Chapter 632

632.835(6)(a)3. 3. A national, state or local trade association of health care providers, or an affiliate of any such association.

632.835(6)(b) (b) An independent review organization appointed to conduct an independent review and a clinical peer reviewer assigned by an independent review organization to conduct an independent review may not have a material professional, familial or financial interest with any of the following:

632.835(6)(b)1. 1. The insurer that issued the health benefit plan that is the subject of the independent review.

632.835(6)(b)2. 2. Any officer, director or management employee of the insurer that issued the health benefit plan that is the subject of the independent review.

632.835(6)(b)3. 3. The health care provider that recommended or provided the health care service or treatment that is the subject of the independent review, or the health care provider’s medical group or independent practice association.

632.835(6)(b)4. 4. The facility at which the health care service or treatment that is the subject of the independent review was or would be provided.

632.835(6)(b)5. 5. The developer or manufacturer of the principal procedure, equipment, drug or device that is the subject of the independent review.

632.835(6)(b)6. 6. The insured or his or her authorized representative.

632.835(6m) (6m) Qualifications of clinical peer reviewers. A clinical peer reviewer who conducts a review on behalf of a certified independent review organization must satisfy all of the following requirements:

632.835(6m)(a) (a) Be a health care provider who is expert in treating the medical condition that is the subject of the review and who is knowledgeable about the treatment that is the subject of the review through current, actual clinical experience.

632.835(6m)(b) (b) Hold a credential, as defined in s. 440.01 (2) (a), that is not limited or restricted; or hold a license, certificate, registration or permit that authorizes or qualifies the health care provider to perform acts substantially the same as those acts authorized by a credential, as defined in s. 440.01 (2) (a), that was issued by a governmental authority in a jurisdiction outside this state and that is not limited or restricted.

632.835(6m)(c) (c) If a physician, hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the review.

632.835(6m)(d) (d) Have no history of disciplinary sanctions, including loss of staff privileges but excluding temporary suspension of staff privileges due to incomplete records, taken or pending by the medical examining board or another regulatory body or by any hospital or government.

632.835(7) (7) Immunity.

632.835(7)(a) (a) A certified independent review organization is immune from any civil or criminal liability that may result because of an independent review determination made under this section. An employee, agent or contractor of a certified independent review organization is immune from civil liability and criminal prosecution for any act or omission done in good faith within the scope of his or her powers and duties under this section.

632.835(7)(b) (b) A health benefit plan that is the subject of an independent review and the insurer that issued the health benefit plan shall not be liable to any person for damages attributable to the insurer’s or plan’s actions taken in compliance with any decision regarding an adverse determination or an experimental treatment determination rendered by a certified independent review organization.

632.835(8) (8) Notice of sufficient independent review organizations.

632.835(8)(a) (a) Adverse and experimental treatment determinations. The commissioner shall make a determination that at least one independent review organization has been certified under sub. (4) that is able to effectively provide the independent reviews required under this section for adverse determinations and experimental treatment determinations and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating with respect to adverse determinations and experimental treatment determinations.

632.835(8)(b) (b) Preexisting condition exclusion denials and rescissions. The commissioner shall make a determination that at least one independent review organization has been certified under sub. (4) that is able to effectively provide the independent reviews required under this section for preexisting condition exclusion denial determinations and rescissions and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating with respect to preexisting condition exclusion denial determinations and rescissions.

632.835(9) (9) Applicability.

632.835(9)(a) (a) Adverse and experimental treatment determinations. The independent review required under this section with respect to an adverse determination or an experimental treatment determination shall be available to an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000. Notwithstanding sub. (2) (c), an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000, but before June 15, 2002, with respect to an adverse determination or an experimental treatment determination must request an independent review no later than 4 months after June 15, 2002.

632.835(9)(b) (b) Preexisting condition exclusion denials and rescissions. The independent review required under this section with respect to a preexisting condition exclusion denial determination or a rescission shall be available to an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after the date stated in the notice published in the Wisconsin Administrative Register by the commissioner under sub. (8) (b).

632.835 History History: 1999 a. 155; 2001 a. 65; 2009 a. 28, 276; 2017 a. 365 s. 112.

632.835 Cross-reference Cross-reference: See also ch. Ins 18, Wis. adm. code.

632.84 632.84 Benefit appeals under certain policies.

632.84(1) (1) Definitions. In this section:

632.84(1)(a) (a) “Nursing home” has the meaning given in s. 50.01 (3).

632.84(1)(b) (b) “Nursing home insurance policy” means an individual or group insurance policy which provides coverage primarily for confinement or care in a nursing home.

632.84(2) (2) Review and appeal.

632.84(2)(a) (a) Except as provided in sub. (3), an insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall establish an internal procedure by which the policyholder or the certificate holder or a representative of the policyholder or the certificate holder may appeal the denial of any benefits under the medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy. The procedure established under this paragraph shall include all of the following:

632.84(2)(a)1. 1. The opportunity for the policyholder or certificate holder or a representative of the policyholder or certificate holder to submit a written request, which may be in any form and which may include supporting material, for review by the insurer of the denial of any benefits under the policy.

632.84(2)(a)2. 2. Within 30 days after receiving the request under subd. 1., disposition of the review and notification to the person submitting the request of the results of the review.

632.84(2)(b) (b) An insurer shall describe the procedure established under par. (a) in every policy, group certificate and outline of coverage issued in connection with a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy.

632.84(2)(c) (c) If an insurer denies any benefits under a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy, the insurer shall, at the time the insurer gives notice of the denial of any benefits, provide the policyholder and certificate holder with a written description of the appeal process established under par. (a).

632.84(2)(d) (d) An insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall annually report to the commissioner a summary of all appeals filed under this section and the disposition of those appeals.

632.84(3) (3) Exceptions. This section does not apply to a health maintenance organization, limited service health organization or preferred provider plan, as defined in s. 609.01.

632.84 History History: 1987 a. 156, 403; 1989 a. 31.

632.84 Cross-reference Cross-reference: See also s. Ins 3.55, Wis. adm. code.

632.845 632.845 Prohibiting refusal to cover services because liability policy may cover.

632.845(1) (1) In this section, “health care plan” has the meaning given in s. 628.36 (2) (a) 1.

632.845(2) (2) An insurer that provides coverage under a health care plan may not refuse to cover health care services that are provided to an insured under the plan and for which there is coverage under the plan on the basis that there may be coverage for the services under a liability insurance policy.

632.845 History History: 2009 a. 28.

632.85 632.85 Coverage without prior authorization for treatment of an emergency medical condition.

632.85(1) (1) In this section:

632.85(1)(a) (a) “Emergency medical condition” means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following:

632.85(1)(a)1. 1. Serious jeopardy to the person’s health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child.

632.85(1)(a)2. 2. Serious impairment to the person’s bodily functions.

632.85(1)(a)3. 3. Serious dysfunction of one or more of the person’s body organs or parts.

632.85(1)(b) (b) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1.

632.85(1)(c) (c) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town or school district.

632.85(2) (2) If a health care plan or a self-insured health plan provides coverage of any emergency medical services, the health care plan or self-insured health plan shall provide coverage of emergency medical services that are provided in a hospital emergency facility and that are needed to evaluate or stabilize, as defined in section 1867 of the federal Social Security Act, an emergency medical condition.

632.85(3) (3) A health care plan or a self-insured health plan that is required to provide the coverage under sub. (2) may not require prior authorization for the provision or coverage of the emergency medical services specified in sub. (2).

632.85 History History: 1997 a. 155.

632.853 632.853 Coverage of drugs and devices. A health care plan, as defined in s. 628.36 (2) (a) 1., or a self-insured health plan, as defined in s. 632.85 (1) (c), that provides coverage of only certain specified prescription drugs or devices shall develop a process through which a physician may present medical evidence to obtain an individual patient exception for coverage of a prescription drug or device not routinely covered by the plan. The process shall include timelines for both urgent and nonurgent review.

632.853 History History: 1997 a. 237.

632.855 632.855 Requirements if experimental treatment limited.

632.855(1) (1) Definitions. In this section:

632.855(1)(a) (a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1.

