Mandated Benefits

Health insurance policies sold in Wisconsin often include "mandated benefits." These are benefits that an insurer must include in certain types of health insurance policies. Except for health maintenance organizations (HMOs) organized as cooperatives under ch. 185, Wis. Stat., HMOs are required to provide the same benefits as traditional insurers.

The mandated benefits required by Wisconsin state law include coverage for: health care services provided by certain nonphysician health care providers; adopted children; handicapped children; nervous and mental disorders, alcoholism, and other drug abuse; home health care; skilled nursing care; kidney disease; mammography; new born infants; grandchildren born to dependent children under the age of 18 who are covered by the policy; diabetes; lead screening, temporomandibular joint treatment, breast reconstruction following a mastectomy, anesthesia for certain dental procedures, maternity coverage for all persons covered under the policy if it provides maternity coverage for anyone, immunizations for children under the age of 6, coverage of certain health care costs in cancer clinical trials and coverage of student on medical leave.

If a health insurance plan limits coverage of an experimental treatment, procedure, drug or device, the insurer is required to clearly disclose those limitations in the policy. Additionally, the insurer must have a process for the enrollee to request a timely review of a denied experimental treatment.

If the health insurer limits coverage of drugs to those on a preapproved list, often called a formulary, the insurer must have a process for the enrollee's physician to present medical evidence to request coverage of a drug that is not on the approved list.

Health insurance plans must provide at least the minimum mandated coverage but may provide benefits that are greater than those mandated by law. Some mandated benefits apply only to group policies. Some apply both to policies sold to individuals and to groups.

For more information on mandated benefits, you may call the OCI at 1-800-236-8517 and request a copy of Fact Sheet on Mandated Benefits in Health Insurance Policies. A copy is also available on OCI's Web site at http://oci.wi.gov/pub_list/pi-019.htm.