (h). A copy of the actuary’s determination, and all underlying documentation that the actuary relied on in making the determination, shall be filed with and, in accordance with rules promulgated by the commissioner, retained by the insurer issuing the group health benefit plan or by the self-insured health plan.