Current through August 26, 2024
(1) PURPOSE. This
section implements s.
632.89(4) (a), Stats.
(2) APPLICABILITY.
(a) This section applies to group and blanket
disability insurance policies issued or renewed on and after November 1, 1992,
and prior to December 1, 2010, and group health benefit plans and self-insured
governmental plans that elect and are eligible to be exempt pursuant to s.
632.89(3c), (3f) or (5), Stats., that provide coverage
for inpatient hospital services or outpatient services, as defined in s.
632.89(1) (d) or (e), Stats. Group and blanket
disability insurance policies and exempted group health benefit plans and
self-insured governmental plans shall cover transitional treatment services and
comply with subs. (2m), (3), (4), and (5).
(b) Policies issued on or after December 1,
2010, by a group health benefit plan and a self-insured governmental health
plan that are not otherwise exempt under s.
632.89(3c), (3f) or (5), Stats., shall comply with subs.
(2m), (3m), (4m), and (5m).
(2m) DEFINITIONS. In addition to the
definitions in s.
632.89(1),
Stats., in this section:
(a) "Individual
health benefit plan" means an insurance product offered on an individual basis
that meets the criteria established for a health benefit plan in s.
632.745(11),
Stats.
(b) "Eligible employee" has
the meaning provided in s.
632.745(5),
Stats.
(c) "Qualified actuary"
means a member in good standing of the American Academy of Actuaries who meets
any other requirements that the commissioner may by rule specify as defined in
s.
623.06(1) (h), Stats., and in accordance with s.
632.89(3c) (b), Stats.
(d) "Self-insured governmental plan" has the
meaning of a self-insured health plan as defined at s.
632.89(1) (em), Stats.
(e) "Substance use disorder" has the same
meaning as alcoholism and other drug abuse problems" as the phrase appears
throughout s.
632.89,
Stats.
(f) "Substantially all" has
the meaning as provided in
29 CFR
2590.712(a).
(g) "Treatment limitations" means the
limitations that insurers offering group or individual health benefit plans and
self-insured governmental plans may impose on treatment of nervous and mental
disorders and substance use disorders as described in s.
632.89(3),
Stats.
(3) COVERED
SERVICES. An insurer offering a policy subject to this subsection shall provide
at least the amount of coverage required under s.
632.89(2) (dm) 2, 2007 Stats., subject to the
exclusions or limitations, including deductibles and copayments, that are
generally applicable to coverage required under s.
632.89(2),
2007 Stats., for all of the following:
(a)
Mental health services for adults in a day treatment program compliant with the
services identified at s.
DHS 61.75(2) and offered by a provider
certified by the department of health services under s.
DHS 61.75.
(b)
Mental health services for children and adolescents in a day treatment program
compliant with the services identified at s.
DHS 40.11 and
offered by a provider certified by the department of health services under s.
DHS 40.04.
(c)
Services for persons with chronic mental illness provided through a community
support program compliant with the services identified at s.
DHS 63.11 and certified by the department of health
services under s.
DHS 63.03.
(d)
Residential treatment programs compliant with the services identified at s.
DHS 75.14(1), for alcohol or drug
dependent persons, or both, certified by the department of health services
under s.
DHS 75.14(2) and under supervision as
required in s.
DHS 75.14(5).
(e) Services for substance use disorders
provided in a day treatment program compliant with the services identified at
s.
DHS 75.12(1), certified by the department
of health services under s.
DHS 75.12(2) and under supervision as
required in s.
DHS 75.12(5).
(f) Intensive outpatient programs for
narcotic treatment services for opiate addiction compliant with the services
under s.
DHS 75.15(1) and (9), certified by the
department of health services under s.
DHS 75.15(2) and under supervision as
required in s.
DHS 75.15(4).
(g) Coordinated emergency mental health
services for persons who are experiencing a mental health crisis or who are in
a situation likely to turn into a mental health crisis if support is not
provided. Services are provided by a program compliant with s.
DHS 34.22, certified by the department of health services
under s.
