632.87(1)(1) No insurer may refuse to provide or pay for benefits for health care services provided by a licensed health care professional on the ground that the services were not rendered by a physician as defined in s. 990.01 (28), unless the contract clearly excludes services by such practitioners, but no contract or plan may exclude services in violation of sub. (2), (2m), (3), (4), (4m), (5), or (6). 632.87(2)(2) No insurer may, under a contract or plan covering vision care services or procedures, refuse to provide coverage for vision care services or procedures provided by an optometrist licensed under ch. 449 within the scope of the practice of optometry, as defined in s. 449.01 (1), if the contract or plan includes coverage for the same services or procedures when provided by another health care provider. 632.87(2m)(2m) No health maintenance organization or preferred provider plan that provides vision care services or procedures within the scope of the practice of optometry, as defined in s. 449.01 (1), may do any of the following: 632.87(2m)(am)(am) Fail to provide to persons covered by the health maintenance organization or preferred provider plan, at the time of enrollment and annually thereafter, a listing of then participating vision care providers, including participating optometrists, setting forth the names of the vision care providers in alphabetical order by last name and their respective business addresses and telephone numbers, with the listing of participating vision care providers to be incorporated in any listing of all participating health care providers that includes the same information regarding all providers, if such listing is provided at the time of enrollment and annually thereafter, or with the listing of participating vision care providers otherwise to be provided separately. 632.87(2m)(b)(b) Fail to provide to persons covered by the health maintenance organization or preferred provider plan, at the time vision care services or procedures are needed, the opportunity to choose optometrists from the listing under par. (am) from whom the persons may obtain covered vision care services and procedures within the scope of the practice of optometry, as defined in s. 449.01 (1). 632.87(2m)(c)(c) Fail to include as participating providers in the health maintenance organization or preferred provider plan optometrists licensed under ch. 449 in sufficient numbers to meet the demand of persons covered by the health maintenance organization or preferred provider plan for optometric services. 632.87(2m)(d)(d) When vision care services or procedures are deemed appropriate by the health maintenance organization or preferred provider plan, restrict or discourage a person covered by the health maintenance organization or preferred provider plan from obtaining covered vision care services or procedures, within the scope of the practice of optometry as defined in s. 449.01 (1), from participating optometrists solely on the basis that the providers are optometrists. 632.87(3)(a)(a) No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by a licensed physician or osteopath, even if different nomenclature is used to describe the condition or complaint. Examination by or referral from a physician shall not be a condition precedent for receipt of chiropractic care under this paragraph. This paragraph does not: 632.87(3)(a)1.1. Prohibit the application of deductibles or coinsurance provisions to chiropractic and physician charges on an equal basis. 632.87(3)(a)2.2. Prohibit the application of cost containment or quality assurance measures to chiropractic services in a manner that is consistent with cost containment or quality assurance measures generally applicable to physician services and that is consistent with this section. 632.87(3)(b)(b) No insurer, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, may do any of the following: 632.87(3)(b)1.1. Restrict or terminate coverage for the treatment of a condition or a complaint by a licensed chiropractor within the scope of the chiropractor’s professional license on the basis of other than an examination or evaluation by or a recommendation of a licensed chiropractor or a peer review committee that includes a licensed chiropractor. 632.87(3)(b)2.2. Refuse to provide coverage to an individual because that individual has been treated by a chiropractor. 632.87(3)(b)3.3. Establish underwriting standards that are more restrictive for chiropractic care than for care provided by other health care providers. 632.87(3)(b)4.4. Exclude or restrict health care coverage of a health condition solely because the condition may be treated by a chiropractor. 632.87(3)(c)(c) An exclusion or a restriction that violates par. (b) is void in its entirety. 632.87(4)(4) No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed dentist or dental therapist within the scope of the dentist’s or dental therapist’s license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by another health care provider, as defined in s. 146.81 (1) (a) to (p). 632.87(4m)(4m) No policy, plan, or contract may exclude coverage for mental health or behavioral health treatment or services provided by the charter school established under a contract under s. 118.40 (2x) (cm), if the policy, plan, or contract covers the mental health or behavioral health treatment or services when provided by another health care provider, as defined in s. 146.81 (1) (a) to (p). The operator of the charter school established under a contract under s. 118.40 (2x) (cm) shall, upon the enrollment of a pupil in the charter school, notify the policy, plan, or contract that covers the pupil’s mental health or behavioral health treatment or services of the services that the policy, plan, or contract may be required to cover under this subsection. If requested by a policy, plan, or contract, an operator of the charter school established under a contract under s. 118.40 (2x) (cm) shall enter into a memorandum of understanding with a policy, plan, or contract on matters other than the coverage required under this subsection, including reimbursement, payment terms, and compliance with state and federal patient health information privacy laws. 632.87(5)(5) No insurer or self-insured school district, city or village may, under a policy, plan or contract covering gynecological services or procedures, exclude or refuse to provide coverage for Papanicolaou tests, pelvic examinations or associated laboratory fees when the test or examination is performed by a licensed nurse practitioner, as defined in s. 632.895 (8) (a) 3., within the scope of the nurse practitioner’s professional license, if the policy, plan or contract includes coverage for Papanicolaou tests, pelvic examinations or associated laboratory fees when the test or examination is performed by a physician. 632.87(6)(a)1.1. Except as provided in subd. 2., in this subsection, “routine patient care” means all of the following: 632.87(6)(a)1.a.a. All health care services, items, and drugs for the treatment of cancer. 632.87(6)(a)1.b.b. All health care services, items, and drugs that are typically provided in health care; including health care services, items, and drugs provided to a patient during the course of treatment in a cancer clinical trial for a condition or any of its complications; and that are consistent with the usual and customary standard of care, including the type and frequency of any diagnostic modality. 632.87(6)(a)2.2. “Routine patient care” does not include the health care service, item, or investigational drug that is the subject of the cancer clinical trial; any health care service, item, or drug provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient; an investigational drug or device that has not been approved for market by the federal food and drug administration; transportation, lodging, food, or other expenses for the patient or a family member or companion of the patient that are associated with travel to or from a facility providing the cancer clinical trial; any services, items, or drugs provided by the cancer clinical trial sponsors free of charge for any patient; or any services, items, or drugs that are eligible for reimbursement by a person other than the insurer, including the sponsor of the cancer clinical trial. 632.87(6)(b)(b) No policy, plan, or contract may exclude coverage for the cost of any routine patient care that is administered to an insured in a cancer clinical trial satisfying the criteria under par. (c) and that would be covered under the policy, plan, or contract if the insured were not enrolled in a cancer clinical trial. 632.87(6)(c)(c) A cancer clinical trial under par. (b) must satisfy all of the following criteria: 632.87(6)(c)1.1. A purpose of the trial is to test whether the intervention potentially improves the trial participant’s health outcomes. 632.87(6)(c)2.2. The treatment provided as part of the trial is given with the intention of improving the trial participant’s health outcomes. 632.87(6)(c)3.3. The trial has therapeutic intent and is not designed exclusively to test toxicity or disease pathophysiology. 632.87(6)(c)4.a.a. Tests how to administer a health care service, item, or drug for the treatment of cancer. 632.87(6)(c)4.b.b. Tests responses to a health care service, item, or drug for the treatment of cancer. 632.87(6)(c)4.c.c. Compares the effectiveness of health care services, items, or drugs for the treatment of cancer with that of other health care services, items, or drugs for the treatment of cancer. 632.87(6)(c)4.d.d. Studies new uses of health care services, items, or drugs for the treatment of cancer. 632.87(6)(c)5.a.a. A National Institute of Health, or one of its cooperative groups or centers, under the federal department of health and human services. 632.87(6)(d)1.1. The coverage that may not be excluded under this subsection shall apply to all phases of a cancer clinical trial. 632.87(6)(d)2.2. The coverage that may not be excluded under this subsection is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to any other coverage under the policy, plan, or contract, including the treatment under the policy, plan, or contract of services performed by participating and nonparticipating providers. 632.87(6)(e)1.1. Nothing in the subsection requires a policy, plan, or contract to offer; or prohibits a policy, plan, or contract from offering; cancer clinical trial services by a participating provider. 632.87(6)(e)2.2. Nothing in this subsection requires services that are performed in a cancer clinical trial by a nonparticipating provider of a policy, plan, or contract to be reimbursed at the same rate as a participating provider of the policy, plan, or contract. 632.87 AnnotationLegislative Council Note, 1975: This [sub. (1)] continues (and expands the scope of) s. 207.04 (1) (k) [repealed by this act], which does not deal with an unfair marketing practice but an unduly restrictive interpretation of an insurance contract. Presently it applies only to podiatrists but the same principles apply to all health care professionals. Since the legislature has licensed podiatrists (s. 448.10 et. seq.), as well as other health care professionals who are not physicians, applicable insurance contracts should provide benefits for their services or payment to them, as well as for those of physicians, unless they are specifically and clearly excluded by a policy which has been approved by the commissioner. But general principles of freedom of contract should be operative if the contract is clear enough. Parties negotiating for insurance coverage should be free to decide what kind of health care services they want and are willing to pay for. [Bill 16-S]
