Chapter 632

632.89 Cross-reference Cross-reference: See also ss. Ins 3.37 and 3.375, Wis. adm. code.

632.895 632.895 Mandatory coverage.

632.895(1) (1) Definitions. In this section:

632.895(1)(a) (a) “Disability insurance policy” means surgical, medical, hospital, major medical or other health service coverage but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.

632.895(1)(b) (b) “Home care” means care and treatment of an insured under a plan of care established, approved in writing and reviewed at least every 2 months by the attending physician, unless the attending physician determines that a longer interval between reviews is sufficient, and consisting of one or more of the following:

632.895(1)(b)1. 1. Part-time or intermittent home nursing care by or under the supervision of a registered nurse.

632.895(1)(b)2. 2. Part-time or intermittent home health services that are medically necessary as part of the home care plan, under the supervision of a registered nurse or medical social worker, which consist solely of caring for the patient.

632.895(1)(b)3. 3. Physical or occupational therapy or speech-language pathology or respiratory care.

632.895(1)(b)4. 4. Medical supplies, drugs and medications prescribed by a physician and laboratory services by or on behalf of a hospital, if necessary under the home care plan, to the extent such items would be covered under the policy if the insured had been hospitalized.

632.895(1)(b)5. 5. Nutrition counseling provided by or under the supervision of one of the following, where such services are medically necessary as part of the home care plan:

632.895(1)(b)5.a. a. A registered dietitian.

632.895(1)(b)5.b. b. A dietitian certified under subch. V of ch. 448, if the nutrition counseling is provided on or after July 1, 1995.

632.895(1)(b)6. 6. The evaluation of the need for and development of a plan, by a registered nurse, physician extender or medical social worker, for home care when approved or requested by the attending physician.

632.895(1)(c) (c) “Hospital indemnity policies” means policies which provide benefits in a stated amount for confinement in a hospital, regardless of the hospital expenses actually incurred by the insured, due to such confinement.

632.895(1)(d) (d) “Immediate family” means the spouse, children, parents, grandparents, brothers and sisters of the insured and their spouses.

632.895(2) (2) Home care.

632.895(2)(a) (a) Every disability insurance policy which provides coverage of expenses incurred for inpatient hospital care shall provide coverage for the usual and customary fees for home care. Such coverage shall be subject to the same deductible and coinsurance provisions of the policy as other covered services. The maximum weekly benefit for such coverage need not exceed the usual and customary weekly cost for care in a skilled nursing facility. If an insurer provides disability insurance, or if 2 or more insurers jointly provide disability insurance, to an insured under 2 or more policies, home care coverage is required under only one of the policies.

632.895(2)(b) (b) Home care shall not be reimbursed unless the attending physician certifies that:

632.895(2)(b)1. 1. Hospitalization or confinement in a skilled nursing facility would otherwise be required if home care was not provided.

632.895(2)(b)2. 2. Necessary care and treatment are not available from members of the insured’s immediate family or other persons residing with the insured without causing undue hardship.

632.895(2)(b)3. 3. The home care services shall be provided or coordinated by a state-licensed or medicare-certified home health agency or certified rehabilitation agency.

632.895(2)(c) (c) If the insured was hospitalized immediately prior to the commencement of home care, the home care plan shall also be initially approved by the physician who was the primary provider of services during the hospitalization.

632.895(2)(d) (d) Each visit by a person providing services under a home care plan or evaluating the need for or developing a plan shall be considered as one home care visit. The policy may contain a limit on the number of home care visits, but not less than 40 visits in any 12-month period, for each person covered under the policy. Up to 4 consecutive hours in a 24-hour period of home health service shall be considered as one home care visit.

632.895(2)(e) (e) Every disability insurance policy which purports to provide coverage supplementing parts A and B of Title XVIII of the social security act shall make available and if requested by the insured provide coverage of supplemental home care visits beyond those provided by parts A and B, sufficient to produce an aggregate coverage of 365 home care visits per policy year.

632.895(2)(f) (f) This subsection does not require coverage for any services provided by members of the insured’s immediate family or any other person residing with the insured.

632.895(2)(g) (g) Insurers reviewing the certified statements of physicians as to the appropriateness and medical necessity of the services certified by the physician under this subsection may apply the same review criteria and standards which are utilized by the insurer for all other business.

632.895(3) (3) Skilled nursing care. Every disability insurance policy filed after November 29, 1979, which provides coverage for hospital care shall provide coverage for at least 30 days for skilled nursing care to patients who enter a licensed skilled nursing care facility. A disability insurance policy, other than a medicare supplement policy or medicare replacement policy, may limit coverage under this subsection to patients who enter a licensed skilled nursing care facility within 24 hours after discharge from a general hospital. The daily rate payable under this subsection to a licensed skilled nursing care facility shall be no less than the maximum daily rate established for skilled nursing care in that facility by the department of health services for purposes of reimbursement under the medical assistance program under subch. IV of ch. 49. The coverage under this subsection shall apply only to skilled nursing care which is certified as medically necessary by the attending physician and is recertified as medically necessary every 7 days. If the disability insurance policy is other than a medicare supplement policy or medicare replacement policy, coverage under this subsection shall apply only to the continued treatment for the same medical or surgical condition for which the insured had been treated at the hospital prior to entry into the skilled nursing care facility. Coverage under any disability insurance policy governed by this subsection may be subject to a deductible that applies to the hospital care coverage provided by the policy. The coverage under this subsection shall not apply to care which is essentially domiciliary or custodial, or to care which is available to the insured without charge or under a governmental health care program, other than a program provided under ch. 49.