DHS 34.03, and provided in accordance with subch. III of
ch. DHS 34 for the period of time the person is experiencing a mental health
crisis until the person is stabilized or referred to other providers for
stabilization. Certified emergency mental health service plans shall provide
timely notice to third-party payors to facilitate coordination of services for
persons who are experiencing or are in a situation likely to turn into a mental
health crisis.
(3m)
COVERED SERVICES. An insurer offering a group health benefit plan or a
self-insured governmental plan subject to this subsection shall provide at
least the amount of coverage for services included in s.
632.89(2) (dm), Stats., subject to the exclusions or
limitations, including deductibles and copayments, that are generally
applicable to coverage required under s.
632.89(3),
Stats., for all of the following:
(a) Mental
health services for adults in a day treatment program compliant with the
services identified at s.
DHS 61.75(2) and offered by a provider
certified by the department of health services under s.
DHS 61.75.
(b)
Mental health services for children and adolescents in a day treatment program
compliant with the services identified at s.
DHS 40.11 and
offered by a provider certified by the department of health services under s.
DHS 40.04.
(c)
Services for persons with chronic mental illness provided through a community
support program compliant with the services identified at s.
DHS 63.11 and certified by the department of health
services under s.
DHS 63.03.
(d)
Residential treatment programs compliant with the services identified at s.
DHS 75.14(1), for alcohol or drug
dependent persons, or both, certified by the department of health services
under s.
DHS 75.14(2) and under supervision as
required in s.
DHS 75.14(5).
(e) Services for substance use disorders
provided in a day treatment program compliant with the services identified at
s.
DHS 75.12(1), certified by the department
of health services under s.
DHS 75.12(2) and under supervision as
required in s.
DHS 75.12(5).
(f) Intensive outpatient programs for
narcotic treatment service for opiate addiction compliant with the services
under s.
DHS 75.15(1) and (9), certified by the
department of health services under s.
DHS 75.15(2) and under supervision as
required in s.
DHS 75.15(4).
(g) Coordinated emergency mental health
services for persons who are experiencing a mental health crisis or who are in
a situation likely to turn into a mental health crisis if support is not
provided. Services are provided by a program compliant with s.
DHS 34.22, certified by the department of health services
under s.
DHS 34.03, and provided in accordance with subch. III of
ch. DHS 34 for the period of time the person is experiencing a mental health
crisis until the person is stabilized or referred to other providers for
stabilization. Certified emergency mental health service plans shall provide
timely notice to third-party payors to facilitate coordination of services for
persons who are experiencing or are in a situation likely to turn into a mental
health crisis.
(4)
OUT-OF-STATE SERVICES AND PROGRAMS. An insurer offering a group and blanket
disability plan or exempt group health benefit plans and self-insured
governmental plans may comply with sub. (3) (a) to (g) by providing coverage
for services and programs that are substantially similar to those specified in
sub. (3) (a) to (g), if the provider is in compliance with similar requirements
of the state in which the provider is located.
(4m) OUT-OF-STATE SERVICES AND PROGRAMS. An
insurer offering a group health benefit plan and self-insured governmental
health plan may comply with sub. (3m) (a) to (g) by providing coverage for
services and programs that are substantially similar to those specified in sub.
(3m) (a) to (g), if the provider complies with similar requirements of the
state in which the provider is located.
(5) POLICY FORM REQUIREMENTS. An insurer
offering a group and blanket disability plan or exempt group health benefit
plans and self-insured governmental plans shall specify in each policy form all
of the following:
(a) The types of
transitional treatment programs and services covered by the policy as specified
in sub. (3).
(b) The method the
insurer uses to evaluate a transitional treatment program or service to
determine if it is medically necessary and covered under the terms of the
policy.
(5m) POLICY FORM
REQUIREMENTS. An insurer offering a group health benefits plan and self-insured
governmental health plan shall specify in each policy form all of the
following:
(a) The types of transitional
treatment programs and services covered by the policy as specified in sub.
(3m).
(b) The method the insurer
and the self-insured governmental health plan uses to evaluate a transitional
treatment program or service to determine if it is medically necessary and
covered under the terms of the policy.
