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Ins 3.54 Ins 3.54 Home health care benefits under disability insurance policies.

Ins 3.54(1) (1) Purpose. This section implements and interprets ss. 628.34 (1) and (12), 631.20 and 632.895 (1) and (2), Stats., for the purpose of facilitating the administration of claims for coverage of home health care under disability insurance policies and the review of policy forms. The commissioner of insurance shall disapprove a policy under s. 631.20, Stats., if that policy does not meet the minimum requirements specified in this section.

Ins 3.54(2) (2) Scope. This section applies to disability insurance policies.

Ins 3.54(3) (3) Definitions. In this section:

Ins 3.54(3)(a) (a) “Disability insurance policy” means a disability insurance policy as defined under s. 632.895 (1) (a), Stats., which provides coverage of expenses incurred for in-patient hospital care.

Ins 3.54(3)(b) (b) “Home health aide services” means nonmedical services performed by a home health aide which:

Ins 3.54(3)(b)1. 1. Are not required to be performed by a registered nurse or licensed practical nurse; and

Ins 3.54(3)(b)2. 2. Primarily aid the patient in performing normal activities of daily living.

Ins 3.54(3)(c) (c) “Home care visits” means the period of a visit to provide home care, without limit on the duration of the visit, except each consecutive 4 hours in a 24-hour period of home health aide services is one visit.

Ins 3.54(3)(d) (d) “Medically necessary” means that the service or supply is:

Ins 3.54(3)(d)1. 1. Required to diagnose or treat an injury or sickness and shall be performed or prescribed by the physician;

Ins 3.54(3)(d)2. 2. Consistent with the diagnosis and treatment of the sickness or injury;

Ins 3.54(3)(d)3. 3. In accordance with generally accepted standards of medical practice; and

Ins 3.54(3)(d)4. 4. Not solely for the convenience of the insured or the physician.

Ins 3.54(4) (4) Minimum requirements.

Ins 3.54(4)(a) (a) All disability insurance policies including, but not limited to, medicare supplement or replacement policies, shall provide a minimum of 40 home care visits in a consecutive 12-month period for each person covered under the policy and shall make available coverage for supplemental home care visits as required by s. 632.895 (2) (e), Stats.

Ins 3.54(4)(b) (b) An insurer shall review each home care claim under a disability insurance policy and may not deny coverage of a home care claim based solely on Medicare’s denial of benefits.

Ins 3.54(4)(c) (c) An insurer may deny coverage of all or a portion of a home health aide service visit because the visit is not medically necessary, not appropriately included in the home care plan or not necessary to prevent or postpone confinement in a hospital or skilled nursing facility only if:

Ins 3.54(4)(c)1. 1. The insurer has a reasonable, and documented factual basis for the determination; and