632.895(4) (4) Kidney disease treatment.

632.895(4)(a) (a) Every disability insurance policy which provides hospital treatment coverage on an expense incurred basis shall provide coverage for hospital inpatient and outpatient kidney disease treatment, which may be limited to dialysis, transplantation and donor-related services, in an amount not less than $30,000 annually, as defined by the department of health services under par. (d).

632.895(4)(b) (b) No insurer is required to duplicate coverage available under the federal medicare program, nor duplicate any other insurance coverage the insured may have. Other insurance coverage does not include public assistance under ch. 49.

632.895(4)(c) (c) Coverage under this subsection may not be subject to exclusions or limitations, including deductibles and coinsurance factors, which are not generally applicable to other conditions covered under the policy.

632.895(4)(d) (d) The department of health services may by rule impose reasonable standards for the treatment of kidney diseases required to be covered under this subsection, which shall not be inconsistent with or less stringent than applicable federal standards.

632.895(5) (5) Coverage of newborn infants.

632.895(5)(a) (a) Every disability insurance policy shall provide coverage for a newly born child of the insured from the moment of birth.

632.895(5)(b) (b) Coverage for newly born children required under this subsection shall consider congenital defects and birth abnormalities as an injury or sickness under the policy and shall cover functional repair or restoration of any body part when necessary to achieve normal body functioning, but shall not cover cosmetic surgery performed only to improve appearance.

632.895(5)(c) (c) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy may require that notification of the birth of a child and payment of the required premium or fees shall be furnished to the insurer within 60 days after the date of birth. The insurer may refuse to continue coverage beyond the 60-day period if such notification is not received, unless within one year after the birth of the child the insured makes all past-due payments and in addition pays interest on such payments at the rate of 5 1/2 percent per year.

632.895(5)(d) (d) If payment of a specific premium or subscription fee is not required to provide coverage for a child, the policy or contract may request notification of the birth of a child but may not deny or refuse to continue coverage if such notification is not furnished.

632.895(5)(e) (e) This subsection applies to all policies issued or renewed after May 5, 1976, and to all policies in existence on June 1, 1976. All policies issued or renewed after June 1, 1976, shall be amended to comply with the requirements of this subsection.

632.895(5m) (5m) Coverage of grandchildren. Every disability insurance policy issued or renewed on or after May 7, 1986, that provides coverage for any child of the insured shall provide the same coverage for all children of that child until that child is 18 years of age.

632.895(6) (6) Equipment and supplies for treatment of diabetes. Every disability insurance policy which provides coverage of expenses incurred for treatment of diabetes shall provide coverage for expenses incurred by the installation and use of an insulin infusion pump, coverage for all other equipment and supplies, including insulin or any other prescription medication, used in the treatment of diabetes, and coverage of diabetic self-management education programs. Coverage required under this subsection shall be subject to the same exclusions, limitations, deductibles, and coinsurance provisions of the policy as other covered expenses, except that insulin infusion pump coverage may be limited to the purchase of one pump per year and the insurer may require the insured to use a pump for 30 days before purchase.

632.895(7) (7) Maternity coverage. Every group disability insurance policy which provides maternity coverage shall provide maternity coverage for all persons covered under the policy. Coverage required under this subsection may not be subject to exclusions or limitations which are not applied to other maternity coverage under the policy.

632.895(8) (8) Coverage of mammograms.

632.895(8)(a) (a) In this subsection:

632.895(8)(a)1. 1. “Direction” means verbal or written instructions, standing orders or protocols.

632.895(8)(a)2. 2. “Low-dose mammography” means the X-ray examination of a breast using equipment dedicated specifically for mammography, including the X-ray tube, filter, compression device, screens, films and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with 2 views for each breast.

632.895(8)(a)3. 3. “Nurse practitioner” means an individual who is licensed as a registered nurse under ch. 441 or the laws of another state and who satisfies any of the following:

632.895(8)(a)3.a. a. Is certified as a primary care nurse practitioner or clinical nurse specialist by the American nurses’ association or by the national board of pediatric nurse practitioners and associates.

632.895(8)(a)3.am. am. Holds a master’s degree in nursing from an accredited school of nursing.

632.895(8)(a)3.b. b. Before March 31, 1990, has successfully completed a formal one-year academic program that prepares registered nurses to perform an expanded role in the delivery of primary care, includes at least 4 months of classroom instruction and a component of supervised clinical practice, and awards a degree, diploma or certificate to individuals who successfully complete the program.

632.895(8)(a)3.c. c. Has successfully completed a formal education program that is intended to prepare registered nurses to perform an expanded role in the delivery of primary care but that does not meet the requirements of subd. 3. b., and has performed an expanded role in the delivery of primary care for a total of 12 months during the 18-month period immediately before July 1, 1978.

