Wisconsin Mandated Benefits: What Must Be Covered
Wisconsin requires health policies to include certain benefits and to pay certain licensed providers. Most of these mandates apply to a “disability insurance policy” as s. 632.895 (1) (a), Wis. Stat., defines it: surgical, medical, hospital, major medical or other health service coverage. Hospital indemnity policies and ancillary coverage such as income continuation are not included. Many mandates also carve out specified-disease, dental-only, Medicare supplement or long-term care policies, as noted below.
Most mandates are conditional: they apply only if the policy already covers something related, such as hospital care. So when a client asks whether their policy must cover something, start with what else it covers.
Mental Health and Substance Use (s. 632.89)
Wisconsin requires a group health plan that covers any inpatient hospital treatment to cover inpatient hospital services for nervous and mental disorders and alcoholism and other drug abuse problems. A group plan covering any outpatient treatment must cover outpatient services for them. If it covers either, it must also cover transitional treatment arrangements, care more intensive than outpatient but less restrictive than a hospital stay (s. 632.89 (2)).
The central rule is parity. When a group plan, or an individual plan, covers these conditions, its deductibles, copayments, coinsurance, out-of-pocket limits and day or visit limits for them may be no more restrictive than the most common limits applied to substantially all other coverage under the plan. Expenses for these conditions count toward the plan’s overall deductible and out-of-pocket limit (s. 632.89 (3)). An employer with fewer than 10 eligible employees on the first day of the plan year may elect out of parity, as may an employer whose costs rise beyond set limits, after notifying enrollees (s. 632.89 (3c), (3f)). On request, the plan must disclose its medical necessity criteria and the reason for any denial (s. 632.89 (3p)).
Home Health Care (s. 632.895 (2))
A policy that covers inpatient hospital care must also cover the usual and customary fees for home care, with the same deductible and coinsurance as other services. The weekly benefit need not exceed the usual weekly cost of a skilled nursing facility (s. 632.895 (2) (a)). The attending physician must certify that:
- hospital or skilled nursing facility care would otherwise be required;
- the care is not available from family or others living with the insured without undue hardship; and
- a state-licensed or Medicare-certified home health agency or certified rehabilitation agency will provide or coordinate it (s. 632.895 (2) (b)).
The policy may limit visits, but to no fewer than 40 visits in any 12-month period per covered person. Up to 4 consecutive hours of home health service in a 24-hour period counts as one visit (s. 632.895 (2) (d)). A Medicare supplement policy must offer, on request, enough supplemental visits to reach 365 home care visits per policy year (s. 632.895 (2) (e)). An insurer may not deny a home care claim solely because Medicare denied it, and it may not use the words “homebound” or “custodial” in its home care provisions (s. Ins 3.54 (4) (b), (e), Wis. Adm. Code).
Skilled Nursing Care (s. 632.895 (3))
A policy covering hospital care must cover at least 30 days of skilled nursing care in a licensed facility. Except under Medicare supplement and Medicare replacement policies, the coverage applies only to continued treatment of the condition treated in the hospital, and the policy may limit it to patients who enter within 24 hours after discharge from a general hospital. The care must be certified as medically necessary and recertified every 7 days. Domiciliary or custodial care is not covered.
Kidney Disease (s. 632.895 (4))
A policy with hospital coverage on an expense-incurred basis must cover inpatient and outpatient kidney disease treatment, which may be limited to dialysis, transplantation and donor-related services, in an amount not less than $30,000 annually. It may not impose deductibles, coinsurance or limits that do not apply generally to other conditions, and it need not duplicate Medicare.
Diabetes (s. 632.895 (6))
A policy that covers diabetes treatment must cover an insulin infusion pump, all other equipment and supplies (including insulin and other prescription medication) and diabetic self-management education. Normal cost sharing applies. The insurer may limit pump coverage to one pump per year and may require 30 days of use before purchase.
Maternity (s. 632.895 (7))
A group policy that provides maternity coverage must provide it for all persons covered under the policy, dependents as well as employees, without exclusions that do not apply to its other maternity coverage.
Mammograms (s. 632.895 (8))
- Ages 45 to 49: coverage of 2 screening examinations by low-dose mammography, each at least 2 years after the last.
