Chapter 632

632.895(14)(a)1.f. f. Mumps.

632.895(14)(a)1.g. g. Rubella.

632.895(14)(a)1.h. h. Hemophilus influenza B.

632.895(14)(a)1.i. i. Hepatitis B.

632.895(14)(a)1.j. j. Varicella.

632.895(14)(a)2. 2. “Dependent” means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.

632.895(14)(b) (b) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for a dependent who is a child of the insured.

632.895(14)(c) (c) The coverage required under par. (b) may not be subject to any deductibles, copayments, or coinsurance under the policy or plan. This paragraph applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in s. 609.01 (3m), in the plan.

632.895(14)(d) (d) This subsection does not apply to any of the following:

632.895(14)(d)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(14)(d)2. 2. A disability insurance policy that covers only hospital and surgical charges.

632.895(14)(d)3. 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

632.895(14)(d)4. 4. A long-term care insurance policy, as defined in s. 600.03 (28g).

632.895(14)(d)5. 5. A medicare replacement policy, as defined in s. 600.03 (28p).

632.895(14)(d)6. 6. A medicare supplement policy, as defined in s. 600.03 (28r).

632.895(14g) (14g) Coverage of COVID-19 testing.

632.895(14g)(a) (a) In this subsection, “COVID-19” means an infection caused by the SARS-CoV-2 coronavirus.

632.895(14g)(b) (b) Before March 13, 2021, every disability insurance policy, and every self-insured health plan of the state or of a county, city, town, village, or school district, that generally covers testing for infectious diseases shall provide coverage of testing for COVID-19 without imposing any copayment or coinsurance on the individual covered under the policy or plan.

632.895(15) (15) Coverage of student on medical leave.

632.895(15)(a) (a) Subject to pars. (b) and (c), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a person as a dependent of the insured because the person is a full-time student, including the coverage under s. 632.885 (2) (b), shall continue to provide dependent coverage for the person if, due to a medically necessary leave of absence, he or she ceases to be a full-time student.

632.895(15)(b) (b) A policy or plan is not required to continue coverage under par. (a) unless the person submits documentation and certification of the medical necessity of the leave of absence from the person’s attending physician. The date on which the person ceases to be a full-time student due to the medically necessary leave of absence shall be the date on which the coverage continuation under par. (a) begins.

632.895(15)(c) (c) A policy or plan is required to continue coverage under par. (a) only until any of the following occurs:

632.895(15)(c)1. 1. The person advises the policy or plan that he or she does not intend to return to school full time.

632.895(15)(c)2. 2. The person becomes employed full time.

632.895(15)(c)3. 3. The person obtains other health care coverage.

632.895(15)(c)4. 4. The person marries and is eligible for coverage under his or her spouse’s health care coverage.

632.895(15)(c)5. 5. Except for a person who has coverage as a dependent under s. 632.885 (2) (b), the person reaches the age at which coverage as a dependent who is a full-time student would otherwise end under the terms and conditions of the policy or plan.

632.895(15)(c)6. 6. Coverage of the insured through whom the person has dependent coverage under the policy or plan is discontinued or not renewed.

632.895(15)(c)7. 7. One year has elapsed since the person’s coverage continuation under par. (a) began and the person has not returned to school full time.

632.895(16) (16) Hearing aids, cochlear implants, and related treatment for infants and children.

632.895(16)(a) (a) In this subsection:

632.895(16)(a)1. 1. “Cochlear implant” includes any implantable instrument or device that is designed to enhance hearing.

632.895(16)(a)2. 2. “Hearing aid” means any externally wearable instrument or device designed for or offered for the purpose of aiding or compensating for impaired human hearing and any parts, attachments, or accessories of such an instrument or device, except batteries and cords.

632.895(16)(a)3. 3. “Physician” has the meaning given in s. 448.01 (5).

632.895(16)(a)4. 4. “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

632.895(16)(a)5. 5. “Treatment” means services, diagnoses, procedures, surgery, and therapy provided by a health care professional.

632.895(16)(b) (b)

632.895(16)(b)1. 1. Except as provided in par. (c), every disability insurance policy and every self-insured health plan shall provide the following coverages:

632.895(16)(b)1.a. a. Coverage of the cost of hearing aids and cochlear implants that are prescribed by a physician, or by an audiologist who is licensed under subch. II of ch. 459 or who holds a compact privilege under subch. III of ch. 459, in accordance with accepted professional medical or audiological standards, for a child covered under the policy or plan who is under 18 years of age and who is certified as deaf or hearing impaired by a physician or by an audiologist who is licensed under subch. II of ch. 459 or who holds a compact privilege under subch. III of ch. 459.

632.895(16)(b)1.b. b. Coverage of the cost of treatment related to hearing aids and cochlear implants, including procedures for the implantation of cochlear devices, for a child specified in subd. 1. a.

632.895(16)(b)2. 2. Coverage of the cost of hearing aids under this subsection is not required to exceed the cost of one hearing aid per ear per child more often than once every 3 years.

632.895(16)(b)3. 3. The coverage required under this subsection may be subject to any cost-sharing provisions, limitations, or exclusions, other than a preexisting condition exclusion, that apply generally under the disability insurance policy or self-insured health plan.

632.895(16)(c) (c) This subsection does not apply to any of the following:

632.895(16)(c)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(16)(c)2. 2. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.

632.895(16)(c)3. 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

632.895(16)(c)4. 4. A long-term care insurance policy.

632.895(16)(c)5. 5. A medicare replacement policy or a medicare supplement policy.

632.895(16)(c)5m. 5m. An individual health benefit plan that is not renewable and that has a specified termination date that, including any extensions that the policyholder may elect without the insurer’s consent, is less than 12 months after the original effective date.

632.895(16m) (16m) Colorectal cancer screening.

632.895(16m)(a) (a) Except as provided in par. (c), every disability insurance policy, and every self-insured health plan of the state or a county, city, village, town, or school district, that provides coverage of any diagnostic or surgical procedures shall provide coverage of colorectal cancer examinations and laboratory tests, in accordance with guidelines specified by the commissioner by rule under par. (d) 1. and 3., for all of the following:

632.895(16m)(a)1. 1. An insured or enrollee who is 50 years of age or older.

632.895(16m)(a)2. 2. An insured or enrollee who is under 50 years of age and at high risk for colorectal cancer, as specified by the commissioner by rule under par. (d) 2. and 3.

632.895(16m)(b) (b) The coverage required under this subsection may be subject to any limitations, exclusions, or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan.

632.895(16m)(c) (c) This subsection does not apply to any of the following:

632.895(16m)(c)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(16m)(c)2. 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

632.895(16m)(c)3. 3. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.

632.895(16m)(d) (d) The commissioner, in consultation with the secretary of health services and after considering nationally validated guidelines, including guidelines issued by the American Cancer Society for colorectal cancer screening, shall promulgate rules that do all of the following:

632.895(16m)(d)1. 1. Specify guidelines for the colorectal cancer screening that must be covered under this subsection.

632.895(16m)(d)2. 2. Specify the factors for determining whether an individual is at high risk for colorectal cancer.

632.895(16m)(d)3. 3. Periodically update the guidelines under subd. 1. and the factors under subd. 2., as medically appropriate.

632.895 Cross-reference Cross-reference: See also s. Ins 3.35, Wis. adm. code.

632.895(16t) (16t) Prescription eye drops. Every disability insurance policy and every self-insured health plan of the state or of a county, city, town, village, or school district that provides coverage of prescription eye drops shall cover a refill of the prescription eye drops that satisfies all of the following:

632.895(16t)(a) (a) The refill is requested by the insured or plan participant when 75 percent or more of the days have elapsed from the later of the original date the prescription was distributed to the insured or plan participant or the date on which the most recent refill was distributed to the insured or plan participant.

632.895(16t)(b) (b) The prescription allows for a refill of the prescription eye drops.

632.895(16t)(c) (c) The requested refill does not exceed the number of refills allowed by the prescription.