632.855(1)(b) (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

632.855(2) (2) Disclosure of limitations. Subject to s. 632.87 (6), a health care plan or a self-insured health plan that limits coverage of experimental treatment shall define the limitation and disclose the limits in any agreement, policy or certificate of coverage. This disclosure shall include the following information:

632.855(2)(a) (a) Who is authorized to make a determination on the limitation.

632.855(2)(b) (b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.

632.855(3) (3) Denial of treatment.

632.855(3)(am) (am) A health care plan or a self-insured health plan that receives a request for prior authorization of an experimental procedure that includes all of the required information upon which to make a decision shall, within 5 working days after receiving the request, issue a coverage decision. If the health care plan or self-insured health plan denies coverage of an experimental treatment, procedure, drug or device for an insured who has a terminal condition or illness, the health care plan or self-insured health plan shall, as part of its coverage decision, provide the insured with a denial letter that includes all of the following:

632.855(3)(am)1. 1. A statement setting forth the specific medical and scientific reasons for denying coverage.

632.855(3)(am)2. 2. Notice of the insured’s right to appeal and a description of the appeal procedure.

632.855(3)(bm) (bm) A health care plan or a self-insured health plan may not deny coverage under par. (am) of an experimental treatment, procedure, drug, or device for an insured if the denial violates s. 632.87 (6).

632.855 History History: 1997 a. 237; 2005 a. 194.

632.857 632.857 Explanation required for restriction or termination of coverage. If an insurer restricts or terminates an insured’s coverage for the treatment of a condition or complaint and, as a result, the insured becomes liable for payment for all of his or her treatment for the condition or complaint, the insurer shall provide on the explanation of benefits form a detailed explanation of the clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer’s restriction or termination of coverage.

632.857 History History: 2007 a. 20.

632.861 632.861 Prescription drug charges.

632.861(1) (1) Definitions. In this section:

632.861(1)(a) (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

632.861(1)(b) (b) “Enrollee” means an individual who is covered under a disability insurance policy or a self-insured health plan.

632.861(1)(c) (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

632.861(1)(d) (d) “Prescription drug” has the meaning given in s. 450.01 (20).

632.861(1)(e) (e) “Prescription drug benefit” has the meaning given in s. 632.865 (1) (e).

632.861(1)(f) (f) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

632.861(2) (2) Allowing disclosures.

632.861(2)(a) (a) A disability insurance policy or self-insured health plan that provides a prescription drug benefit may not restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.

632.861(2)(b) (b) A disability insurance policy or self-insured health plan that provides a prescription drug benefit shall ensure that any pharmacy benefit manager that provides services under a contract with the policy or plan does not, with respect to such policy or plan, restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.

632.861(3) (3) Cost-sharing limitation. A disability insurance policy or self-insured health plan that provides a prescription drug benefit or a pharmacy benefit manager that provides services under a contract with a policy or plan may not require an enrollee to pay at the point of sale for a covered prescription drug an amount that is greater than the lowest of all of the following amounts:

632.861(3)(a) (a) The cost-sharing amount for the prescription drug for the enrollee under the policy or plan.

632.861(3)(b) (b) The amount a person would pay for the prescription drug if the enrollee purchased the prescription drug at the dispensing pharmacy without using any health plan or health insurance coverage.

632.861(4) (4) Drug substitution.

632.861(4)(a) (a) Except as provided in par. (b), a disability insurance policy that offers a prescription drug benefit, a self-insured health plan that offers a prescription drug benefit, or a pharmacy benefit manager acting on behalf of a disability insurance policy or self-insured health plan shall provide to an enrollee advanced written notice of a formulary change that removes a prescription drug from the formulary of the policy or plan or that reassigns a prescription drug to a benefit tier for the policy or plan that has a higher deductible, copayment, or coinsurance. The advanced written notice of a formulary change under this paragraph shall be provided no fewer than 30 days before the expected date of the removal or reassignment and shall include information on the procedure for the enrollee to request an exception to the formulary change. The policy, plan, or pharmacy benefit manager is required to provide the advanced written notice under this paragraph only to those enrollees in the policy or plan who are using the drug at the time the notification must be sent according to available claims history.

632.861(4)(b) (b)

632.861(4)(b)1. 1. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if the prescription drug that is to be removed or reassigned is any of the following:

632.861(4)(b)1.a. a. No longer approved by the federal food and drug administration.