632.895(8)(b) (b)

632.895(8)(b)1. 1. Except as provided in subd. 2. and par. (f), every disability insurance policy that provides coverage for a woman age 45 to 49 shall provide coverage for that woman of 2 examinations by low-dose mammography performed when the woman is age 45 to 49, if all of the following are satisfied:

632.895(8)(b)1.a. a. Each examination by low-dose mammography is performed at the direction of a licensed physician or a nurse practitioner, except as provided in par. (e).

632.895(8)(b)1.b. b. The woman has not had an examination by low-dose mammography within 2 years before each examination is performed.

632.895(8)(b)2. 2. A disability insurance policy need not provide coverage under subd. 1. to the extent that the woman had obtained one or more examinations by low-dose mammography while between the ages of 45 and 49 and before obtaining coverage under the disability insurance policy.

632.895(8)(c) (c) Except as provided in par. (f), every disability insurance policy that provides coverage for a woman age 50 or older shall provide coverage for that woman of an annual examination by low-dose mammography to screen for the presence of breast cancer, if the examination is performed at the direction of a licensed physician or a nurse practitioner or if par. (e) applies.

632.895(8)(d) (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c) and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy.

632.895(8)(e) (e) A disability insurance policy shall cover an examination by low-dose mammography that is not performed at the direction of a licensed physician or a nurse practitioner but that is otherwise required to be covered under par. (b) or (c), if all of the following are satisfied:

632.895(8)(e)1. 1. The woman does not have an assigned or regular physician or nurse practitioner when the examination is performed.

632.895(8)(e)2. 2. The woman designates a physician to receive the results of the examination.

632.895(8)(e)3. 3. Any examination by low-dose mammography previously obtained by the woman was at the direction of a licensed physician or a nurse practitioner.

632.895(8)(f) (f) This subsection does not apply to any of the following:

632.895(8)(f)1. 1. A disability insurance policy that only provides coverage of certain specified diseases.

632.895(8)(f)2. 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3).

632.895(8)(f)3. 3. A medicare replacement policy, a medicare supplement policy or a long-term care insurance policy.

632.895(9) (9) Drugs for treatment of HIV infection.

632.895(9)(a) (a) In this subsection, “HIV infection” means the pathological state produced by a human body in response to the presence of HIV, as defined in s. 631.90 (1).

632.895(9)(b) (b) Except as provided in par. (d), every disability insurance policy that is issued or renewed on or after April 28, 1990, and that provides coverage of prescription medication shall provide coverage for each drug that satisfies all of the following:

632.895(9)(b)1. 1. Is prescribed by the insured’s physician for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection.

632.895(9)(b)2. 2. Is approved by the federal food and drug administration for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection, including each investigational new drug that is approved under 21 CFR 312.34 to 312.36 for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection and that is in, or has completed, a phase 3 clinical investigation performed in accordance with 21 CFR 312.20 to 312.33.

632.895(9)(b)3. 3. If the drug is an investigational new drug described in subd. 2., is prescribed and administered in accordance with the treatment protocol approved for the investigational new drug under 21 CFR 312.34 to 312.36.

632.895(9)(c) (c) Coverage of a drug under par. (b) may be subject to any copayments and deductibles that the disability insurance policy applies generally to other prescription medication covered by the disability insurance policy.

632.895(9)(d) (d) This subsection does not apply to any of the following:

632.895(9)(d)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(9)(d)2. 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3).

632.895(9)(d)3. 3. A medicare replacement policy or a medicare supplement policy.

632.895(10) (10) Lead poisoning screening.

632.895(10)(a) (a) Except as provided in par. (b), every disability insurance policy and every health care benefits plan provided on a self-insured basis by a county board under s. 59.52 (11), by a city or village under s. 66.0137 (4), by a local governmental unit or technical college district under s. 66.0137 (4m), by a town under s. 60.23 (25), or by a school district under s. 120.13 (2) shall provide coverage for blood lead tests for children under 6 years of age, which shall be conducted in accordance with any recommended lead screening methods and intervals contained in any rules promulgated by the department of health services under s. 254.158.

632.895(10)(b) (b) This subsection does not apply to any of the following:

632.895(10)(b)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(10)(b)2. 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3).

632.895(10)(b)3. 3. A long-term care insurance policy, as defined in s. 600.03 (28g).

632.895(10)(b)4. 4. A medicare replacement policy, as defined in s. 600.03 (28p).

632.895(10)(b)5. 5. A medicare supplement policy, as defined in s. 600.03 (28r).

632.895(11) (11) Treatment for the correction of temporomandibular disorders.

632.895(11)(a) (a) Except as provided in par. (e), 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 procedure involving a bone, joint, muscle or tissue shall provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders if all of the following apply:

632.895(11)(a)1. 1. The condition is caused by congenital, developmental or acquired deformity, disease or injury.

632.895(11)(a)2. 2. Under the accepted standards of the profession of the health care provider rendering the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of the condition.

632.895(11)(a)3. 3. The purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction.