Ins 3.36(10)(b)(b) Drugs and devices. Insurers and self-insured health plans shall not provide coverage for pharmaceuticals or durable medical equipment through s. 632.895 (12m), Stats. Coverage of pharmaceuticals and durable medical equipment shall be covered in compliance with the terms of the insured’s policy. Ins 3.36(10)(c)(c) Fraudulent claims. Insurers and self-insured health plans shall not be required to pay claims that have been determined to be fraudulent. Ins 3.36(10)(d)(d) Parents of children diagnosed with autism spectrum disorders. Insurers and self-insured health plans shall not be required to pay for treatment rendered by parents or legal guardians who are otherwise qualified providers, qualified supervising providers, qualified therapists, qualified professionals or qualified paraprofessionals for treatment rendered to their own children. Ins 3.36(10)(e)(e) Denial of coverage. If an insurer or self-funded health plan generally provides benefits for an illness or injury, the insurer or self-funded health plan may not deny benefits otherwise provided for treatment of that illness or injury solely because the illness or injury relates to the insured’s autism spectrum disorder. Ins 3.36(11)(a)(a) Insurers and self-insured health plans shall cover treatments, therapies and services to an insured diagnosed with autism spectrum disorders in locations including the provider’s office, clinic or in a setting conducive to the acquisition of the target skill. Treatments may be provided in schools when they are related to the goals of the treatment plan and do not duplicate services provided by a school. Ins 3.36(11)(b)(b) Insurers and self-insured health plans are not required to cover therapy, treatment or services when provided to an insured who is residing in a residential treatment center, inpatient treatment or day treatment facility. Ins 3.36(11)(c)(c) Insurers and self-insured health plans are not required to cover the cost for the facility or location or for the use of a facility or location when treatment, services or evidence-based therapy are provided outside an insured’s home. Ins 3.36(12)(12) Annual publication CPI adjustment. The commissioner shall publish to the office of the commissioner of insurance website on or before December 1 of each year beginning December 1, 2011, the consumer price index for urban consumers as determined by the U.S. Department of Labor and publish the adjusted dollar amount in accordance with s. 632.895 (12m) (c) 1., Stats. The adjusted dollar amount published each December shall be used by insurers and self-insured health plans when complying with s. 632.895 (12m), Stats., effective the following January 1 for newly issued policies or on the first date of a modified, extended or renewed policy or certificate after January 1. Ins 3.36(14)(a)(a) Insurers and self-insured health plans are required to verify the licensure, certification and all training or other credentials of a qualified supervising or intensive-level provider, a qualified provider and a qualified therapist. Ins 3.36(14)(b)(b) Insurers and self-insured health plans shall require the following: Ins 3.36(14)(b)1.1. All service providers employing qualified paraprofessionals to verify the qualified paraprofessional’s credentials and to document that such employee or contractee has not been convicted of a felony or any crime involving maltreatment of a child in any jurisdiction and to periodically review and verify continuing compliance with this paragraph. Ins 3.36(14)(b)2.2. Certified outpatient mental health clinics employing or contracting for the services of qualified intensive-level professionals or qualified professionals to verify the credentials of a qualified intensive-level professional or qualified professional and to document that such employee or contractee has not been convicted of a felony or any crime involving maltreatment of a child in any jurisdiction and to periodically review and verify continuing compliance with this paragraph. Ins 3.36(14)(c)(c) A provider, therapist, or professional working under the supervision of a certified outpatient mental health clinic, who is approved by the department and who has a signed Medicaid provider agreement to provide services through the waiver program to individuals with autism spectrum disorders prior to November 1, 2009 shall be deemed to be a qualified intensive-level provider or qualified intensive-level professional through October 31, 2011. Beginning November 1, 2011 any provider, therapist or professional shall comply with the training and education requirements for a qualified supervising provider, qualified intensive-level provider, qualified provider, qualified intensive-level professional, qualified professional or qualified therapist. Ins 3.36(14)(d)(d) An insurer or self-insured health plans may elect to contract with certain providers, therapists and professionals who do not meet all of the requirements necessary to be