Chapter 632

632.795 History History: 1989 a. 23; 1995 a. 27 s. 9126 (19); 2007 a. 20 s. 9121 (6) (a).

632.797 632.797 Disclosure of group health claims experience.

632.797(1) (1) 

632.797(1)(a) (a) Except as provided in subs. (2) and (3), an insurer shall provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employees through a multiple-employer trust, with the policyholder’s or the employer’s aggregate group health claims experience for the current policy period, and for up to 2 policy periods immediately preceding the current policy period if the insurer provided coverage during those periods, upon request from the policyholder or employer.

632.797(1)(b) (b) The insurer shall provide the information under par. (a) no later than 30 days after receiving a request for that information from the policyholder or employer.

632.797(1)(c) (c) The insurer may not charge the policyholder or the employer for providing the information under par. (a) one time in a 12-month period.

632.797(1)(d) (d) Except for charging a fee under par. (c), an insurer may not change the rating methodology between community rating and experience rating or otherwise penalize a policyholder or employer for requesting the information under par. (a).

632.797(2) (2) An insurer is not required to provide the information under sub. (1) unless the policyholder or employer requesting the information provides coverage under the policy for at least 50 individuals, exclusive of individuals who have coverage under the policy as a dependent of another individual.

632.797(3) (3) Notwithstanding sub. (1), an insurer is not required to provide health claims experience under sub. (1) for any period of time that is before 18 months before the date on which the information is requested.

632.797(4) (4) Subsection (1) does not require that an insurer provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employees through a multiple-employer trust, with the health claims experience of an individual employee or insured.

632.797(5) (5) An insurer is not required under sub. (1) to provide information that identifies an individual or that is confidential under s. 146.82.

632.797(6) (6) An insurer that provides aggregate health claims experience information in compliance with this section is immune from civil liability for its acts or omissions in providing such information.

632.797 History History: 1993 a. 448; 2011 a. 32.

632.798 632.798 Out-of-pocket costs.

632.798(1) (1) Definitions. In this section:

632.798(1)(a) (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

632.798(1)(b) (b) “Health care provider” has the meaning given in s. 146.903 (1) (c) and includes a hospital, as defined in s. 50.33 (2).

632.798(1)(c) (c) “Insured” includes an enrollee under a self-insured health plan and a representative or designee of an insured or enrollee.

632.798(1)(d) (d) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

632.798(2) (2) Provide estimate.

632.798(2)(a) (a) A self-insured health plan or an insurer that provides coverage under a disability insurance policy shall, at the request of an insured, provide to the insured a good faith estimate, as of the date of the request and assuming no medical complications or modifications in the insured’s treatment plan, of the insured’s total out-of-pocket cost according to the insured’s benefit terms for a specified health care service in the geographic region in which the health care service will be provided.

632.798(2)(b) (b) An estimate provided by an insurer or self-insured health plan under this section is not a legally binding estimate of the out-of-pocket cost.

632.798(2)(c) (c) An insurer or self-insured health plan may not charge an insured for providing the information under this section.

632.798(2)(d) (d) Before providing the information requested under par. (a), the insurer or self-insured health plan may require the insured to provide in writing any of the following information:

632.798(2)(d)1. 1. The name of the health care provider providing the service.

632.798(2)(d)2. 2. The facility at which the service will be provided.

632.798(2)(d)3. 3. The date the service will be provided.

632.798(2)(d)4. 4. The health care provider’s estimate of the charge for the service.

632.798(2)(d)5. 5. The codes for the service under the Current Procedural Terminology of the American Medical Association or under the Current Dental Terminology of the American Dental Association.

632.798(2)(e) (e) The requirement to provide the information requested under par. (a) does not apply if the health care provider providing the health care service is any of the following:

632.798(2)(e)1. 1. A health care provider that practices individually or in association with not more than 2 other individual health care providers.

632.798(2)(e)2. 2. A health care provider that is an association of 3 or fewer individual health care providers.