632.873632.873 Restrictions relating to fees for dental services. 632.873(1)(1) Definitions. In this section, unless the context requires otherwise: 632.873(1)(a)(a) “Covered service” means, with respect to dental or related services specified in a policy or plan that provides coverage for those services, a service provided by a dentist or at the direction of a dentist to an insured under the policy or an enrollee of the plan for which the policy or plan makes payment, administered consistently with policies traditionally governing covered services, or for which the policy or plan would make payment but for the application of contractual limitations of deductibles, copayments, coinsurance, waiting periods, annual maximums, lifetime maximums applicable to the same course of treatment, frequency limitations, or alternative benefit payments. 632.873(1)(b)(b) “Policy” means a policy, certificate, or contract of insurance that provides only limited-scope dental benefits. 632.873(1)(c)(c) “Related service” means a service that is commonly provided, by a dentist or at the direction of a dentist, in conjunction with a dental service. 632.873(2)(a)1.1. A contract between an insurer offering a policy that provides coverage for dental and related services and a dentist for the provision of dental and related services to an insured under the policy may not require the dentist to provide a service to an insured under the policy at a fee set by the insurer unless the service is a covered service under the policy. 632.873(2)(a)2.2. A policy that provides coverage for dental and related services may not provide nominal or de minimis coverage for a dental or related service for the sole purpose of avoiding the requirements under subd. 1. 632.873(2)(b)(b) An administrator providing 3rd-party administration services or a provider network for a plan that provides coverage for dental and related services may not require any dentist in the administrator’s provider network that is eligible to provide services under the plan to charge set fees for dental or related services provided to enrollees of the plan that are not covered services under the plan. 632.873(3)(3) Prohibition on charges. A dentist who, under a contract with an insurer offering a policy that provides coverage for dental and related services, provides dental or related services to an insured under the policy may not charge the insured more than the dentist’s usual nondiscounted fee for a dental or related service that is not a covered service under the policy. 632.873 HistoryHistory: 2013 a. 26. 632.875632.875 Independent evaluations relating to chiropractic treatment. 632.875(1)(a)(a) “Chiropractor” means a person licensed to practice chiropractic under ch. 446. 632.875(1)(b)(b) “Independent evaluation” means an examination or evaluation by or recommendation of a chiropractor or a peer review committee under s. 632.87 (3) (b) 1. 632.875(1)(c)(c) “Patient” means a person whose treatment by a chiropractor is the subject of an independent evaluation. 632.875(1)(d)(d) “Treating chiropractor” means a chiropractor who is treating a patient and whose treatment of the patient is the subject of an independent evaluation. 632.875(2)(2) If, on the basis of an independent evaluation, an insurer restricts or terminates a patient’s coverage for the treatment of a condition or complaint by a chiropractor acting within the scope of his or her license and the restriction or termination of coverage results in the patient becoming liable for payment for his or her treatment, the insurer shall, within the time required under s. 628.46 (2m), provide to the patient and to the treating chiropractor a written statement that contains all of the following: 632.875(2)(d)(d) A description of the insurer’s internal appeal process that is available to the patient. 632.875(2)(e)(e) A statement indicating that the patient may, no later than 30 days after receiving the statement required under this subsection, request an internal appeal of the insurer’s restriction or termination of coverage. 632.875(2)(f)(f) The address to which the patient should send the request for an appeal. 632.875(2)(g)(g) 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. 632.875(2)(h)(h) A list of records and documents reviewed as part of the independent evaluation. 632.875(3)(a)(a) In this subsection, “claim” means a patient’s claim for coverage, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, the restriction or termination of which coverage is the subject of an independent evaluation. 632.875(3)(b)(b) A chiropractor who conducts an independent evaluation may not be compensated by an insurer based on a percentage of the dollar amount by which a claim is reduced as a result of the independent evaluation. 632.875(4)(4) Subject to sub. (2) (e), an insurer shall make available to a patient an internal procedure by which the patient may appeal an insurer’s decision to restrict or terminate coverage. 632.875(5)(5) This section does not apply to any of the following: 632.875(5)(b)(b) Any line of property and casualty insurance except disability insurance. In this paragraph, “disability insurance” does not include uninsured motorist coverage, underinsured motorist coverage or medical payment coverage. 632.88632.88 Policy extension for handicapped children. 632.88(1)(1) Termination of coverage. Every hospital or medical expense insurance policy or contract that provides that coverage of a dependent child of a person insured under the policy shall terminate upon attainment of a limiting age for dependent children specified in the policy shall also provide that the age limitation may not operate to terminate the coverage of a dependent child while the child is and continues to be both: 632.88(1)(a)(a) Incapable of self-sustaining employment because of intellectual disability or physical handicap; and 632.88(1)(b)(b) Chiefly dependent upon the person insured under the policy for support and maintenance. 632.88(2)(2) Proof of incapacity. The insurer may require that proof of the incapacity and dependency be furnished by the person insured under the policy within 31 days of the date the child attains the limiting age, and at any time thereafter except that the insurer may not require proof more frequently than annually after the 2-year period immediately following attainment of the limiting age by the child.
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