632.79 Notice of termination of group hospital, surgical or medical expense insurance coverage due to cessation of business or default in payment of premiums. (1) Scope. This section shall apply to every group hospital, surgical or medical expense insurance policy or service plan purchased by or on behalf of an employer to provide coverage for […]
632.793 Notice of loss of primary insurance coverage due to age. (1) Notice to insured and employer. If an individual who is covered under a group disability insurance policy, as defined in s. 632.895 (1) (a), that is purchased by or on behalf of an employer to provide coverage for employees will lose primary coverage […]
632.795 Open enrollment upon liquidation. (1) Definition. In this section, “liquidated insurer” means an insurer ordered liquidated under ch. 645 or under similar laws of another jurisdiction. (2) Coverage for group members. Except as provided in sub. (5) and unless otherwise provided by rule or order of the commissioner, an insurer described in sub. (3) […]
632.797 Disclosure of group health claims experience. (1) (a) Except as provided in subs. (2) and (3), an insurer shall provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employees through a multiple-employer trust, with the policyholder’s or the employer’s aggregate group health […]
632.798 Out-of-pocket costs. (1) Definitions. In this section: (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a). (b) “Health care provider” has the meaning given in s. 146.903 (1) (c) and includes a hospital, as defined in s. 50.33 (2). (c) “Insured” includes an enrollee under a self-insured health plan and […]
632.80 Restrictions on medical payments insurance. The provisions of this subchapter do not apply to medical payments insurance when it is a part of or supplemental to liability, steam boiler, elevator, automobile or other insurance covering loss of or damage to property, provided the loss, damage or expense arises out of a hazard directly related […]
632.81 Minimum standards for certain disability policies. The commissioner may by rule establish minimum standards for benefits, claims payments, marketing practices, compensation arrangements and reporting practices for medicare supplement policies, medicare replacement policies and long-term care insurance policies. The commissioner may by rule exempt from the minimum standards certain types of coverage, if the commissioner […]
632.82 Renewability of long-term care insurance policies. Notwithstanding s. 631.36 (2) to (5), the commissioner shall, by rule, require long-term care insurance policies that are issued on an individual basis to include a provision restricting the insurer’s ability to terminate or alter the long-term care insurance policy except for nonpayment of premium. The rule may […]
632.825 Midterm termination of long-term care insurance policy by insured. (1) Permitted cancellation and refund. (a) No insurer that provides coverage under a long-term care insurance policy may prohibit the insured under the policy from canceling the policy before the expiration of the agreed term. (b) If an insured under a long-term care insurance policy […]
632.83 Internal grievance procedure. (1) In this section, “health benefit plan” has the meaning given in s. 632.745 (11), except that “health benefit plan” includes the coverage specified in s. 632.745 (11) (b) 10. and includes a policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits. […]
632.835 Independent review of coverage denial determinations. (1) Definitions. In this section: (a) “Adverse determination” means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply: 1. An admission to a health care facility, the availability of care, the continued stay or other […]
632.84 Benefit appeals under certain policies. (1) Definitions. In this section: (a) “Nursing home” has the meaning given in s. 50.01 (3). (b) “Nursing home insurance policy” means an individual or group insurance policy which provides coverage primarily for confinement or care in a nursing home. (2) Review and appeal. (a) Except as provided in […]
632.845 Prohibiting refusal to cover services because liability policy may cover. (1) In this section, “health care plan” has the meaning given in s. 628.36 (2) (a) 1. (2) An insurer that provides coverage under a health care plan may not refuse to cover health care services that are provided to an insured under the […]
632.85 Coverage without prior authorization for treatment of an emergency medical condition. (1) In this section: (a) “Emergency medical condition” means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a […]
632.853 Coverage of drugs and devices. A health care plan, as defined in s. 628.36 (2) (a) 1., or a self-insured health plan, as defined in s. 632.85 (1) (c), that provides coverage of only certain specified prescription drugs or devices shall develop a process through which a physician may present medical evidence to obtain […]
632.855 Requirements if experimental treatment limited. (1) Definitions. In this section: (a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1. (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). (2) Disclosure of limitations. Subject to s. 632.87 (6), a health care plan or a self-insured health […]
632.857 Explanation required for restriction or termination of coverage. If an insurer restricts or terminates an insured’s coverage for the treatment of a condition or complaint and, as a result, the insured becomes liable for payment for all of his or her treatment for the condition or complaint, the insurer shall provide on the explanation […]
632.861 Prescription drug charges. (1) Definitions. In this section: (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a). (b) “Enrollee” means an individual who is covered under a disability insurance policy or a self-insured health plan. (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c). (d) “Prescription […]
632.865 Pharmacy benefit managers. (1) Definitions. In this section: (ae) “Health benefit plan” has the meaning given in s. 632.745 (11). (ak) “Health care provider” has the meaning given in s. 146.81 (1). (aw) “Pharmacist” has the meaning given in s. 450.01 (15). (b) “Pharmacy” means an entity licensed under s. 450.06 or 450.065. (c) […]
632.866 Step therapy protocols. (1) Definitions. In this section: (a) “Clinical practice guideline” means a systematically developed statement to assist decision making by health care providers and patients about appropriate health care for specific clinical circumstances and conditions. (b) “Clinical review criteria” means written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used […]
