Chapter 632

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.

632.896 632.896 Mandatory coverage of adopted children.

632.896(1) (1) Definitions. In this section:

632.896(1)(a) (a) “Department” means the department of health services.

632.896(1)(b) (b) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

632.896(1)(c) (c) “Placed for adoption” means any of the following:

632.896(1)(c)1. 1. The department, a county department under s. 48.57 (1) (e) or (hm), or a child welfare agency licensed under s. 48.60 places a child in the insured’s home for adoption and enters into an agreement under s. 48.63 (3) (b) 4. or 48.833 (1) or (2) with the insured.

632.896(1)(c)2. 2. The department, a county department under s. 48.57 (1) (e) or (hm), or a child welfare agency under s. 48.837 (1r) places, or a court under s. 48.837 (4) (d) or (6) (b) orders, a child placed in the insured’s home for adoption.

632.896(1)(c)3. 3. A sending agency, as defined in s. 48.988 (2) (d), places a child in the insured’s home under s. 48.988 for adoption, or a public child placing agency, as defined in s. 48.99 (2) (r), or a private child placing agency, as defined in s. 48.99 (2) (p), of a sending state, as defined in s. 48.99 (2) (w), places a child in the insured’s home under s. 48.99 as a preliminary step to a possible adoption, and the insured takes physical custody of the child at any location within the United States.

632.896(1)(c)4. 4. The person bringing the child into this state has complied with s. 48.98, and the insured takes physical custody of the child at any location within the United States.

632.896(1)(c)5. 5. A court of a foreign jurisdiction appoints the insured as guardian of a child who is a citizen of that jurisdiction, and the child arrives in the insured’s home for the purpose of adoption by the insured under s. 48.839.

632.896(2) (2) Adopted or placed for adoption. Every disability insurance policy that is issued or renewed on or after March 1, 1991, and that provides coverage for dependent children of the insured, as defined in the disability insurance policy, shall cover adopted children of the insured and children placed for adoption with the insured, on the same terms and conditions, including exclusions, limitations, deductibles and copayments, as other dependent children, except as provided in subs. (3) to (6).

632.896(3) (3) When coverage begins and ends.

632.896(3)(a) (a)

632.896(3)(a)1. 1. Coverage of a child under this section shall begin on the date that a court makes a final order granting adoption of the child by the insured or on the date that the child is placed for adoption with the insured, whichever occurs first.

632.896(3)(a)2. 2. Subdivision 1. does not require coverage to begin before coverage is available under the disability insurance policy for other dependent children.

632.896(3)(b) (b) Coverage of a child placed for adoption with the insured is required under this section despite whether a court ultimately makes a final order granting adoption of the child by the insured. If adoption of a child who is placed for adoption with the insured is not finalized, the insurer may terminate coverage of the child when the child’s adoptive placement with the insured terminates.

632.896(4) (4) Preexisting conditions. Notwithstanding ss. 632.746 and 632.76 (2) (a), a disability insurance policy that is subject to sub. (2) and that is in effect when a court makes a final order granting adoption or when the child is placed for adoption may not exclude or limit coverage of a disease or physical condition of the child on the ground that the disease or physical condition existed before coverage is required to begin under sub. (3).

632.896(6) (6) Notice to insurer. The disability insurance policy may require the insured to notify the insurer that a child is adopted or placed for adoption and to pay the insurer any premium or fees required to provide coverage for the child, within 60 days after coverage is required to begin under sub. (3). If the insured fails to give notice or make payment within 60 days as required by the disability insurance policy in accordance with this subsection, the disability insurance policy shall treat the adopted child or child placed for adoption no less favorably than it treats other dependents, other than newborn children, who seek coverage at a time other than when the dependent was first eligible to apply for coverage.

632.896 History History: 1989 a. 336; 1995 a. 27 s. 9126 (19); 1995 a. 289; 1997 a. 27; 2007 a. 20 s. 9121 (6) (a); 2007 a. 186; 2009 a. 339.

632.897 632.897 Hospital and medical coverage for persons insured under individual and group policies.

632.897(1) (1) In this section:

632.897(1)(ac) (ac) “Custodial parent” means the parent of a child who has been awarded physical placement with the child for more than 50 percent of the time.

632.897(1)(am) (am) “Dependent” means a person who is or would be covered as a dependent of a group member under the terms of the group policy including, but not limited to, age limits, if the group member continues or had continued as a member of the group.

