Chapter 632

632.895(4)(b) (b) No insurer is required to duplicate coverage available under the federal medicare program, nor duplicate any other insurance coverage the insured may have. Other insurance coverage does not include public assistance under ch. 49.

632.895(4)(c) (c) Coverage under this subsection may not be subject to exclusions or limitations, including deductibles and coinsurance factors, which are not generally applicable to other conditions covered under the policy.

632.895(4)(d) (d) The department of health services may by rule impose reasonable standards for the treatment of kidney diseases required to be covered under this subsection, which shall not be inconsistent with or less stringent than applicable federal standards.

632.895(5) (5) Coverage of newborn infants.

632.895(5)(a) (a) Every disability insurance policy shall provide coverage for a newly born child of the insured from the moment of birth.

632.895(5)(b) (b) Coverage for newly born children required under this subsection shall consider congenital defects and birth abnormalities as an injury or sickness under the policy and shall cover functional repair or restoration of any body part when necessary to achieve normal body functioning, but shall not cover cosmetic surgery performed only to improve appearance.

632.895(5)(c) (c) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy may require that notification of the birth of a child and payment of the required premium or fees shall be furnished to the insurer within 60 days after the date of birth. The insurer may refuse to continue coverage beyond the 60-day period if such notification is not received, unless within one year after the birth of the child the insured makes all past-due payments and in addition pays interest on such payments at the rate of 5 1/2 percent per year.

632.895(5)(d) (d) If payment of a specific premium or subscription fee is not required to provide coverage for a child, the policy or contract may request notification of the birth of a child but may not deny or refuse to continue coverage if such notification is not furnished.

632.895(5)(e) (e) This subsection applies to all policies issued or renewed after May 5, 1976, and to all policies in existence on June 1, 1976. All policies issued or renewed after June 1, 1976, shall be amended to comply with the requirements of this subsection.

632.895(5m) (5m) Coverage of grandchildren. Every disability insurance policy issued or renewed on or after May 7, 1986, that provides coverage for any child of the insured shall provide the same coverage for all children of that child until that child is 18 years of age.

632.895(6) (6) Equipment and supplies for treatment of diabetes. Every disability insurance policy which provides coverage of expenses incurred for treatment of diabetes shall provide coverage for expenses incurred by the installation and use of an insulin infusion pump, coverage for all other equipment and supplies, including insulin or any other prescription medication, used in the treatment of diabetes, and coverage of diabetic self-management education programs. Coverage required under this subsection shall be subject to the same exclusions, limitations, deductibles, and coinsurance provisions of the policy as other covered expenses, except that insulin infusion pump coverage may be limited to the purchase of one pump per year and the insurer may require the insured to use a pump for 30 days before purchase.

632.895(7) (7) Maternity coverage. Every group disability insurance policy which provides maternity coverage shall provide maternity coverage for all persons covered under the policy. Coverage required under this subsection may not be subject to exclusions or limitations which are not applied to other maternity coverage under the policy.

632.895(8) (8) Coverage of mammograms.

632.895(8)(a) (a) In this subsection:

632.895(8)(a)1. 1. “Direction” means verbal or written instructions, standing orders or protocols.

632.895(8)(a)2. 2. “Low-dose mammography” means the X-ray examination of a breast using equipment dedicated specifically for mammography, including the X-ray tube, filter, compression device, screens, films and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with 2 views for each breast.

632.895(8)(a)3. 3. “Nurse practitioner” means an individual who is licensed as a registered nurse under ch. 441 or the laws of another state and who satisfies any of the following:

632.895(8)(a)3.a. a. Is certified as a primary care nurse practitioner or clinical nurse specialist by the American nurses’ association or by the national board of pediatric nurse practitioners and associates.

632.895(8)(a)3.am. am. Holds a master’s degree in nursing from an accredited school of nursing.

632.895(8)(a)3.b. b. Before March 31, 1990, has successfully completed a formal one-year academic program that prepares registered nurses to perform an expanded role in the delivery of primary care, includes at least 4 months of classroom instruction and a component of supervised clinical practice, and awards a degree, diploma or certificate to individuals who successfully complete the program.

632.895(8)(a)3.c. c. Has successfully completed a formal education program that is intended to prepare registered nurses to perform an expanded role in the delivery of primary care but that does not meet the requirements of subd. 3. b., and has performed an expanded role in the delivery of primary care for a total of 12 months during the 18-month period immediately before July 1, 1978.

