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 (1)] continues (and expands the scope of) s. 207.04 (1) (k) [repealed by this act], which does not deal with an unfair marketing practice but an unduly restrictive interpretation of an insurance contract.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.