632.798 History History: 2009 a. 146.

632.80 632.80 Restrictions on medical payments insurance. The provisions of this subchapter do not apply to medical payments insurance when it is a part of or supplemental to liability, steam boiler, elevator, automobile or other insurance covering loss of or damage to property, provided the loss, damage or expense arises out of a hazard directly related to such other insurance.

632.80 History History: 1975 c. 375.

632.81 632.81 Minimum standards for certain disability policies. The commissioner may by rule establish minimum standards for benefits, claims payments, marketing practices, compensation arrangements and reporting practices for medicare supplement policies, medicare replacement policies and long-term care insurance policies. The commissioner may by rule exempt from the minimum standards certain types of coverage, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.

632.81 History History: 1981 c. 82; 1985 a. 29; 1989 a. 31, 332.

632.81 Cross-reference Cross-reference: See also ss. Ins 3.39, 3.455, and 3.46, Wis. adm. code.

632.82 632.82 Renewability of long-term care insurance policies. Notwithstanding s. 631.36 (2) to (5), the commissioner shall, by rule, require long-term care insurance policies that are issued on an individual basis to include a provision restricting the insurer’s ability to terminate or alter the long-term care insurance policy except for nonpayment of premium. The rule may specify exceptions to the restriction, including exceptions that allow insurers to do any of the following:

632.82(1) (1) Change the rates charged on a long-term care insurance policy if the rate change is made on a class basis.

632.82(2) (2) Refuse to renew a long-term care insurance policy if conditions specified in the rule are satisfied. The conditions shall, at a minimum, require all of the following:

632.82(2)(a) (a) That the nonrenewal be on other than an individual basis.

632.82(2)(b) (b) That the insurer demonstrate to the commissioner that renewal will affect the insurer’s solvency or loss experience as specified in the rule.

632.82 History History: 1989 a. 31.

632.825 632.825 Midterm termination of long-term care insurance policy by insured.

632.825(1) (1) Permitted cancellation and refund.

632.825(1)(a) (a) No insurer that provides coverage under a long-term care insurance policy may prohibit the insured under the policy from canceling the policy before the expiration of the agreed term.

632.825(1)(b) (b) If an insured under a long-term care insurance policy cancels the policy before the expiration of the agreed term, the insurer shall issue a prorated premium refund to the insured.

632.825(1)(c) (c) If an insured under a long-term care insurance policy dies during the term of the policy, the insurer shall issue a prorated premium refund to the insured’s estate.

632.825(2) (2) Policy provision. Every long-term care insurance policy shall contain a provision that apprises the insured of the insured’s right to cancel and the insurer’s premium refund responsibilities under sub. (1).

632.825 History History: 1993 a. 207.

632.825 Cross-reference Cross-reference: See also ss. Ins 3.455 and 3.46, Wis. adm. code.

632.83 632.83 Internal grievance procedure.

632.83(1) (1) In this section, “health benefit plan” has the meaning given in s. 632.745 (11), except that “health benefit plan” includes the coverage specified in s. 632.745 (11) (b) 10. and includes a policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.

632.83(2) (2) Every insurer that issues a health benefit plan shall do all of the following:

632.83(2)(a) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (3) for the resolution of insureds’ grievances with the health benefit plan.

632.83(2)(b) (b) Provide insureds with complete and understandable information describing the internal grievance procedure under par. (a).

632.83(2)(c) (c) Submit an annual report to the commissioner describing the internal grievance procedure under par. (a) and summarizing the experience under the procedure for the year.

632.83(3) (3) The internal grievance procedure established under sub. (2) (a) shall include all of the following elements:

632.83(3)(a) (a) The opportunity for an insured to submit a written grievance in any form.

632.83(3)(b) (b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one insured other than the grievant, if an insured is available to serve on the grievance panel.

632.83(3)(c) (c) Prompt investigation of each grievance submitted under par. (a).

632.83(3)(d) (d) Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.

632.83(3)(e) (e) Retention of records pertaining to each grievance for at least 3 years after the date of notification under par. (d).

