Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 8 - Employee Welfare Funds; Employee Benefit Plan Administrators; Small Employer Health Insurance
Subchapter IV - Basic Health Benefit Plan For Small Employers
Section Ins 8.77 - Copayments; coinsurance

Universal Citation: WI Admin Code ยง Ins 8.77

Current through August 26, 2024

(1) DEFINITIONS. In this section:

(a) "Primary care provider" means any of the following:
1. If the plan is an indemnity plan, a preferred provider organization or health maintenance organization that does not require the insured to designate a primary provider, the physician who normally provides care to the insured, if the physician is any of the following:
a. A physician who is not certified by any specialty board.

b. A physician certified by the American board of family practice.

c. A physician certified by the American board of internal medicine.

d. A physician certified by the American board of obstetrics and gynecology.

e. A physician certified by the American board of pediatrics.

2. If the plan is a health maintenance organization that requires an insured to designate a primary provider, the physician designated.

(b) "Specialist" means any physician other than a primary care provider.

(2) COPAYMENTS.

(a) Except as provided in par. (b), sub. (4) and s. Ins 8.79, a copayment in the specified amount applies each time an insured receives any of the following:
1. Professional services from a primary care provider or from a specialist who is consulted with a referral from a primary care provider when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01(2), Stats.: $25.

2. Professional services from a specialist when provided during an office visit or on an outpatient basis in a hospital, ambulatory surgery center or approved treatment facility, as defined in s. 51.01(2), Stats., when the specialist is consulted without a referral from a primary care provider: $35.

3. Professional services from a chiropractor: $11.

4. Ambulance service, unless immediately admitted to the hospital: $75.

5. Treatment in a hospital emergency room, unless immediately admitted to the hospital: $75.

6. Inpatient hospitalization: $100.

7. Prescription drugs, proprietary: $20 or the cost of the prescription, whichever is less.

8. Prescription drugs, generic: $10, or the cost of the prescription, whichever is less.

(b) The copayments specified in par. (a) 1. and 2. do not apply to professional services in connection with prenatal care or well baby care from birth to 24 months.

(3) COINSURANCE. Except as provided in sub. (4) and s. Ins 8.79, for each insured individual, a plan shall pay the following portions of the amount by which covered charges in a calendar year exceed the copayments:

(a) For all charges other than for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems:
1. 80% of the first $5,000 of charges until the plan has paid $4,000.

2. 95% of the remainder of charges until the plan limit under s. Ins 8.75(2) has been met.

(b) For the treatment of nervous or mental disorders or alcoholism or other drug abuse problems, 80% of the charges until the plan has paid $1,400 or the plan limit under s. Ins 8.75(2) has been met.

(4) EXCEPTION FOR HEALTH MAINTENANCE ORGANIZATIONS. A plan offered by a health maintenance organization that requires participants to use only specified health care providers may elect to offer either copayments or coinsurance if the amount for which a participant is responsible is the actuarial equivalent of the copayments and coinsurance required under subs. (2) and (3). Upon request, a health maintenance organization shall provide the office of the commissioner of insurance with sufficient documentation to support its determination of actuarial equivalence.

(5) DEDUCTIBLES AND OTHER COST-SHARING PROHIBITED. A plan shall not include an annual deductible or any copayment or coinsurance requirement other than those specified in this section, except as provided in s. Ins 8.79.

Disclaimer: These regulations may not be the most recent version. Wisconsin may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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