Ins 8.70Ins 8.70 Purpose. This subchapter implements ch. 635, Stats., by establishing the basic health benefit plan that small employer insurers shall actively market and offer to small employers. Ins 8.70 HistoryHistory: Cr. Register, June, 1993, No. 450, eff. 7-1-93; correction in (intro.) made under 13.93 (2m) (b) 7., Stats., Register, March, 2000, No. 531. Ins 8.71(2)(2) In this subchapter, “health care provider” means any of the following: Ins 8.71(2)(a)(a) A medical or osteopathic physician, podiatrist, physical therapist or physician’s assistant licensed or certified under ch. 448, Stats. Ins 8.71(2)(f)(f) A nurse licensed under ch. 441, Stats., who is certified as a nurse anesthetist by the American association of nurse anesthetists. Ins 8.71 HistoryHistory: Cr. Register, June, 1993, No. 450, eff. 7-1-93; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register April 2004 No. 580. Ins 8.72Ins 8.72 Basic benefits. Subject to the limitations and restrictions under s. Ins 8.75 and copayments and coinsurance under s. Ins 8.77, each plan shall provide coverage for all of the following, if medically necessary: Ins 8.72(1)(1) Professional services by a health care provider acting within the scope and limitations of his or her license or certificate or a person acting under the direction of a health care provider, including all of the following: Ins 8.72(1)(a)(a) Office, outpatient, inpatient and emergency room visits including treatment rendered during those visits. Ins 8.72(1)(b)(b) Surgical services including postoperative care following inpatient or outpatient surgery. Ins 8.72(1)(c)(c) Services of an assistant surgeon if necessary to perform surgery. Ins 8.72(2)(2) Hospital care, including all of the following: Ins 8.72(2)(a)(a) Semi-private room, board and ancillary services and supplies that are generally provided to hospital inpatients. Ins 8.72(2)(b)(b) Confinement in an intensive care or coronary care unit of a hospital. Ins 8.72(2)(d)(d) Medical care and treatment provided in a hospital emergency room. Ins 8.72(4)(4) Outpatient x-ray, laboratory and other diagnostic tests. Ins 8.72(6)(6) Services provided by a home health agency licensed under s. 50.49, Stats. Ins 8.72(8)(8) Local ground licensed ambulance services. Ins 8.72(10)(10) Rental and purchase of durable medical equipment and supplies. Ins 8.72(12)(12) Reconstructive surgery which is either of the following: Ins 8.72(12)(a)(a) Incidental to or following surgery necessitated by illness or injury. Ins 8.72(12)(b)(b) Caused by a congenital disease or anomaly of a covered dependent child which results in a functional defect. Ins 8.72(14)(14) Maternity services including all of the following: Ins 8.72(14)(b)(b) Delivery services normally associated with a vaginal or caesarean section delivery. Ins 8.72(14)(c)(c) Routine nursery care from the moment of birth until the infant is discharged from the hospital. Ins 8.72(16)(16) Inpatient, outpatient and transitional treatment for nervous and mental disorders and alcoholism and other drug abuse, subject to s. Ins 8.75 (3). Ins 8.72(17)(17) Preventive services appropriate to the age and sex of the covered person including all of the following: Ins 8.72(17)(a)(a) Routine physical examinations and health screening tests. Ins 8.72(17)(b)(b) Immunizations for poliomyelitis, diphtheria, pertussis, typhoid, measles, mumps and rubella. Ins 8.72(18)(18) Organ transplants that are covered by medicare. Ins 8.72(19)(19) Services provided by a dentist for the repair of accidental dental injuries. Ins 8.72 HistoryHistory: Cr. Register, June, 1993, No. 450, eff. 7-1-93; corrections in (3) and (6) made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562; correction in (7) made under s. 13.92 (4) (b) 7., Stats., Register March 2017 No. 735. Ins 8.73Ins 8.73 Health insurance mandates. A plan shall comply with the health insurance mandates, as defined in s. 601.423, Stats., and may not exclude or limit coverage for any mandate except as provided in s. Ins 8.75 (3). Ins 8.73 HistoryHistory: Cr. Register, June, 1993, No. 450, eff. 7-1-93. Ins 8.74(1)(1) The policy form for a plan submitted to the office of the commissioner of insurance for approval under s. 631.20, Stats., shall be entitled “basic health benefit plan.” Ins 8.74(2)(2) The term period for plan coverage shall not be less than 12 months. Ins 8.74 HistoryHistory: Cr. Register, June, 1993, No. 450, eff. 7-1-93. Ins 8.75Ins 8.75 Limitations and restrictions. Ins 8.75(1)(1) Preexisting conditions. Section 635.17 (1), Stats., applies to a plan subject to this subchapter. Ins 8.75 NoteNote: 1995 Wis. Act 289 repealed s. 635.17, Stats. See s. 632.746, Stats. Ins 8.75(2)(2) Annual maximum. The annual calendar year maximum benefit for a plan is $30,000 per insured individual. Charges for a hospitalization which extends from one calendar year to another shall be subject to the calendar year maximum for the year in which each charge was incurred and only one $100 copayment shall apply to the confinement. Ins 8.75(3)(3) Limitation on coverage for mental health and substance abuse treatment. The annual calendar year benefit payable for treatment of a covered person for nervous and mental disorders and alcoholism and other drug abuse is $1,400. A plan may not apply the cost of outpatient prescription drugs used in the treatment of nervous and mental disorders or alcoholism or other drug abuse toward the annual limit specified in this subsection. Ins 8.75 HistoryHistory: Cr. Register, June, 1993, No. 450, eff. 7-1-93. Ins 8.76Ins 8.76 Policy terms; exclusions; limitations. Ins 8.76(1)(1) Except as otherwise provided in this subchapter, a plan’s policy terms shall be defined consistently with the definitions in the small employer insurer’s other small group health benefit plans. Ins 8.76(2)(2) A plan may exclude from coverage or limit coverage for specified conditions and services other than those required under s. Ins 8.72 but may exclude or limit only those conditions and services which are generally excluded from coverage or limited under the small employer insurer’s other small group health benefit plans. Ins 8.76(3)(3) A plan may apply the same limitations on provider choice, coverage and geographical service area that apply under the small employer insurer’s other small group health benefit plans. Ins 8.76 HistoryHistory: Cr. Register, June, 1993, No. 450, eff. 7-1-93. Ins 8.77Ins 8.77 Copayments; coinsurance. Ins 8.77(1)(a)1.1. If the plan is an indemnity plan, a preferred provider organization or health maintenance organization that does not require the insured to designate a primary provider, the physician who normally provides care to the insured, if the physician is any of the following: Ins 8.77(1)(a)1.d.d. A physician certified by the American board of obstetrics and gynecology. Ins 8.77(1)(a)2.2. If the plan is a health maintenance organization that requires an insured to designate a primary provider, the physician designated. Ins 8.77(1)(b)(b) “Specialist” means any physician other than a primary care provider. Ins 8.77(2)(a)(a) Except as provided in par. (b), sub. (4) and s. Ins 8.79, a copayment in the specified amount applies each time an insured receives any of the following: Ins 8.77(2)(a)1.1. Professional services from a primary care provider or from a specialist who is consulted with a referral from a primary care provider when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01 (2), Stats.: $25. Ins 8.77(2)(a)2.2. Professional services from a specialist when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01 (2), Stats., when the specialist is consulted without a referral from a primary care provider: $35. Ins 8.77(2)(a)4.4. Ambulance service, unless immediately admitted to the hospital: $75. Ins 8.77(2)(a)5.5. Treatment in a hospital emergency room, unless immediately admitted to the hospital: $75.
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