considered qualified supervising providers, qualified intensive-level providers, qualified providers, qualified therapists, qualified intensive-level professionals or qualified professionals but who are approved by the department and who have a signed Medicaid provider agreement to provide services through the waiver program to individuals with autism spectrum disorders and who meet any criteria established by the insurer or self-insured health plan. The insurer or self-insured health plans shall have a verifiable and established process for rendering its determination for otherwise qualified supervising provider, qualified intensive-level provider, qualified provider, qualified intensive-level professional, qualified professional or qualified therapist. Ins 3.36 HistoryHistory: EmR1005: emerg. cr. eff. 3-8-10; CR 10-043: cr. Register September 2010 No. 657, eff. 10-1-10. Ins 3.37Ins 3.37 Transitional treatment arrangements. Ins 3.37(2)(a)(a) This section applies to group and blanket disability insurance policies issued or renewed on and after November 1, 1992, and prior to December 1, 2010, and group health benefit plans and self-insured governmental plans that elect and are eligible to be exempt pursuant to s. 632.89 (3c), (3f) or (5), Stats., that provide coverage for inpatient hospital services or outpatient services, as defined in s. 632.89 (1) (d) or (e), Stats. Group and blanket disability insurance policies and exempted group health benefit plans and self-insured governmental plans shall cover transitional treatment services and comply with subs. (2m), (3), (4), and (5). Ins 3.37(2)(b)(b) Policies issued on or after December 1, 2010, by a group health benefit plan and a self-insured governmental health plan that are not otherwise exempt under s. 632.89 (3c), (3f) or (5), Stats., shall comply with subs. (2m), (3m), (4m), and (5m). Ins 3.37(2m)(a)(a) “Individual health benefit plan” means an insurance product offered on an individual basis that meets the criteria established for a health benefit plan in s. 632.745 (11), Stats. Ins 3.37(2m)(c)(c) “Qualified actuary” means a member in good standing of the American Academy of Actuaries who meets any other requirements that the commissioner may by rule specify as defined in s. 623.06 (1) (h), Stats., and in accordance with s. 632.89 (3c) (b), Stats. Ins 3.37(2m)(e)(e) “Substance use disorder” has the same meaning as “alcoholism and other drug abuse problems” as the phrase appears throughout s. 632.89, Stats. Ins 3.37(2m)(g)(g) “Treatment limitations” means the limitations that insurers offering group or individual health benefit plans and self-insured governmental plans may impose on treatment of nervous and mental disorders and substance use disorders as described in s. 632.89 (3), Stats. Ins 3.37(3)(3) Covered services. An insurer offering a policy subject to this subsection shall provide at least the amount of coverage required under s. 632.89 (2) (dm) 2., 2007 Stats., subject to the exclusions or limitations, including deductibles and copayments, that are generally applicable to coverage required under s. 632.89 (2), 2007 Stats., for all of the following: Ins 3.37(3)(a)(a) Mental health services for adults in a day treatment program compliant with the services identified at s. DHS 61.75 (2) and offered by a provider certified by the department of health services under s. DHS 61.75. Ins 3.37(3)(b)(b) Mental health services for children and adolescents in a day treatment program compliant with the services identified at s. DHS 40.11 and offered by a provider certified by the department of health services under s. DHS 40.04. Ins 3.37(3)(c)(c) Services for persons with chronic mental illness provided through a community support program compliant with the services identified at s. DHS 63.11 and certified by the department of health services under s. DHS 63.03. Ins 3.37(3)(d)(d) Residential treatment programs compliant with the services identified at s. DHS 75.14 (1), for alcohol or drug dependent persons, or both, certified by the department of health services under s. DHS 75.14 (2) and under supervision as required in s. DHS 75.14 (5). Ins 3.37(3)(e)(e) Services for substance use disorders provided in a day treatment program compliant with the services identified at s. DHS 75.12 (1), certified by the department of health services under s. DHS 75.12 (2) and under supervision as required in s. DHS 75.12 (5). Ins 3.37(3)(f)(f) Intensive outpatient programs for narcotic treatment services for opiate addiction compliant with the services under s. DHS 75.15 (1) and (9), certified by the department of health services under s. DHS 75.15 (2) and under supervision as required in s. DHS 75.15 (4). Ins 3.37(3)(g)(g) Coordinated emergency mental health services for persons who are experiencing a mental health crisis or who are in a situation likely to turn into a mental health crisis if support is not provided. Services are provided by a program compliant with s. DHS 34.22, certified by the department of health services under s. DHS 34.03, and provided in accordance with subch. III of ch. DHS 34 for the period of time the person is experiencing a mental health crisis until the person is stabilized or referred to other providers for stabilization. Certified emergency mental health service plans shall provide timely notice to third-party payors to facilitate coordination of services for persons who are experiencing or are in a situation likely to turn into a mental health crisis. Ins 3.37(3m)(3m) Covered Services. An insurer offering a group health benefit plan or a self-insured governmental plan subject to this subsection shall provide at least the amount of coverage for services included in s. 632.89 (2) (dm), Stats., subject to the exclusions or limitations, including deductibles and copayments, that are generally applicable to coverage required under s. 632.89 (3), Stats., for all of the following: Ins 3.37(3m)(a)(a) Mental health services for adults in a day treatment program compliant with the services identified at s. DHS 61.75 (2) and offered by a provider certified by the department of health services under s. DHS 61.75. Ins 3.37(3m)(b)(b) Mental health services for children and adolescents in a day treatment program compliant with the services identified at s. DHS 40.11 and offered by a provider certified by the department of health services under s. DHS 40.04. Ins 3.37(3m)(c)(c) Services for persons with chronic mental illness provided through a community support program compliant with the services identified at s. DHS 63.11 and certified by the department of health services under s. DHS 63.03. Ins 3.37(3m)(d)(d) Residential treatment programs compliant with the services identified at s. DHS 75.14 (1), for alcohol or drug dependent persons, or both, certified by the department of health services under s. DHS 75.14 (2) and under supervision as required in s. DHS 75.14 (5). Ins 3.37(3m)(e)(e) Services for substance use disorders provided in a day treatment program compliant with the services identified at s. DHS 75.12 (1), certified by the department of health services under s. DHS 75.12 (2) and under supervision as required in s. DHS 75.12 (5). Ins 3.37(3m)(f)(f) Intensive outpatient programs for narcotic treatment service for opiate addiction compliant with the services under s. DHS 75.15 (1) and (9), certified by the department of health services under s. DHS 75.15 (2) and under supervision as required in s. DHS 75.15 (4). Ins 3.37(3m)(g)(g) Coordinated emergency mental health services for persons who are experiencing a mental health crisis or who are in a situation likely to turn into a mental health crisis if support is not provided. Services are provided by a program compliant with s. DHS 34.22, certified by the department of health services under s. DHS 34.03, and provided in accordance with subch. III of ch. DHS 34 for the period of time the person is experiencing a mental health crisis until the person is stabilized or referred to other providers for stabilization. Certified emergency mental health service plans shall provide timely notice to third-party payors to facilitate coordination of services for persons who are experiencing or are in a situation likely to turn into a mental health crisis. Ins 3.37(4)(4) Out-of-state services and programs. An insurer offering a group and blanket disability plan or exempt group health benefit plans and self-insured governmental plans may comply with sub. (3) (a) to (g) by providing coverage for services and programs that are substantially similar to those specified in sub. (3) (a) to (g), if the provider is in compliance with similar requirements of the state in which the provider is located. Ins 3.37(4m)(4m) Out-of-state Services And Programs. An insurer offering a group health benefit plan and self-insured governmental health plan may comply with sub. (3m) (a) to (g) by providing coverage for services and programs that are substantially similar to those specified in sub. (3m) (a) to (g), if the provider complies with similar requirements of the state in which the provider is located. Ins 3.37(5)(5) Policy form requirements. An insurer offering a group and blanket disability plan or exempt group health benefit plans and self-insured governmental plans shall specify in each policy form all of the following: Ins 3.37(5)(a)(a) The types of transitional treatment programs and services covered by the policy as specified in sub. (3). Ins 3.37(5)(b)(b) The method the insurer uses to evaluate a transitional treatment program or service to determine if it is medically necessary and covered under the terms of the policy. Ins 3.37(5m)(5m) Policy Form Requirements. An insurer offering a group health benefits plan and self-insured governmental health plan shall specify in each policy form all of the following: Ins 3.37(5m)(a)(a) The types of transitional treatment programs and services covered by the policy as specified in sub. (3m). Ins 3.37(5m)(b)(b) The method the insurer and the self-insured governmental health plan uses to evaluate a transitional treatment program or service to determine if it is medically necessary and covered under the terms of the policy. Ins 3.37 HistoryHistory: Emerg. cr. eff. 9-29-92; cr. Register, February, 1993, No. 446, eff. 3-1-93; corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, June, 1997, No. 498; correction in (3) (c) made under s. 13.93 (2m) (b) 7., Stats., Register, July, 2000, No. 535; CR 02-051: am. (3) (intro.), (b), (d) and (e), cr. (3) (g) Register December 2002 No. 564, eff. 1-1-03; corrections in (3) (a) to (e) and (g) made under s. 13.92 (4) (b) 6. and 7., Stats., Register October 2008 No. 634; EmR1043: emerg. am. (1) to (4) and (5) (intro.), cr. (2m), (3m), (4m) and (5m) eff. 11-29-10; CR 10-149: am. (1) to (4) and (5) (intro.), cr. (2m), (3m), (4m) and (5m) Register June 2011 No. 666, eff. 7-1-11; correction in (2m) (c) made under s. 13.92 (4) (b) 7., Stats., Register March 2017 No. 735. Ins 3.375Ins 3.375 Coverage of nervous and mental disorders and substance use disorders. Ins 3.375(2)(a)(a) This section applies to group health benefit plans as defined in s. 632.745 (9), Stats., health benefit plans as defined in s. 632.745 (11), Stats., and self-insured governmental health plans unless otherwise excluded pursuant to s. 632.89 (5), Stats. Ins 3.375(2)(b)(b) For group health benefit plans and self-insured governmental plans covering employees who are affected by a collective bargaining agreement, the coverage under this section applies as follows: Ins 3.375(2)(b)1.1. If the collective bargaining agreement contains provisions consistent with s. 632.89, Stats., the coverage under this section first applies on the earliest of any of the following: the date the group health benefit plan is issued or renewed on or after December 1, 2010, or the date the self-insured governmental health plan is established, modified, extended or renewed on or after December 1, 2010. Ins 3.375(2)(b)2.2. If the collective bargaining agreement contains provisions inconsistent with s. 632.89, Stats., the coverage under this section applies on the earliest of any of the following: the date the collective bargaining agreement expires, or the date the collective bargaining agreement is extended, modified, or renewed. Ins 3.375(4)(a)(a) An insurer offering a health benefit plan on an individual basis that provides benefit coverage for the treatment of nervous and mental disorders or substance use disorders shall provide their criteria for determining medical necessity for coverage upon request and provide a detailed explanation of the reason for a benefit denial to the insured or the insured’s authorized representative. The detailed explanation shall be in addition to the explanation of benefits required pursuant to s. 632.857, Stats. Ins 3.375(4)(b)(b) Insurers offering individual health benefit plans that provide coverage of the treatment of nervous and mental disorders or substance use disorders may impose treatment limitations if the treatment limitations are no more restrictive than the most common or frequent type of treatment limitations applied to substantially all other coverage under the plan and in accordance with s. 632.89 (2), Stats., 29 CFR 2590.712, and s. 2707 (a) of Pub. L. 111-148, as applicable. Ins 3.375(4)(c)(c) Expenses incurred for the treatment of nervous and mental disorders or substance use disorders shall be included in any overall deductible amount, annual, lifetime, or out-of-pocket limits for the plan. Ins 3.375(5)(a)(a) Insurers offering group health benefit plans and self-insured governmental health plans that provide coverage of the treatment of nervous and mental disorders, and substance use disorders may impose treatment limitations. If treatment limitations are utilized by an insurer or self-insured governmental plan than the treatment limitations shall be no more restrictive than the most common or frequent type of treatment limitations applied to substantially all other coverage under the plan, in accordance with this section, s. 632.89 (2), Stats., 29 CFR 2590.712, and s. 2707 (a) of Pub. L. 111-148, as applicable. Ins 3.375(5)(b)(b) Expenses incurred for the treatment of nervous and mental disorders and substance use disorders shall be included in any overall deductible amount, annual, lifetime, or out-of-pocket limits for the plan. Ins 3.375(6)(a)(a) Solely claims-experience rated employer. At the request of an employer that is solely claims experience rated, an insurer offering a group health benefit plan shall have a qualified actuary determine whether the employer is eligible for a cost exemption based on the actual group claims experience in accordance with s. 632.89 (3c), Stats. Insurers may require employers to give at least 90-days advance notice to the insurer from the employer’s renewal date for obtaining the determination. Ins 3.375(6)(a)1.1. The