- Age 50 or older: an annual screening mammogram.
- Diagnostic examinations of a suspected abnormality, and supplemental screening by MRI or ultrasound for women at increased risk or with dense breast tissue, must also be covered.
Screening is covered whether or not the woman has symptoms and must be ordered by a physician or nurse practitioner, with a narrow exception for a woman who has neither. The policy may not charge cost sharing for a diagnostic breast examination or the first supplemental screening in a policy year, though an HSA-qualified high-deductible plan may first apply its minimum deductible (s. 632.895 (8) (d)). These rules do not apply to specified-disease, Medicare supplement, Medicare replacement or long-term care policies.
Children’s Mandates
Lead screening. Policies must cover blood lead tests for children under 6 years of age (s. 632.895 (10)).
Hospital and anesthesia for dental care. Policies must cover hospital or ambulatory surgery center charges, and anesthetics, for dental care provided there if the patient is a child under the age of 5, has a qualifying chronic disability, or has a medical condition that requires hospitalization or general anesthesia for dental care (s. 632.895 (12)). Dental-only policies are exempt.
TMJ and Breast Reconstruction
Temporomandibular disorders. A policy covering any diagnostic or surgical procedure involving a bone, joint, muscle or tissue must cover diagnosis and medically necessary surgical or nonsurgical treatment of TMJ disorders caused by a congenital, developmental or acquired deformity, disease or injury. Nonsurgical treatment includes prescribed intraoral splints. Cosmetic or elective orthodontic, periodontic and general dental care are excluded. The required coverage for diagnosis and nonsurgical treatment may not exceed $1,250 annually, and the insurer may require prior authorization (s. 632.895 (11)).
Breast reconstruction. A policy that covers mastectomy must cover reconstruction of the affected tissue incident to the mastectomy, subject to the policy’s usual cost sharing (s. 632.895 (13)).
Provider Mandates (s. 632.87)
These rules govern who may be paid for a covered service:
| Provider | Wisconsin rule |
|---|---|
| Any licensed professional | An insurer may not refuse benefits because a service was not performed by a physician, unless the contract clearly excludes that kind of practitioner (s. 632.87 (1)). |
| Nurse practitioners | A policy covering Pap tests, pelvic exams and related lab fees when a physician performs them must cover them when a licensed nurse practitioner does (s. 632.87 (5)). |
| Optometrists | A policy covering vision care must cover services an optometrist provides within the scope of optometry, if it covers the same services from another provider (s. 632.87 (2)). HMOs and preferred provider plans must include enough optometrists to meet demand (s. 632.87 (2m)). |
| Chiropractors | A policy covering a condition when treated by a physician may not exclude its treatment by a chiropractor, and may not require a physician’s referral. Deductibles and coinsurance must apply equally (s. 632.87 (3) (a)). |
An insurer also may not refuse to cover a person because they have seen a chiropractor, or underwrite chiropractic care more strictly. An exclusion that breaks these rules is void in its entirety (s. 632.87 (3) (b), (c)).
Lesson summary
- Group plans covering inpatient or outpatient care must cover mental health and substance use treatment, and cost sharing and limits for those conditions must be at parity with other coverage (s. 632.89).
- Policies covering inpatient hospital care must cover home care, with at least 40 visits a year, and at least 30 days of skilled nursing care (s. 632.895 (2), (3)).
- Kidney disease treatment must be covered for at least $30,000 a year; diabetes coverage must include pumps, supplies, insulin and education (s. 632.895 (4), (6)).
- Group maternity coverage must extend to every covered person (s. 632.895 (7)).
- Screening mammograms are covered twice between ages 45 and 49 and annually from age 50, and diagnostic breast exams carry no cost sharing (s. 632.895 (8)).
- Children under 6 get lead tests; children under 5 get hospital and anesthesia coverage for dental care (s. 632.895 (10), (12)).
- TMJ treatment and breast reconstruction after mastectomy must be covered (s. 632.895 (11), (13)).
- Optometrists and chiropractors must be covered for services the policy covers from other providers; nurse practitioners, for Pap tests and pelvic exams (s. 632.87).