Except as provided in subd. 2.
, in this subsection, “routine patient care" means all of the following:
All health care services, items, and drugs for the treatment of cancer.
All health care services, items, and drugs that are typically provided in health care; including health care services, items, and drugs provided to a patient during the course of treatment in a cancer clinical trial for a condition or any of its complications; and that are consistent with the usual and customary standard of care, including the type and frequency of any diagnostic modality.
“Routine patient care" does not include the health care service, item, or investigational drug that is the subject of the cancer clinical trial; any health care service, item, or drug provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient; an investigational drug or device that has not been approved for market by the federal food and drug administration; transportation, lodging, food, or other expenses for the patient or a family member or companion of the patient that are associated with travel to or from a facility providing the cancer clinical trial; any services, items, or drugs provided by the cancer clinical trial sponsors free of charge for any patient; or any services, items, or drugs that are eligible for reimbursement by a person other than the insurer, including the sponsor of the cancer clinical trial.
No policy, plan, or contract may exclude coverage for the cost of any routine patient care that is administered to an insured in a cancer clinical trial satisfying the criteria under par. (c)
and that would be covered under the policy, plan, or contract if the insured were not enrolled in a cancer clinical trial.
A cancer clinical trial under par. (b)
must satisfy all of the following criteria:
A purpose of the trial is to test whether the intervention potentially improves the trial participant's health outcomes.
The treatment provided as part of the trial is given with the intention of improving the trial participant's health outcomes.
The trial has therapeutic intent and is not designed exclusively to test toxicity or disease pathophysiology.
Tests how to administer a health care service, item, or drug for the treatment of cancer.
Tests responses to a health care service, item, or drug for the treatment of cancer.
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.
Studies new uses of health care services, items, or drugs for the treatment of cancer.
A National Institute of Health, or one of its cooperative groups or centers, under the federal department of health and human services.
The coverage that may not be excluded under this subsection shall apply to all phases of a cancer clinical trial.
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.
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.
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.
Legislative 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]
Restrictions relating to fees for dental services. 632.873(1)(1)
In this section, unless the context requires otherwise:
“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.
“Policy" means a policy, certificate, or contract of insurance that provides only limited-scope dental benefits.
“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.
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.
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.
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.
Prohibition on charges.
A dentist who, under a contract with an insurer offering a policy that provides coverage for dental and related services, provides dental or related services to an insured under the policy may not charge the insured more than the dentist's usual nondiscounted fee for a dental or related service that is not a covered service under the policy.
History: 2013 a. 26
Independent evaluations relating to chiropractic treatment. 632.875(1)(a)
“Chiropractor" means a person licensed to practice chiropractic under ch. 446
“Independent evaluation" means an examination or evaluation by or recommendation of a chiropractor or a peer review committee under s. 632.87 (3) (b) 1.
“Patient" means a person whose treatment by a chiropractor is the subject of an independent evaluation.
“Treating chiropractor" means a chiropractor who is treating a patient and whose treatment of the patient is the subject of an independent evaluation.
If, on the basis of an independent evaluation, an insurer restricts or terminates a patient's coverage for the treatment of a condition or complaint by a chiropractor acting within the scope of his or her license and the restriction or termination of coverage results in the patient becoming liable for payment for his or her treatment, the insurer shall, within the time required under s. 628.46 (2m)
, provide to the patient and to the treating chiropractor a written statement that contains all of the following:
A description of the insurer's internal appeal process that is available to the patient.
A statement indicating that the patient may, no later than 30 days after receiving the statement required under this subsection, request an internal appeal of the insurer's restriction or termination of coverage.
The address to which the patient should send the request for an appeal.
A detailed explanation of the clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer's restriction or termination of coverage.
A list of records and documents reviewed as part of the independent evaluation.
In this subsection, “claim" means a patient's claim for coverage, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license, the restriction or termination of which coverage is the subject of an independent evaluation.
A chiropractor who conducts an independent evaluation may not be compensated by an insurer based on a percentage of the dollar amount by which a claim is reduced as a result of the independent evaluation.
Subject to sub. (2) (e)
, an insurer shall make available to a patient an internal procedure by which the patient may appeal an insurer's decision to restrict or terminate coverage.
This section does not apply to any of the following:
Any line of property and casualty insurance except disability insurance. In this paragraph, “disability insurance" does not include uninsured motorist coverage, underinsured motorist coverage or medical payment coverage.
History: 1995 a. 94
; 2001 a. 16
; 2007 a. 20
Policy extension for handicapped children. 632.88(1)(1)
Termination of coverage.
Every hospital or medical expense insurance policy or contract that provides that coverage of a dependent child of a person insured under the policy shall terminate upon attainment of a limiting age for dependent children specified in the policy shall also provide that the age limitation may not operate to terminate the coverage of a dependent child while the child is and continues to be both:
Incapable of self-sustaining employment because of intellectual disability or physical handicap; and
Chiefly dependent upon the person insured under the policy for support and maintenance.
Proof of incapacity.
The insurer may require that proof of the incapacity and dependency be furnished by the person insured under the policy within 31 days of the date the child attains the limiting age, and at any time thereafter except that the insurer may not require proof more frequently than annually after the 2-year period immediately following attainment of the limiting age by the child.
History: 1975 c. 375
; 2011 a. 126
Coverage of dependents. 632.885(1)(ar)
“Grandfathered health plan" has the meaning given under section 1251 of the Patient Protection and Affordable Care Act (P.L. 111-148
Requirement to offer dependent coverage. 632.885(2)(a)
Subject to ss. 632.88
and 632.895 (5)
, and except as provided in pars. (b)
, every insurer that offers health insurance coverage that provides dependent coverage of children, and every self-insured health plan that provides dependent coverage of children, shall provide coverage for any child of an applicant or insured as a dependent of the applicant or insured if the child is under the age of 26.
Except as provided in par. (c)
, the coverage requirement under this section applies to an adult child who satisfies all of the following criteria:
The child was called to federal active duty in the national guard or in a reserve component of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher education.
The child was under the age of 27 years when called to federal active duty under subd. 3.
For any policy year or plan year beginning before January 1, 2014, health insurance coverage or a self-insured health plan described in par. (a)
that is a grandfathered health plan is required to provide dependent coverage for an adult child described in par. (a)
only if the child is not eligible for coverage under an eligible employer-sponsored plan other than the health insurance coverage or self-insured health plan.
Defining dependent; uniform terms.
An insurer or self-insured health plan described in sub. (2)
may not do any of the following:
Define “dependent" for purposes of eligibility for dependent coverage of children other than in terms of the relationship between a child and an applicant or insured.
Vary the terms of coverage under the health insurance coverage or self-insured health plan on the basis of age except for children 26 years of age or older.
History: 2009 a. 28
; 2011 a. 32
See also s. Ins 3.34
, Wis. adm. code.