632.897(1)(b) (b) “Employer” means the policyholder in the case of a group policy as defined in par. (c) 1. or 1m. and the sponsor in the case of a group policy as defined in par. (c) 2. or 3.

632.897(1)(c) (c) “Group policy” means:

632.897(1)(c)1. 1. An insurance policy issued by an insurer to a policyholder on behalf of a group whose members thereby receive hospital or medical coverage on either an expense incurred or service basis, other than for specified diseases or for accidental injuries;

632.897(1)(c)1m. 1m. A long-term care insurance policy issued by an insurer to a policyholder on behalf of a group;

632.897(1)(c)2. 2. An uninsured plan or program whereby a health maintenance organization, limited service health organization, preferred provider plan, labor union, religious community or other sponsor contracts to provide hospital or medical coverage to members of a group on either an expense incurred or service basis, other than for specified diseases or for accidental injuries; or

632.897(1)(c)3. 3. A plan or program whereby a sponsor arranges for the mass marketing of franchise insurance to members of a group related to one another through their relationship with the sponsor.

632.897(1)(cm) (cm) “Individual policy” means an insurance policy whereby an insured receives hospital or medical coverage on either an expense incurred or service basis, other than for specified diseases or for accidental injuries, and a long-term care insurance policy.

632.897(1)(d) (d) “Insurer” means the insurer in the case of a group policy as defined in par. (c) 1., 1m. or 3. and the sponsor in the case of a group policy as defined in par. (c) 2.

632.897(1)(e) (e) “Medicare” means coverage under both part A and part B of Title XVIII of the federal social security act, 42 USC 1395 et seq., as amended.

632.897(1)(em) (em) “Physical placement” has the meaning given in s. 767.001 (5).

632.897(1)(f) (f) “Terminated insured” means a person entitled to elect continued or conversion coverage under sub. (2) (b) or (9).

632.897(1m) (1m) Except as provided in sub. (10), this section applies to any group policy which would otherwise be exempt under s. 600.01 (1) (b) 3. if at least 150 of the certificate holders or insureds are residents of this state.

632.897(2) (2) 

632.897(2)(a) (a) No group policy which provides coverage to the spouse of the group member may contain a provision for termination of coverage for the spouse solely as a result of a break in their marital relationship except by reason of the entry of a judgment of divorce or annulment of their marriage.

632.897(2)(b) (b) An insurer issuing or renewing a group policy on or after May 14, 1980 and every insurer on and after the date which is 2 years after May 14, 1980 shall permit the following persons who have been continuously covered under a group policy for at least 3 months to elect to continue group policy coverage under sub. (3) or to convert to individual coverage under sub. (4):

632.897(2)(b)1. 1. The former spouse of a group member who otherwise would terminate coverage because of divorce or annulment.

632.897(2)(b)2. 2. A group member who would otherwise terminate eligibility for coverage under the group policy other than a group member who terminates eligibility for coverage due to discharge for misconduct shown in connection with his or her employment.

632.897(2)(b)3. 3. The spouse or dependent of a group member if the group member dies while covered by the group policy and the spouse or dependent was also covered.

632.897(2)(c) (c) Group policy coverage of a terminated insured who is entitled under par. (b) to elect continued group policy coverage or conversion to individual coverage and coverage of the spouse and dependents of the terminated insured provided for in the group policy continues until the terminated insured is notified under par. (d) of the right to elect continued or conversion coverage if the premium for the coverage continues to be paid.

632.897(2)(d) (d) If the employer is notified to terminate the coverage for any of the reasons provided under par. (b), the employer shall provide the terminated insured written notification of the right to continue group coverage or convert to individual coverage and the payment amounts required for either continued or converted coverage including the manner, place and time in which the payments shall be made. This notice shall be given not more than 5 days after the employer receives notice to terminate coverage. The payment amount for continued group coverage may not exceed the group rate in effect for a group member, including an employer’s contribution, if any, for a group policy as defined in sub. (1) (c) 1. or 1m. or the equivalent value of the monthly contribution of a group member to a group policy as defined in sub. (1) (c) 2. or the equivalent value of the monthly premium for franchise insurance as defined in sub. (1) (c) 3. The premium for converted coverage shall be determined in accordance with the insurer’s table of premium rates applicable to the age and class of risks of each person to be covered under that policy and to the type and amount of coverage provided. The notice may be sent to the terminated insured’s home address as shown on the records of the employer.

