Section 632.89. Coverage of mental disorders, alcoholism, and other diseases.

 

(1)   Definitions. In this section:

(a) “Collateral" means a member of an insured's immediate family, as defined in s. 632.895 (1) .

(at) “Group health benefit plan" has the meaning given in s. 632.745 (9) .

(b) “Health benefit plan" has the meaning given in s. 632.745 (11) .

(c) “Hospital" means any of the following:

1. A hospital licensed under s. 50.35 .

2. An approved private treatment facility as defined in s. 51.45 (2) (b) .

3. An approved public treatment facility as defined in s. 51.45 (2) (c) .

(d) “Inpatient hospital services" means services for the treatment of nervous and mental disorders or alcoholism and other drug abuse problems that are provided in a hospital to a bed patient in the hospital.

(dm) “Licensed mental health professional" means a clinical social worker who is licensed under ch. 457 , a marriage and family therapist who is licensed under s. 457.10 , or a professional counselor who is licensed under s. 457.12 .

(e) “Outpatient services" means nonresidential services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems provided to an insured and, if for the purpose of enhancing the treatment of the insured, a collateral by any of the following:

1. A program in an outpatient treatment facility, if both are approved by the department of health services, the program is established and maintained according to rules promulgated under s. 51.42 (7) (b) and the facility is certified under s. 51.04 .

2. A licensed physician who has completed a residency in psychiatry, in an outpatient treatment facility or the physician's office.

3. A psychologist licensed under ch. 455 .

4. A licensed mental health professional practicing within the scope of his or her license under ch. 457 and applicable rules.

(em) “Self-insured health plan" has the meaning given in s. 632.745 (24) .

(f) “Transitional treatment arrangements" means services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems that are provided to an insured in a less restrictive manner than are inpatient hospital services but in a more intensive manner than are outpatient services, and that are specified by the commissioner by rule under sub. (4) .

(2)   Required coverage for group plans.

(a) Conditions covered. A group health benefit plan and a self-insured health plan shall provide coverage of nervous and mental disorders and alcoholism and other drug abuse problems if required by pars. (c) to (dm) and as provided in pars. (c) to (dm) and subs. (3) to (3f) .

(c) Coverage of inpatient hospital services. If a group health benefit plan or a self-insured health plan provides coverage of any inpatient hospital treatment, the plan shall provide coverage for inpatient hospital services for the treatment of conditions under par. (a) .

(d) Coverage of outpatient services. If a group health benefit plan or a self-insured health plan provides coverage of any outpatient treatment, the plan shall provide coverage for outpatient services for the treatment of conditions under par. (a) .

(dm) Coverage of transitional treatment arrangements. If a group health benefit plan or a self-insured health plan provides coverage of any inpatient hospital treatment or any outpatient treatment, the plan shall provide coverage for transitional treatment arrangements for the treatment of conditions under par. (a) .

(3)   Limitations. For a group health benefit plan and a self-insured health plan that provide coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems, and for an individual health benefit plan that provides coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems, the exclusions and limitations; deductibles; copayments; coinsurance; annual and lifetime payment limitations; out-of-pocket limits; out-of-network charges; day, visit, or appointment limits; limitations regarding referrals to nonphysician providers and treatment programs; and duration or frequency of coverage limits under the plan may be no more restrictive for coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems than the most common or frequent type of treatment limitations applied to substantially all other coverage under the plan. The plan shall include in any overall deductible amount or annual or lifetime limit or out-of-pocket limit for the plan, expenses incurred for the treatment of nervous and mental disorders or alcoholism and other drug abuse problems.

(3c)   Exemption for cost increase.

(a) Notwithstanding sub. (3) , an employer that provides health care coverage for its employees through a group health benefit plan or a self-insured health plan that provides coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems may elect for the employer's plan to be exempt from the requirements under sub. (3) during the plan year following any plan year in which, as a result of the requirements under sub. (3) , there is an increase under the plan in the employer's total cost of coverage for the treatment of physical conditions and nervous and mental disorders and alcoholism and other drug abuse problems by a percentage that exceeds either of the following:

1. Two percent in the first plan year in which the requirements apply.

2. One percent in any plan year after the first plan year in which the requirements apply.

(b) A cost increase specified under par. (a) may not be determined until the employer's group health benefit plan or self-insured health plan has complied with the requirements under sub. (3) for at least the first 6 months of the plan year for which the increase is to be determined. The cost increase shall be determined, and certified, by a qualified actuary, as defined in s. 623.06 (1) (h) . A copy of the actuary's determination, and all underlying documentation that the actuary relied on in making the determination, shall be filed with and, in accordance with rules promulgated by the commissioner, retained by the insurer issuing the group health benefit plan or by the self-insured health plan.

(c) A group health benefit plan or a self-insured health plan that qualifies for an exemption under par. (a) and for which the employer providing coverage under the plan has elected for the plan to be exempt from the requirements under sub. (3) during a plan year shall promptly notify all enrollees under the plan.