632.895(16v) (16v) Prohibiting coverage limitations on prescription drugs.

632.895(16v)(a) (a) During the period covered by the state of emergency related to public health declared by the governor on March 12, 2020, by executive order 72, an insurer offering a disability insurance policy that covers prescription drugs, a self-insured health plan of the state or of a county, city, town, village, or school district that covers prescription drugs, or a pharmacy benefit manager acting on behalf of a policy or plan may not do any of the following in order to maintain coverage of a prescription drug:

632.895(16v)(a)1. 1. Require prior authorization for early refills of a prescription drug or otherwise restrict the period of time in which a prescription drug may be refilled.

632.895(16v)(a)2. 2. Impose a limit on the quantity of prescription drugs that may be obtained if the quantity is no more than a 90-day supply.

632.895(16v)(b) (b) This subsection does not apply to a prescription drug that is a controlled substance, as defined in s. 961.01 (4).

632.895(17) (17) Contraceptives and services.

632.895(17)(a) (a) In this subsection, “contraceptives” means drugs or devices approved by the federal food and drug administration to prevent pregnancy.

632.895(17)(b) (b) Every disability insurance policy, and every self-insured health plan of the state or of a county, city, town, village, or school district, that provides coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices shall provide coverage for all of the following:

632.895(17)(b)1. 1. Contraceptives prescribed by a health care provider, as defined in s. 146.81 (1).

632.895(17)(b)2. 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan.

632.895(17)(c) (c) Coverage under par. (b) may be subject only to the exclusions, limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan.

632.895(17)(d) (d) This subsection does not apply to any of the following:

632.895(17)(d)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(17)(d)2. 2. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.

632.895(17)(d)3. 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

632.895(17)(d)4. 4. A long-term care insurance policy.

632.895(17)(d)5. 5. A Medicare replacement policy or a Medicare supplement policy.

632.895 History History: 1981 c. 39 ss. 4 to 12, 18, 20; 1981 c. 85, 99; 1981 c. 314 ss. 122, 123, 125; 1983 a. 36, 429; 1985 a. 29, 56, 311; 1987 a. 195, 327, 403; 1989 a. 129, 201, 229, 316, 332, 359; 1991 a. 32, 45, 123; 1993 a. 443, 450; 1995 a. 27 ss. 7048, 9126 (19); 1995 a. 201, 225; 1997 a. 27, 35, 75, 175, 237; 1999 a. 32, 115; 1999 a. 150 s. 672; 2001 a. 16, 82; 2007 a. 20 s. 9121 (6) (a); 2007 a. 36, 153; 2009 a. 14, 28, 282, 346; 2011 a. 260 s. 80; 2015 a. 55; 2017 a. 305; 2019 a. 185; 2023 a. 56.

632.895 Cross-reference Cross-reference: See also ss. Ins 3.38 and 3.54, Wis. adm. code.

632.895 Annotation The commissioner can reasonably construe sub. (3) to require an insurer to pay a facility’s charge for care up to the maximum Department of Health and Social Services rate. Mutual Benefit Life Ins. Co. v. OCI, 151 Wis. 2d 411, 444 N.W.2d 450 (Ct. App. 1989).

632.895 Annotation Sub. (2) (g) does not prohibit an insurer from contracting away the right to review medical necessity. The provision does not apply until the insurer has shown that its own determination is relevant to a insurance contract. Schroeder v. Blue Cross & Blue Shield United of Wisconsin, 153 Wis. 2d 165, 450 N.W.2d 470 (Ct. App. 1989).

632.895 Annotation Sub. (7) permits an insurer to exclude or limit certain services and procedures, as long as the exclusion or limitation applies to all policies. However, an insurer may not make routine maternity services that are generally covered under the policy unavailable to a specific subgroup of insureds, surrogate mothers, based solely on the insured’s reasons for becoming pregnant or the method used to achieve pregnancy. Mercycare Insurance Co. v. OCI, 2010 WI 87, 328 Wis. 2d 110, 786 N.W.2d 785, 08-2937.