Ins 8.75(3) (3) Limitation on coverage for mental health and substance abuse treatment. The annual calendar year benefit payable for treatment of a covered person for nervous and mental disorders and alcoholism and other drug abuse is $1,400. A plan may not apply the cost of outpatient prescription drugs used in the treatment of nervous and mental disorders or alcoholism or other drug abuse toward the annual limit specified in this subsection.

Ins 8.75 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.76 Ins 8.76 Policy terms; exclusions; limitations.

Ins 8.76(1) (1) Except as otherwise provided in this subchapter, a plan’s policy terms shall be defined consistently with the definitions in the small employer insurer’s other small group health benefit plans.

Ins 8.76(2) (2) A plan may exclude from coverage or limit coverage for specified conditions and services other than those required under s. Ins 8.72 but may exclude or limit only those conditions and services which are generally excluded from coverage or limited under the small employer insurer’s other small group health benefit plans.

Ins 8.76(3) (3) A plan may apply the same limitations on provider choice, coverage and geographical service area that apply under the small employer insurer’s other small group health benefit plans.

Ins 8.76 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.77 Ins 8.77 Copayments; coinsurance.

Ins 8.77(1) (1) Definitions. In this section:

Ins 8.77(1)(a) (a) “Primary care provider” means any of the following:

Ins 8.77(1)(a)1. 1. If the plan is an indemnity plan, a preferred provider organization or health maintenance organization that does not require the insured to designate a primary provider, the physician who normally provides care to the insured, if the physician is any of the following:

Ins 8.77(1)(a)1.a. a. A physician who is not certified by any specialty board.

Ins 8.77(1)(a)1.b. b. A physician certified by the American board of family practice.

Ins 8.77(1)(a)1.c. c. A physician certified by the American board of internal medicine.

Ins 8.77(1)(a)1.d. d. A physician certified by the American board of obstetrics and gynecology.

Ins 8.77(1)(a)1.e. e. A physician certified by the American board of pediatrics.

Ins 8.77(1)(a)2. 2. If the plan is a health maintenance organization that requires an insured to designate a primary provider, the physician designated.

Ins 8.77(1)(b) (b) “Specialist” means any physician other than a primary care provider.

Ins 8.77(2) (2) Copayments.

Ins 8.77(2)(a) (a) Except as provided in par. (b), sub. (4) and s. Ins 8.79, a copayment in the specified amount applies each time an insured receives any of the following:

Ins 8.77(2)(a)1. 1. Professional services from a primary care provider or from a specialist who is consulted with a referral from a primary care provider when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01 (2), Stats.: $25.

Ins 8.77(2)(a)2. 2. Professional services from a specialist when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01 (2), Stats., when the specialist is consulted without a referral from a primary care provider: $35.

Ins 8.77(2)(a)3. 3. Professional services from a chiropractor: $11.

Ins 8.77(2)(a)4. 4. Ambulance service, unless immediately admitted to the hospital: $75.

Ins 8.77(2)(a)5. 5. Treatment in a hospital emergency room, unless immediately admitted to the hospital: $75.

Ins 8.77(2)(a)6. 6. Inpatient hospitalization: $100.

Ins 8.77(2)(a)7. 7. Prescription drugs, proprietary: $20 or the cost of the prescription, whichever is less.

Ins 8.77(2)(a)8. 8. Prescription drugs, generic: $10, or the cost of the prescription, whichever is less.

Ins 8.77(2)(b) (b) The copayments specified in par. (a) 1. and 2. do not apply to professional services in connection with prenatal care or well baby care from birth to 24 months.