632.83 History History: 1999 a. 155 ss. 8 to 17; Stats. 1999 s. 632.83.

632.835 632.835 Independent review of coverage denial determinations.

632.835(1) (1) Definitions. In this section:

632.835(1)(a) (a) “Adverse determination” means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:

632.835(1)(a)1. 1. An admission to a health care facility, the availability of care, the continued stay or other treatment that is a covered benefit has been reviewed.

632.835(1)(a)2. 2. Based on the information provided, the treatment under subd. 1. does not meet the health benefit plan’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness.

632.835(1)(a)3. 3. Based on the information provided, the insurer that issued the health benefit plan reduced, denied or terminated the treatment under subd. 1. or payment for the treatment under subd. 1.

632.835(1)(a)4. 4. Subject to sub. (5) (c), the amount of the reduction or the cost or expected cost of the denied or terminated treatment or payment exceeds, or will exceed during the course of the treatment, $250.

632.835(1)(ag) (ag) “Coverage denial determination” means an adverse determination, an experimental treatment determination, a preexisting condition exclusion denial determination, or the rescission of a policy or certificate.

632.835(1)(b) (b) “Experimental treatment determination” means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:

632.835(1)(b)1. 1. A proposed treatment has been reviewed.

632.835(1)(b)2. 2. Based on the information provided, the treatment under subd. 1. is determined to be experimental under the terms of the health benefit plan.

632.835(1)(b)3. 3. Based on the information provided, the insurer that issued the health benefit plan denied the treatment under subd. 1. or payment for the treatment under subd. 1.

632.835(1)(b)4. 4. Subject to sub. (5) (c), the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, $250.

632.835(1)(c) (c) “Health benefit plan” has the meaning given in s. 632.745 (11), except that “health benefit plan” includes the coverage specified in s. 632.745 (11) (b) 10.

632.835(1)(cm) (cm) “Preexisting condition exclusion denial determination” means a determination by or on behalf of an insurer that issues a health benefit plan denying or terminating treatment or payment for treatment on the basis of a preexisting condition exclusion, as defined in s. 632.745 (23).

632.835(1)(d) (d) “Treatment” means a medical service, diagnosis, procedure, therapy, drug or device.

632.835(2) (2) Review requirements; who may conduct.

632.835(2)(a) (a) Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of a coverage denial determination made with respect to the insured.

632.835(2)(b) (b) If a coverage denial determination is made, the insurer involved in the determination shall provide notice to the insured of the insured’s right to obtain the independent review required under this section, how to request the review, and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under sub. (4). An independent review under this section may be conducted only by an independent review organization certified under sub. (4) and selected by the insured.

632.835(2)(bg) (bg) Notwithstanding par. (b), an insurer is not required to provide the notice under par. (b) to an insured until the insurer sends notice of the disposition of the internal grievance if all of the following apply:

632.835(2)(bg)1. 1. The health benefit plan issued by the insurer contains a description of the independent review procedure under this section, including an explanation of the insured’s rights under par. (d), how to request the review, the time within which the review must be requested, and how to obtain a current listing of independent review organizations certified under sub. (4).

632.835(2)(bg)2. 2. The insurer includes on its explanation of benefits form a statement that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited independent review with respect to an urgent matter. The statement shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under subd. 1. The statement shall provide a toll-free telephone number and website, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.

632.835(2)(bg)3. 3. For any coverage denial determination for which an explanation of benefits is not provided to the insured, the insurer provides a notice that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited, independent review with respect to an urgent matter. The notice shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under subd. 1. The notice shall provide a toll-free telephone number and website, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.

632.835(2)(c) (c) Except as provided in par. (d), an insured must exhaust the internal grievance procedure under s. 632.83 before the insured may request an independent review under this section. Except as provided in sub. (9) (a), an insured who uses the internal grievance procedure must request an independent review as provided in sub. (3) (a) within 4 months after the insured receives notice of the disposition of his or her grievance under s. 632.83 (3) (d).