632.895(8)(b) (b)

632.895(8)(b)1. 1. Except as provided in subd. 2. and par. (f), every disability insurance policy that provides coverage for a woman age 45 to 49 shall provide coverage for that woman of 2 examinations by low-dose mammography performed when the woman is age 45 to 49, if all of the following are satisfied:

632.895(8)(b)1.a. a. Each examination by low-dose mammography is performed at the direction of a licensed physician or a nurse practitioner, except as provided in par. (e).

632.895(8)(b)1.b. b. The woman has not had an examination by low-dose mammography within 2 years before each examination is performed.

632.895(8)(b)2. 2. A disability insurance policy need not provide coverage under subd. 1. to the extent that the woman had obtained one or more examinations by low-dose mammography while between the ages of 45 and 49 and before obtaining coverage under the disability insurance policy.

632.895(8)(c) (c) Except as provided in par. (f), every disability insurance policy that provides coverage for a woman age 50 or older shall provide coverage for that woman of an annual examination by low-dose mammography to screen for the presence of breast cancer, if the examination is performed at the direction of a licensed physician or a nurse practitioner or if par. (e) applies.

632.895(8)(d) (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c) and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy.

632.895(8)(e) (e) A disability insurance policy shall cover an examination by low-dose mammography that is not performed at the direction of a licensed physician or a nurse practitioner but that is otherwise required to be covered under par. (b) or (c), if all of the following are satisfied:

632.895(8)(e)1. 1. The woman does not have an assigned or regular physician or nurse practitioner when the examination is performed.

632.895(8)(e)2. 2. The woman designates a physician to receive the results of the examination.

632.895(8)(e)3. 3. Any examination by low-dose mammography previously obtained by the woman was at the direction of a licensed physician or a nurse practitioner.

632.895(8)(f) (f) This subsection does not apply to any of the following:

632.895(8)(f)1. 1. A disability insurance policy that only provides coverage of certain specified diseases.

632.895(8)(f)2. 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3).

632.895(8)(f)3. 3. A medicare replacement policy, a medicare supplement policy or a long-term care insurance policy.

632.895(9) (9) Drugs for treatment of HIV infection.

632.895(9)(a) (a) In this subsection, “HIV infection” means the pathological state produced by a human body in response to the presence of HIV, as defined in s. 631.90 (1).

632.895(9)(b) (b) Except as provided in par. (d), every disability insurance policy that is issued or renewed on or after April 28, 1990, and that provides coverage of prescription medication shall provide coverage for each drug that satisfies all of the following:

632.895(9)(b)1. 1. Is prescribed by the insured’s physician for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection.

632.895(9)(b)2. 2. Is approved by the federal food and drug administration for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection, including each investigational new drug that is approved under 21 CFR 312.34 to 312.36 for the treatment of HIV infection or an illness or medical condition arising from or related to HIV infection and that is in, or has completed, a phase 3 clinical investigation performed in accordance with 21 CFR 312.20 to 312.33.

632.895(9)(b)3. 3. If the drug is an investigational new drug described in subd. 2., is prescribed and administered in accordance with the treatment protocol approved for the investigational new drug under 21 CFR 312.34 to 312.36.

632.895(9)(c) (c) Coverage of a drug under par. (b) may be subject to any copayments and deductibles that the disability insurance policy applies generally to other prescription medication covered by the disability insurance policy.

632.895(9)(d) (d) This subsection does not apply to any of the following:

632.895(9)(d)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(9)(d)2. 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3).

632.895(9)(d)3. 3. A medicare replacement policy or a medicare supplement policy.

632.895(10) (10) Lead poisoning screening.

632.895(10)(a) (a) Except as provided in par. (b), every disability insurance policy and every health care benefits plan provided on a self-insured basis by a county board under s. 59.52 (11), by a city or village under s. 66.0137 (4), by a local governmental unit or technical college district under s. 66.0137 (4m), by a town under s. 60.23 (25), or by a school district under s. 120.13 (2) shall provide coverage for blood lead tests for children under 6 years of age, which shall be conducted in accordance with any recommended lead screening methods and intervals contained in any rules promulgated by the department of health services under s. 254.158.

632.895(10)(b) (b) This subsection does not apply to any of the following:

632.895(10)(b)1. 1. A disability insurance policy that covers only certain specified diseases.