632.897(3) (3) 

632.897(3)(a) (a) If the terminated insured or, with respect to a minor, the parent or guardian of the terminated insured, elects to continue group coverage and tenders to the employer the amount required within 30 days after receiving notice under sub. (2) (d), coverage of the terminated insured and, if the terminated insured is eligible for continued coverage under sub. (2) (b) 2., coverage of the covered spouse and dependents of the terminated insured shall continue without interruption and may not terminate unless one of the following occurs:

632.897(3)(a)1. 1. The terminated insured establishes residence outside this state.

632.897(3)(a)2. 2. The terminated insured fails to make timely payment of a required premium amount.

632.897(3)(a)3. 3. The terminated insured is eligible for continued coverage under sub. (2) (b) 1. and the group member through whom the former spouse originally obtained coverage is no longer eligible for coverage by the group policy.

632.897(3)(a)4. 4. The terminated insured becomes eligible for similar coverage under another group policy.

632.897(3)(b) (b) If the coverage of the terminated insured is terminated under par. (a) 3. and the group member through whom the terminated insured originally obtained coverage becomes eligible for coverage by a replacement group policy providing coverage to the same group, the former spouse shall have the right to coverage by the replacement group policy as provided in this subsection.

632.897(3)(c) (c) If the right of the terminated insured to continue group policy coverage is terminated under par. (a) 3. and the group member does not become eligible for coverage by a replacement group policy, the terminated insured has the right to convert to individual coverage under sub. (4), unless sub. (4) (d) applies.

632.897(3)(d) (d) If the right of the terminated insured to continue group policy coverage is terminated under par. (a) 1. the terminated insured, and a spouse or dependent of the terminated insured, if the terminated insured was eligible for continued group coverage under sub. (2) (b) 2. and the spouse or dependent was covered under the group policy, have the right to convert to individual coverage under sub. (4), unless sub. (4) (d) applies.

632.897(3)(e) (e) This subsection does not require coverage of expenses which are covered by medicare.

632.897(4) (4) 

632.897(4)(a) (a) A terminated insured who elects conversion coverage under sub. (2) (b) or (3) (c) or (d), the spouse or dependent of such a terminated insured, if the terminated insured is eligible under sub. (2) (b) 2. and the spouse or dependent was covered under the group policy, and a terminated insured eligible under sub. (9) and his or her dependents are entitled to have the insurer issue to them, without evidence of insurability, individual coverage reasonably similar to the terminated coverage under the group policy or individual policy. Any probationary or waiting periods required by such individual coverage shall be considered as being met to the extent such limitations have been met under the prior group policy or individual policy.

632.897(4)(b) (b) The commissioner shall promulgate, by rule, 3 plans of individual coverage varying in degree of covered benefits to be offered as individual conversion policies. The insurer provides reasonably similar individual coverage if a person is offered his or her choice of the plans promulgated by the commissioner or is offered a high limit comprehensive plan of benefits regularly provided by the insurer for conversions and approved for this purpose by the commissioner. This paragraph does not apply if the policy being converted is a long-term care insurance policy.

632.897(4)(bm) (bm) The commissioner shall specify, by rule, the minimum standards that an individual conversion policy must satisfy if the policy being converted is a long-term care insurance policy. An insurer provides reasonably similar individual coverage to a person converting a long-term care insurance policy if the person is offered an individual conversion policy that complies with the rules promulgated under this paragraph.

632.897(4)(c) (c) If the first premium for conversion coverage is tendered to the insurer within 30 days after the notice of termination of group coverage, the individual conversion policy shall be issued with an effective date of the day following the termination of group or individual coverage.

632.897(4)(d) (d) This subsection does not require individual coverage to be offered by an insurer offering group policies only. This subsection does not require an insurer to issue an individual conversion policy covering a terminated insured or his or her spouse or dependent if benefits provided or available to the covered person under subds. 1. to 3., together with the converted policy’s benefits, would result in overinsurance according to the insurer’s standards for overinsurance, and these standards have been filed with and approved by the commissioner prior to use:

632.897(4)(d)1. 1. Similar benefits under another individual policy for which the terminated insured, spouse or dependent is eligible.

632.897(4)(d)2. 2. Similar benefits under a group policy for which the terminated insured, spouse or dependent is eligible.