Chapter Ins 8

Ins 8.71 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register April 2004 No. 580.

Ins 8.72 Ins 8.72 Basic benefits. Subject to the limitations and restrictions under s. Ins 8.75 and copayments and coinsurance under s. Ins 8.77, each plan shall provide coverage for all of the following, if medically necessary:

Ins 8.72(1) (1) Professional services by a health care provider acting within the scope and limitations of his or her license or certificate or a person acting under the direction of a health care provider, including all of the following:

Ins 8.72(1)(a) (a) Office, outpatient, inpatient and emergency room visits including treatment rendered during those visits.

Ins 8.72(1)(b) (b) Surgical services including postoperative care following inpatient or outpatient surgery.

Ins 8.72(1)(c) (c) Services of an assistant surgeon if necessary to perform surgery.

Ins 8.72(1)(d) (d) Anesthesia services.

Ins 8.72(2) (2) Hospital care, including all of the following:

Ins 8.72(2)(a) (a) Semi-private room, board and ancillary services and supplies that are generally provided to hospital inpatients.

Ins 8.72(2)(b) (b) Confinement in an intensive care or coronary care unit of a hospital.

Ins 8.72(2)(c) (c) Outpatient medical care and treatment.

Ins 8.72(2)(d) (d) Medical care and treatment provided in a hospital emergency room.

Ins 8.72(3) (3) Medical care and treatment provided in an ambulatory surgery center, as defined in 42 CFR 416.2.

Ins 8.72(4) (4) Outpatient x-ray, laboratory and other diagnostic tests.

Ins 8.72(5) (5) Confinement in a skilled nursing home licensed under subch. I of ch. 50, Stats.

Ins 8.72(6) (6) Services provided by a home health agency licensed under s. 50.49, Stats.

Ins 8.72(7) (7) Care provided by a hospice licensed under subch. VI of ch. 50, Stats.

Ins 8.72(8) (8) Local ground licensed ambulance services.

Ins 8.72(9) (9) Physical therapy.

Ins 8.72(10) (10) Rental and purchase of durable medical equipment and supplies.

Ins 8.72(11) (11) Prescription drugs.

Ins 8.72(12) (12) Reconstructive surgery which is either of the following:

Ins 8.72(12)(a) (a) Incidental to or following surgery necessitated by illness or injury.

Ins 8.72(12)(b) (b) Caused by a congenital disease or anomaly of a covered dependent child which results in a functional defect.

Ins 8.72(13) (13) Sterilization.

Ins 8.72(14) (14) Maternity services including all of the following:

Ins 8.72(14)(a) (a) Prenatal services normally associated with pregnancy.

Ins 8.72(14)(b) (b) Delivery services normally associated with a vaginal or caesarean section delivery.

Ins 8.72(14)(c) (c) Routine nursery care from the moment of birth until the infant is discharged from the hospital.

Ins 8.72(15) (15) Complications of pregnancy.

Ins 8.72(16) (16) Inpatient, outpatient and transitional treatment for nervous and mental disorders and alcoholism and other drug abuse, subject to s. Ins 8.75 (3).

Ins 8.72(17) (17) Preventive services appropriate to the age and sex of the covered person including all of the following:

Ins 8.72(17)(a) (a) Routine physical examinations and health screening tests.

Ins 8.72(17)(b) (b) Immunizations for poliomyelitis, diphtheria, pertussis, typhoid, measles, mumps and rubella.

Ins 8.72(17)(c) (c) Vaccinations for hemophilus influenza, type B.

Ins 8.72(17)(d) (d) Diphtheria and tetanus boosters.

Ins 8.72(17)(e) (e) Influenza and pneumonia vaccinations.

Ins 8.72(17)(f) (f) Tuberculosis skin tests.

Ins 8.72(18) (18) Organ transplants that are covered by medicare.

Ins 8.72(19) (19) Services provided by a dentist for the repair of accidental dental injuries.

Ins 8.72 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93; corrections in (3) and (6) made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562; correction in (7) made under s. 13.92 (4) (b) 7., Stats., Register March 2017 No. 735.

Ins 8.73 Ins 8.73 Health insurance mandates. A plan shall comply with the health insurance mandates, as defined in s. 601.423, Stats., and may not exclude or limit coverage for any mandate except as provided in s. Ins 8.75 (3).

Ins 8.73 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.74 Ins 8.74 Policy title; term.

Ins 8.74(1) (1) The policy form for a plan submitted to the office of the commissioner of insurance for approval under s. 631.20, Stats., shall be entitled “basic health benefit plan.”

Ins 8.74(2) (2) The term period for plan coverage shall not be less than 12 months.

Ins 8.74 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.75 Ins 8.75 Limitations and restrictions.

Ins 8.75(1) (1) Preexisting conditions. Section 635.17 (1), Stats., applies to a plan subject to this subchapter.

Ins 8.75 Note Note: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.746, Stats.

Ins 8.75(2) (2) Annual maximum. The annual calendar year maximum benefit for a plan is $30,000 per insured individual. Charges for a hospitalization which extends from one calendar year to another shall be subject to the calendar year maximum for the year in which each charge was incurred and only one $100 copayment shall apply to the confinement.

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.

Ins 8.77(3) (3) Coinsurance. Except as provided in sub. (4) and s. Ins 8.79, for each insured individual, a plan shall pay the following portions of the amount by which covered charges in a calendar year exceed the copayments:

Ins 8.77(3)(a) (a) For all charges other than for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems:

Ins 8.77(3)(a)1. 1. 80% of the first $5,000 of charges until the plan has paid $4,000.

Ins 8.77(3)(a)2. 2. 95% of the remainder of charges until the plan limit under s. Ins 8.75 (2) has been met.

Ins 8.77(3)(b) (b) For the treatment of nervous or mental disorders or alcoholism or other drug abuse problems, 80% of the charges until the plan has paid $1,400 or the plan limit under s. Ins 8.75 (2) has been met.

Ins 8.77(4) (4) Exception for health maintenance organizations. A plan offered by a health maintenance organization that requires participants to use only specified health care providers may elect to offer either copayments or coinsurance if the amount for which a participant is responsible is the actuarial equivalent of the copayments and coinsurance required under subs. (2) and (3). Upon request, a health maintenance organization shall provide the office of the commissioner of insurance with sufficient documentation to support its determination of actuarial equivalence.

Ins 8.77(5) (5) Deductibles and other cost-sharing prohibited. A plan shall not include an annual deductible or any copayment or coinsurance requirement other than those specified in this section, except as provided in s. Ins 8.79.

Ins 8.77 History History: Cr. Register, June, 1993, No. 450, eff. 7-1-93.

Ins 8.78 Ins 8.78 Participation; enrollment.