632.895(10)(b)2. 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3).

632.895(10)(b)3. 3. A long-term care insurance policy, as defined in s. 600.03 (28g).

632.895(10)(b)4. 4. A medicare replacement policy, as defined in s. 600.03 (28p).

632.895(10)(b)5. 5. A medicare supplement policy, as defined in s. 600.03 (28r).

632.895(11) (11) Treatment for the correction of temporomandibular disorders.

632.895(11)(a) (a) Except as provided in par. (e), 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 procedure involving a bone, joint, muscle or tissue shall provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders if all of the following apply:

632.895(11)(a)1. 1. The condition is caused by congenital, developmental or acquired deformity, disease or injury.

632.895(11)(a)2. 2. Under the accepted standards of the profession of the health care provider rendering the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of the condition.

632.895(11)(a)3. 3. The purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction.

632.895(11)(b) (b)

632.895(11)(b)1. 1. The coverage required under this subsection for nonsurgical treatment includes coverage for prescribed intraoral splint therapy devices.

632.895(11)(b)2. 2. The coverage required under this subsection does not include coverage for cosmetic or elective orthodontic care, periodontic care or general dental care.

632.895(11)(c) (c)

632.895(11)(c)1. 1. 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(11)(c)2. 2. Notwithstanding subd. 1., the coverage required under this subsection for diagnostic procedures and medically necessary nonsurgical treatment for the correction of temporomandibular disorders may not exceed $1,250 annually.

632.895(11)(d) (d) Notwithstanding par. (c) 1., an insurer or a self-insured health plan of the state or a county, city, village, town or school district may require that an insured obtain prior authorization for any medically necessary surgical or nonsurgical treatment for the correction of temporomandibular disorders.

632.895(11)(e) (e) This subsection does not apply to any of the following:

632.895(11)(e)1. 1. A disability insurance policy that covers only dental care.

632.895(11)(e)2. 2. A medicare supplement policy, as defined in s. 600.03 (28r).

632.895(12) (12) Hospital and ambulatory surgery center charges and anesthetics for dental care.

632.895(12)(a) (a) In this subsection, “ambulatory surgery center” has the meaning given in 42 CFR 416.2.

632.895(12)(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, village, town or school district, shall cover hospital or ambulatory surgery center charges incurred, and anesthetics provided, in conjunction with dental care that is provided to a covered individual in a hospital or ambulatory surgery center, if any of the following applies:

632.895(12)(b)1. 1. The individual is a child under the age of 5.

632.895(12)(b)2. 2. The individual has a chronic disability that meets all of the conditions under s. 230.04 (9r) (a) 2. a., b. and c.

632.895(12)(b)3. 3. The individual has a medical condition that requires hospitalization or general anesthesia for dental care.

632.895(12)(c) (c) 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 plan.

632.895(12)(d) (d) This subsection does not apply to a disability insurance policy that covers only dental care.

632.895(12m) (12m) Treatment for autism spectrum disorders.

632.895(12m)(a) (a) In this subsection:

632.895(12m)(a)1. 1. “Autism spectrum disorder” means any of the following:

632.895(12m)(a)1.a. a. Autism disorder.

632.895(12m)(a)1.b. b. Asperger’s syndrome.

632.895(12m)(a)1.c. c. Pervasive developmental disorder not otherwise specified.

632.895(12m)(a)2. 2. “Insured” includes an enrollee and a dependent with coverage under the disability insurance policy or self-insured health plan.

632.895(12m)(a)3. 3. “Intensive-level services” means evidence-based behavioral therapy that is designed to help an individual with autism spectrum disorder overcome the cognitive, social, and behavioral deficits associated with that disorder.

632.895(12m)(a)4. 4. “Nonintensive-level services” means evidence-based therapy that occurs after the completion of treatment with intensive-level services and that is designed to sustain and maximize gains made during treatment with intensive-level services or, for an individual who has not and will not receive intensive-level services, evidence-based therapy that will improve the individual’s condition.

632.895(12m)(a)5. 5. “Physician” has the meaning given in s. 146.34 (1) (g).

632.895(12m)(b) (b) Subject to pars. (c) and (d), and except as provided in par. (e), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, shall provide coverage for an insured of treatment for the mental health condition of autism spectrum disorder if the treatment is prescribed by a physician and provided by any of the following who are qualified to provide intensive-level services or nonintensive-level services: