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. Ins 3.375(7)(a)(a) Employer request. An employer having fewer than 10 eligible employees on the first day of the plan year may elect an exemption from compliance with s. 632.89, Stats. An insurer offering a group health benefit plan or self-funded government plan shall inform the employer that in lieu of those requirements, the plan may cover benefits for nervous and mental disorders and substance use disorders in accordance with the requirements contained in s. 632.89 (2), 2007 Stats. Ins 3.375(7)(b)(b) 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 the small employer exemption under s. 632.89 (3f), Stats. The insurer shall inform the employer to notify promptly all enrollees under the plan of the exemption not to exceed 30 days from the employer’s determination to elect exemption. The notice shall comply with all of the following: Ins 3.375(7)(b)1.1. The notice shall be in substantially the form outlined in Appendix 1, using a standard typeface with at least a 10-point font, indicating the exemption election and that the plan will cover benefits for nervous and mental disorders and substance use disorders in accordance with the requirements contained in s. 632.89 (2), 2007 Stats. Ins 3.375(7)(b)2.2. The notice shall be provided to each plan enrollee in either electronic or paper form. Ins 3.375(7)(b)3.3. The notice shall be posted in a prominent position in each workplace of the employer. Ins 3.375 HistoryHistory: EmR1043: emerg. cr., eff. 11-29-10; CR 10-149: cr. Register June 2011 No. 666, eff. 7-1-11. Ins 3.375 Appendix 1
Small Employer Notice of the Plan’s Election of Exemption from Mental Health and Substance Use Disorder Parity for [This Plan Year]
You are receiving this notice as an employee of [name of employer group]. This notice is to inform you that [name of employer group] qualifies and elects to be exempt from the state nervous and mental disorders and substance use disorders coverage parity requirements for this plan year, beginning [insert date of the first day of the plan year]. The employer is eligible to elect this exemption based upon having fewer than 10 eligible employees. Benefits may change as of [insert the date of the first day of the plan year].
Despite the exemption from the state nervous and mental disorders and substance use disorders coverage requirements, state law requires [name of employer group] to comply with the minimum mandated coverage requirements and limitations contained in s. 632.89 (2), 2007 Stats., for treatment services for nervous and mental disorders and substance use disorders. For this plan year, your plan provides the following coverage related to nervous and mental disorders and substance use disorders:
[Insert plain language benefits summary]
Carefully review your health plan’s benefits, limitations, and exclusions for detailed information on services and coverage available to you and your family this plan year. If you have additional questions please contact [insert contact name, phone number and e-mail address if available].
Ins 3.375 Appendix 2
Group Health Benefit Plan Notice of Election of Exemption from Mental Health and Substance Use Disorder Parity for [This Plan Year]
You are receiving this notice as an employee of [name of employer group]. This notice is to inform you that [name of employer group] qualifies and elects to be exempt from the state nervous and mental disorders and substance use disorders coverage parity requirements for this plan year, beginning [insert date of the first day of the plan year].
A group health benefit plan may elect to be exempt from mental health and substance use disorder parity if there are increases in the employer’s total cost of coverage for the treatment of physical conditions and nervous and mental disorders and substance use disorders by a percentage that exceeds either two percent (2%) in the first plan year in which the nervous and mental disorders and substance use disorders coverage requirements apply or one percent (1%) in any plan year after the first plan year in which the requirements apply. Benefits may change as of [insert the date of the first day of the plan year].
Despite the exemption from the state nervous and mental disorders and substance use disorders coverage requirements, state law requires [name of employer group] to comply with the minimum mandated coverage requirements and limitations contained in s. 632.89 (2), 2007 Stats., for treatment services for nervous and mental disorders and substance use disorders. For this plan year, your plan provides the following coverage related to nervous and mental disorders and substance use disorders:
[Insert plain language benefits summary]
Carefully review your health plan’s benefits, limitations, and exclusions for detailed information on services and coverage available to you and your family this plan year. If you have additional questions please contact [insert contact name, phone number and e-mail address if available].
Ins 3.38Ins 3.38 Coverage of newborn infants. Ins 3.38(2)(a)(a) Coverage of each newborn infant is required under a disability insurance policy if: Ins 3.38(2)(a)1.1. The policy provides coverage for another family member, in addition to the insured person, such as the insured’s spouse or a child, and Ins 3.38(2)(a)2.2. The policy specifically indicates that children of the insured person are eligible for coverage under the policy. Ins 3.38(2)(b)(b) Coverage is required under any type of disability insurance policy as described in par. (a), including not only policies providing hospital, surgical or medical expense benefits, but also all other types of policies described in par. (a), including accident only and short term policies. Ins 3.38(2)(c)(c) The benefits to be provided are those provided by the policy and payable, under the stated conditions except for waiting periods, for children covered or eligible for coverage under the policy. Ins 3.38(2)(d)(d) Benefits are required from the moment of birth for covered occurrences, losses, services or expenses which result from an injury or sickness condition, including congenital defects and birth abnormalities of the newborn infant to the extent that such covered occurrences, losses, services or expenses would not have been necessary for the routine postnatal care of the newborn child in the absence of such injury or sickness. In addition, under a policy providing coverage for hospital confinement and/or in-hospital doctor’s charges, hospital confinement from birth continuing beyond what would otherwise be required for a healthy baby (e.g. 5 days) as certified by the attending physician to be medically necessary will be considered as resulting from a sickness condition. Ins 3.38(2)(e)(e) If a disability insurance policy provides coverage for routine examinations and immunizations, such coverage is required for covered children from the moment of birth. Ins 3.38(2)(f)(f) An insurer may underwrite a newborn, applying the underwriting standards normally used with the disability insurance policy form involved, and charge a substandard premium, if necessary, based upon such underwriting standards and the substandard rating plan applicable to such policy form. The insurer shall not refuse initial coverage for the newborn if the applicable premium, if any, is paid as required by s. 632.895 (4) (c), Stats. Renewal coverage for a newborn shall not be refused except under a policy which permits individual termination of coverage and only as such policy’s provisions permit. Ins 3.38(2)(g)(g) An insurer receiving an application, for a policy as described in par. (a) providing hospital and/or medical expense benefits, from a pregnant applicant or an applicant whose spouse is pregnant, may not issue such a policy to exclude or limit benefits for the expected child. Such a policy must be issued without such an exclusion or limitation, or the application must be declined or postponed. Ins 3.38(2)(h)(h) Coverage is not required for the child born, after termination of the mother’s coverage, to a female insured under family coverage who is provided extended coverage for pregnancy expenses incurred in connection with the birth of such child. Ins 3.38(2)(j)(j) Policies issued or renewed on or after November 8, 1975, and before May 5, 1976, shall be administered to comply with s. 204.325, Stats., contained in chapter 98, Laws of 1975. Policies issued or renewed on or after May 5, 1976, and before June 1, 1976, shall be administered to comply with s. 632.895 (5), Stats., contained in chapter 224, Laws of 1975. Policies issued or renewed on or after June 1, 1976, shall be amended to comply with the requirements of s. 632.895 (5), Stats. Ins 3.38 HistoryHistory: Cr. Register, February, 1977, No. 254, eff. 3-1-77; reprinted, Register, April, 1977, No. 256, to restore dropped text; corrections in (1) (intro.), (i) and (j), made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1992, No. 436; correction in (1) (f) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1994, No. 462. Ins 3.39Ins 3.39 Standards for disability insurance sold to the Medicare eligible. Ins 3.39(1)(a)(a) This section establishes requirements for health and other disability insurance policies primarily sold to Medicare eligible persons. Disclosure provisions are required for other disability policies sold to Medicare eligible person because such policies frequently are represented to, and purchased by, the Medicare eligible as supplements to Medicare products. Ins 3.39(1)(b)(b) This section seeks to reduce abuses and confusion associated with the sale of disability insurance to Medicare eligible persons by providing reasonable standards. The disclosure requirements and established benefit standards are intended to provide to Medicare eligible persons guidelines that they can use to compare disability insurance policies and certificates as described in s. Ins 6.75 (1) (c), and to aid them in the purchase of policies and certificates intended to supplement Medicare policies that are suitable for their needs. This section is designed not only to improve the ability of the Medicare eligible consumer to make an informed choice when purchasing disability insurance, but also to assure the Medicare eligible persons of this state that the commissioner will not approve a policy or certificate as “Medicare supplement” or as “Medicare cost” unless it meets the requirements of this section. Ins 3.39(1)(d)(d) Wisconsin statutes interpreted and implemented by this rule are ss. 185.983 (1m), 600.03, 601.01 (2), 601.42, 609.01 (1g) (b), 625.16, 628.34 (12), 628.38, 631.20 (2), 632.73 (2m), 632.76 (2) (b), 632.81, 632.895 (2), (3), (4) and (6), Stats. Ins 3.39(2)(2) Scope. This section applies to individual and group disability policies sold, delivered or issued for delivery in Wisconsin to Medicare eligible persons as follows: Ins 3.39(2)(a)(a) Except as provided in pars. (d) and (e), this section applies to any group or individual Medicare supplement policy or certificate, or Medicare select policy or certificate as described in s. 600.03 (28r), Stats., or any Medicare cost policy as described in s. 600.03 (28p) (a) and (c), Stats., including all of the following: Ins 3.39(2)(a)1.1. Any Medicare supplement policy, Medicare select policy, or Medicare cost policy issued by a voluntary sickness care plan subject to ch. 185, Stats. Ins 3.39(2)(a)2.2. Any certificate issued under a group Medicare supplement policy or group Medicare select policy. Ins 3.39(2)(a)3.3. Any individual or group policy sold in Wisconsin predominantly to individuals or groups of individuals who are 65 years of age or older that offers hospital, medical, surgical, or other disability coverage, except for a policy that offers solely nursing home, hospital confinement indemnity, or specified disease coverage. Ins 3.39(2)(a)5.5. Any individual or group policy or certificate sold in Wisconsin to persons under 65 years of age and eligible for Medicare by reason of disability that offers hospital, medical, surgical or other disability coverage, except for a policy or certificate that offers solely nursing home, hospital confinement indemnity or specified disease coverage. Ins 3.39(2)(b)(b) Except as provided in pars. (d) and (e), subs. (9) and (11) apply to any individual disability policy sold to a person eligible for Medicare that is not a Medicare supplement, Medicare select, or a Medicare cost policy as described in par. (a). Ins 3.39(2)(c)(c) Except as provided in par. (e), sub. (10) applies to any individual or group hospital or medical policy that continues with changed benefits after the insured becomes eligible for Medicare. Ins 3.39(2)(d)(d) Except as provided in subs. (10) and (13), this section does not apply to any of the following: Ins 3.39(2)(d)1.1. A group policy issued to one or more employers or labor organizations, to the trustees of a fund established by one or more employers or labor organizations, or a combination of both, for employees or former employees or both, or for members or former members or both of the labor organizations; Ins 3.39(2)(d)3.3. Individual or group hospital, surgical, medical, major medical, or comprehensive medical expense coverage which continues after an insured becomes eligible for Medicare; or Ins 3.39(2)(e)(e) This section does not apply to either of the following: Ins 3.39(2)(e)1.1. A policy providing solely accident, dental, vision, disability income, or credit disability income coverage. Ins 3.39(2)(f)(f) This section may be enforced under ss. 601.41, 601.64, 601.65, Stats., or ch. 645, Stats., or any other enforcement provision of chs. 600 to 646, Stats., or Wisconsin Administrative Code Insurance chapters. Ins 3.39(3)(3) Definitions. In this section and for use in policies or certificates: Ins 3.39(3)(a)(a) “Accident,” “Accidental Injury,” or “Accidental Means” shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization. Ins 3.39(3)(a)1.1. The definition shall not be more restrictive than the following: “Injury or injuries for which benefits are provided” means accidental bodily injury sustained by the insured person that is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force.” Ins 3.39(3)(a)2.2. The definition may provide that injuries shall not include injuries for which benefits are provided or available under any workers’ compensation, employer’s liability or similar law or motor vehicle no-fault plan, unless prohibited by law.
