- If there are at least 25 employees, and the plan offers employees an HMO or a preferred provider plan that provides comprehensive health care services, it must also offer the employees a standard plan that provides at least substantially equivalent coverage of health care expenses and a point-of-service option plan. (§609.10)
- A defined network plan must provide an enrollee with coverage for a 2nd opinion from another participating provider. (§609.22)
- The plan must cover eligible enrollees regardless of health condition or claims experience. (§632.747)
- The plan may not discriminate on the basis of health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability — including conditions arising out of act of domestic violence, or disability. (§632.748)
- If the plan covers emergency medical services, it must cover such services provided in a hospital emergency facility without prior authorization. (§632.85)
- If the plan covers prescriptions, it must have a process through which a physician may present medical evidence to obtain an exception for coverage of a prescription not routinely covered by the plan. (§632.853)
- If the plan covers prescriptions, it must not exclude prescriptions provided by a participant-selected pharmacist or pharmacy if the pharmacist or pharmacy provides the prescriptions under the terms of the plan and at the same cost to the insurer issuing the policy, as a mail order plan. (§632.86)
- The plan may not refuse to cover services provided by a health care professional on the ground that the services were not rendered by a physician, unless the plan clearly excludes services by such practitioners. (§632.87)
- The plan may not refuse to cover vision care services provided by an optometrist, if the plan includes coverage for the same services or procedures when provided by another health care provider. (§632.87)
- The plan may not exclude coverage for treatment by a chiropractor if the plan covers treatment of the condition by a physician or osteopath. (§632.87)
- The plan cannot exclude coverage for treatment by a dentist if the plan covers treatment of the condition by another health care provider. (§632.87)
- The plan must cover dependents, regardless of age, while they are and continue to be incapable of self-sustaining employment because of mental retardation or physical handicap and chiefly dependent upon the person insured for support and maintenance. (§632.88)
- If the plan covers inpatient hospital treatment or outpatient treatment, or both, it must cover nervous and mental disorders and alcoholism and other drug abuse problems. (§632.89)
- If the plan covers inpatient hospital care, it must cover home care. (§632.895)
- If the plan covers hospital care, it must cover, for at least 30 days, for skilled nursing care to participants who enter a skilled nursing care facility. (§632.895)
- If the plan covers hospital treatment, it must cover inpatient and outpatient kidney disease treatment, including dialysis, transplantation and donor-related services. (§632.895)
- The plan must cover newborn children from the moment of birth, including congenital defects and birth abnormalities. (§632.895)
- If the plan covers children, it must cover grandchildren (children of dependents) up to age 18. (§632.895)
- If the plan covers diabetes, it must cover equipment and supplies for treatment and self-management education programs. (§632.895)
- If the plan covers prescriptions, it must cover prescriptions for treatment of HIV. (§632.895)
- The plan must cover lead screening for children under six years old. (§632.895)
- If the plan covers diagnostic or surgical procedures, it must cover procedures necessary for treatment of temporomandibular disorders. (§632.895)
- The pan must cover hospital or ambulatory surgery centers and anesthetics for dental care for children under the age of five, individuals with a chronic disability, or individuals with medical conditions that require hospitalization or general anesthesia for dental care. (§632.895)
- If the plan covers dependents, it must cover appropriate and necessary immunizations for such dependents from birth to six years. (§632.895)
- If the plan covers dependents, it must cover adopted children to the same extend as other dependent children, and the coverage is required whether or not the adoption is final. (§632.896)
- If the plan covers dependents, it cannot discriminate against children because they do not live with the insured or are dependent on another parent, or is not claimed for tax purposes by the insured, or is not a marital child, or lives outside the insurer’s service area. The coverage cannot be determined by the proportion of the child’s support provided by the insured. (§632.897)
- If the plan offers employees an HMO or a preferred provider plan that provides comprehensive health care services, it must also offer the employees a standard plan that provides at least substantially equivalent coverage of health care expenses and a point-of-service option plan. (§609.10)
- The plan cannot require individuals to obtain a genetic test. (§631.89)
- The plan cannot require or request any individual to reveal whether the individual has obtained a test for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV or what the results of this test. (§631.90)
- Effective January 1, 2010, the definition of a dependent is a child over age 17 but less than 27 years of age, not married, and not eligible for coverage under a plan offered by the child's employer. It also includes children who are full-time, unmarried students, regardless of age, as well as those who were under 27 when they were called to duty in a reserve component of the Armed Forces.
- Plans must cover treatment for autism spectrum disorders. On November 4, 2011, legislation adopting the federal income tax treatment of employer-provided health coverage for adult children was signed. Such coverage is exempt from state taxation retroactively to January 1, 2011. (WI Act 49)
- Effective January 1, 2010, plans that cover outpatient health care services, preventive treatments and services, or prescription drugs and services, must cover contraceptives and services.
Note: The federal government implemented Medicare Part D insurance for prescription drugs effective January 1, 2006, therefore s. Ins 8.49 Appendix 1 must reflect accurately the status of applicants as it relates to Medicare Part D enrollment. Further, also effective January 1, 2006, the federal government requires employers or insurers to provide an employee specific information on how to elect insurance coverage after a qualifying event subsequent to have waived coverage in accordance with 45 CFR 146.117 (c) (1). In order to have these changes in place prior to January 1, 2006, a rule has been promulgated to add these modifications.
The changes include the ability for the employee applicant to indicate that they carry Medicare Part D effective January 1, 2006 and amends one sentence in the notice portion of the wavier section of the application to add information on how an employee following a qualifying event may opt to obtain health insurance coverage after initially waiving insurance coverage through the small employer group health insurance plan.