(d) Regardless of a cost increase as specified in par. (a) , an employer may elect for the employer's plan to continue to be subject to the requirements under sub. (3) . If an employer elects for the employer's plan to be exempt from the requirements under sub. (3) , during the plan year in which it is exempt the group health benefit plan or self-insured health plan shall comply with the coverage requirements under s. 632.89 (2) (a) to (dm) , 2007 stats.

(3f)   Exemption for small employers.

(a) Notwithstanding sub. (3) , an employer that provides health care coverage for its employees through a group health benefit plan that provides coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems may elect for the employer's plan to be exempt from the requirements under sub. (3) during a plan year if, on the first day of the plan year, the employer will have fewer than 10 eligible employees, as defined in s. 632.745 (5) .

(b) A group health benefit plan that qualifies for an exemption under par. (a) and for which the employer providing coverage under the plan has elected for the plan to be exempt from the requirements under sub. (3) during a plan year shall promptly notify all enrollees under the employer's plan. During the plan year in which it is exempt from the requirements under sub. (3) , the group health benefit plan shall comply with the coverage requirements under s. 632.89 (2) (a) to (dm) , 2007 stats.

(3p)   Availability of plan information. A group health benefit plan and a self-insured health plan that provide coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems, and an individual health benefit plan that provides coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems, shall, upon request, make available to any current or potential insured, participant, beneficiary, or contracting provider the criteria for determining medical necessity under the plan with respect to that coverage. If a group health benefit plan or a self-insured health plan that provides coverage of the treatment of nervous and mental disorders and alcoholism and other drug abuse problems denies any particular insured, participant, or beneficiary coverage for services for that treatment, or if an individual health benefit plan that provides coverage of the treatment of nervous and mental disorders or alcoholism and other drug abuse problems denies any particular insured coverage for services for that treatment, the plan shall, upon request, make the reason for the denial available to the insured, participant, or beneficiary, in addition to complying with s. 632.857 , if applicable.

(4)   Rules.

(a) The commissioner shall specify by rule the services for the treatment of nervous or mental disorders or alcoholism or other drug abuse problems, including but not limited to day hospitalization, that are covered under sub. (2) (dm) .

(b)

1. The commissioner shall promulgate rules for the administration of this section, including rules that specify the information that must be provided in the notices under subs. (3c) (c) and (3f) (b) and the manner in which the notices must be given, that specify who is responsible for the actuarial study and determination under sub. (3c) (b) , and that specify retention requirements for the determination and underlying documentation. In promulgating the rules, the commissioner shall follow, as a minimum standard, any relevant federal regulations or guidelines that are in effect.

2. Using the procedure under s. 227.24 , the commissioner may promulgate the rules under subd. 1. for the period before the effective date of any permanent rules promulgated under subd. 1. , but not to exceed the period authorized under s. 227.24 (1) (c) and (2) . Notwithstanding s. 227.24 (1) (a) , (2) (b) , and (3) , the commissioner is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to make a finding of emergency for a rule promulgated under this subdivision.

(4m)   Liability to the state or county. For any insurance policy issued on or after January 1, 1981, any insurer providing hospital treatment coverage is liable to the state or county for any costs incurred for services an inpatient health care facility, as defined in s. 50.135 (1) , or community-based residential facility, as defined in s. 50.01 (1g) , owned or operated by a state or county, provides to a patient regardless of the patient's liability for the services, to the extent that the insurer is liable to the patient for services provided at any other inpatient health care facility or community-based residential facility.

(5)   Exclusions.

(a) Medicare. No insurer or other organization subject to this section is required to duplicate coverage available under the federal medicare program.

(b) Certain health care plans. This section does not apply to a health care plan offered by a limited service health organization, as defined in s. 609.01 (3) , or by a preferred provider plan, as defined in s. 609.01 (4) , that is not a defined network plan, as defined in s. 609.01 (1b) .

(c) Coverage of autism treatment. This section does not apply to coverage of treatment for autism spectrum disorder, as defined in s. 632.895 (12m) (a) 1. , to which s. 632.895 (12m) applies.

1975 c. 223 , 224 , 375 ; 1977 c. 203 s. 106 ; 1979 c. 175 , 221 ; 1981 c. 20 s. 2202 (20) (q) ; 1981 c. 39 ss. 14 , 15 , 22 ; 1981 c. 314 ; 1983 a. 27 ; 1983 a. 189 s. 329 (5) ; 1985 a. 29 , 176 ; 1987 a. 195 , 403 ; 1991 a. 39 , 250 ; 1993 a. 27 , 270 ; 1995 a. 27 ss. 7047 , 9126 (19) ; 1997 a. 27 ; 1999 a. 9 ; 2003 a. 178 ; 2007 a. 20 s. 9121 (6) (a) ; 2009 a. 28 , 218 ; 2015 a. 90 . Cross-reference: See also ss. Ins 3.37 and 3.375 , Wis. adm. code.