insurer shall request that the qualified actuary prepare an actuarial determination, provide copies of the actuarial determination and all underlying documents that the actuary relied upon in making the determination to the insurer. The insurer shall provide the actuary’s determination to the employer within 45 days of the employer’s request. Ins 3.375(6)(a)2.2. The insurer shall be responsible for all expenses related to the actuarial cost increase determination and certification. Ins 3.375(6)(a)3.3. Both the insurer and the employer shall maintain the actuarial determination and underlying documentation for a period of not less than five years and in accordance with s. Ins 6.80. Ins 3.375(6)(b)(b) Combined pooled and claims experience rated employer. An insurer offering a group health benefit plan shall have a qualified actuary determine whether the employer is eligible for an exemption in accordance with either of the following: Ins 3.375(6)(b)1.1. For an employer that is predominantly rated based on both its own claims experience and has less than 51 percent of the claims experience pooled with other group health plans, the calculation is to be based on the proportionate share applied due to actual group claims experience and the share applied due to the pooled experience and in accordance with s. 632.89 (3c), Stats. Insurers may require employers to give at least 90-days advance notice to the insurer from the employer’s renewal date for obtaining the determination. Ins 3.375(6)(b)1.a.a. The insurer shall request that the qualified actuary prepare an actuarial determination, provide copies of the actuarial determination and all underlying documents that the actuary relied upon in making the determination to the insurer. The insurer shall provide the actuary’s determination to the employer within 45 days of the employer’s request. Ins 3.375(6)(b)1.b.b. The insurer shall be responsible for all expenses related to the actuarial cost increase determination and certification. Ins 3.375(6)(b)1.c.c. Both the insurer and the employer shall maintain the actuarial determination and underlying documentation for a period of not less than five years and in accordance with s. Ins 6.80. Ins 3.375(6)(b)2.2. For an employer that is predominantly rated based on claims experience pooled with other group health benefit plans that constitutes 51 percent or more of the claims experience, the insurer shall have a qualified actuary determine whether the pooled group is eligible for an exemption calculated based on the pool’s claims experience and in accordance with s. 632.89 (3c), Stats. Insurers may require employers give at least 30-days advance notice to the insurer from the employer’s renewal date for obtaining the determination. Ins 3.375(6)(b)2.a.a. The insurer shall have a qualified actuary calculate one time each year a determination of whether the employers participating within the pool are eligible for a cost exemption. Ins 3.375(6)(b)2.b.b. The insurer shall be responsible for all expenses related to the actuarial cost increase determination and certification. Ins 3.375(6)(b)2.c.c. The insurer shall provide a copy of the actuary’s determination to an employer within 15 days of the employer’s request. The insurer shall provide a date on which the actuarial determination will be available annually. The insurer shall maintain the actuarial determination and underlying documentation for a period of not less than five years and in accordance with s. Ins 6.80. Ins 3.375(6)(c)(c) Prior and succeeding insurers. During the first year after an employer changes insurers offering group health benefit plans, the succeeding insurer shall accept as accurate and may rely upon the prior insurer’s determination of eligibility for cost exemption. A succeeding insurer shall provide the prior insurer’s calculation to the employer following a timely request for purposes of calculating the employer’s eligibility for a cost exemption. Ins 3.375(6)(d)(d) Notice of election. An insurer offering a group health benefit plan or a self-insured governmental health plan shall provide the applicable notice to the employer who qualifies for and elects an increased cost exemption under s. 632.89 (3c), Stats. The insurer shall inform the employer to notify promptly all enrollees under the plan of the exemption not to exceed 30-days following the cost increase determination and exemption election. Ins 3.375(6)(d)1.1. The notice shall be in substantially the form outlined in Appendix 2, using a standard typeface with at least a 10-point font, indicating the exemption election and that the plan will comply with benefit coverage requirements contained in s. 632.89 (2), 2007 Stats. Ins 3.375(6)(d)2.2. The notice shall be provided to each plan enrollee in either electronic or paper form. Ins 3.375(6)(d)3.3. The notice shall also be posted in a prominent position in each workplace of the employer.
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