Requirements Applicable to All Health Benefit Plans

Emergency Care
Grievance Procedure
Independent Review
Continuation and Conversion
Mandated Benefits

Emergency Care

Every health plan offered in Wisconsin that covers emergency care, including managed care plans, must cover services required to stabilize a condition that most people would consider to be an emergency, without prior authorization. Managed care plans are permitted to charge a reasonable copayment or coinsurance for this benefit.

Grievance Procedure

All health insurance plans, including all managed care plans are required to have an internal grievance procedure for those who are not satisfied with the service they receive. The procedure must be set forth in the insurance contract and must also be provided in written notice.

The managed care plan must provide each enrollee with complete and understandable information about how to use the grievance procedure. An enrollee has the right to appear in person before the grievance committee and present additional information.

Enrollees may wish to first contact the managed care plan with a question or complaint. Many complaints can be resolved quickly and require no further action. However, filing a complaint with the plan first is not required. An enrollee can file a complaint with the appropriate state agency instead of, before, or at the same time as filing with the managed care plan.

Managed care plans are required to have a separate expedited grievance procedure for situations where the medical condition requires immediate medical attention. The procedure requires managed care organizations to resolve an expedited grievance within 72 hours after receiving the grievance.

Managed care plans are required to file a report with OCI listing the number of grievances they had in the previous year. A summary of this information for HMOs is included in The Consumer's Guide to Managed Care Plans in Wisconsin. To receive a copy of this brochure call 1-800-236-8517. A copy is available on OCI's Web site at http://oci.wi.gov/pub_list/pi-044.htm.

Independent Review

All insurance companies offering health benefit plans in Wisconsin are required to have an internal grievance process to resolve any complaint you may have with the plan. If you are not satisfied with the outcome of the grievance, you have an additional way to resolve some disputes involving medical decisions. You or your authorized representative may request that an Independent Review Organization (IRO) review your health plan's decision.

The independent review process provides you with an opportunity to have medical professionals who have no connection to your health plan review your dispute. You choose the IRO from a list of review organizations certified by the OCI. The IRO assigns your dispute to a clinical peer reviewer who is an expert in the treatment of your medical condition. The IRO has the authority to determine whether the treatment should be covered by your health plan.

The independent reviews are conducted by IROs that are certified by the OCI. In order to be certified the IRO must demonstrate that it is unbiased and that it has procedures to ensure that its clinical peer reviewers are qualified and independent.

In most cases, you will need to complete your health plan's internal grievance procedure. After you receive the insurer's final decision on your grievance, choose an IRO from the list provided by the insurer. Then send a written request for independent review to the insurance company.

Your health plan should provide you with information on your right to request an independent review in its written materials. You can also call the health plan at its toll-free number and request information on independent review.

For more information on the independent review process, call the OCI and request a copy of Fact Sheet on the Independent Review Process in Wisconsin. A copy is also available on OCI's Web site at http://oci.wi.gov/pub_list/pi-203.htm.

Continuation and Conversion

Both state and federal law give certain individuals who would otherwise lose their group health care coverage under an employer or association plan, the right to continue their coverage for a period of time. The two laws are similar in some ways, but also have provisions that are very different. Most employers that have 20 or more employees comply with the federal law, while most group health insurance policies that provide coverage to Wisconsin residents must comply with the state law. When both laws apply to the group coverage, it is the opinion of the OCI that where the federal and state laws differ, the law most favorable to the insured should apply.

The state law also gives conversion rights to certain individuals who are covered under individual health insurance policies.

Federal Law (COBRA)

The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that allows most employees, spouses, and their dependents who lose their health coverage under an employer's group health plan to continue coverage, at their own expense, for a period of time. This law applies to both insured health plans and self-funded employer-sponsored plans in the private sector and those plans sponsored by state and local governments. However, COBRA does not apply to certain church plans, plans covering less than 20 employees, and plans covering federal employees.

Under the federal law, employees who terminate employment for any reason other than gross misconduct, or who lose their eligibility for group coverage because of a reduction in work hours, and the covered spouses and dependents of the employees may continue the group coverage for up to 18 months. A spouse and dependents may continue coverage for up to 36 months if they lose coverage due to the death of the employee, divorce from the employee, loss of dependent status due to age, or due to the employee's eligibility for Medicare. If within the first 60 days of COBRA coverage an individual or dependent is determined to be disabled by Social Security, the disabled individual and other covered family members may continue coverage for up to 29 months.

Wisconsin Law (s. 632.897, Wis. Stat.)

Wisconsin's continuation law applies to most group health insurance policies that provide hospital or medical coverage to Wisconsin residents. The law applies to group policies issued to employers of any size. The law does not apply to employer self-funded health plans, or policies that cover only specified diseases or accidental injuries.

For questions about COBRA, contact:

U.S. Department of Labor - Regional Office
Employee Benefits Security Administration (EBSA)
200 West Adams, Suite 1600
Chicago, IL 60606
(312) 353-0900
http://www.dol.gov/dol/topic/health-plans/cobra.htm

For more information on continuation and conversion, call the OCI at 1-800-236-8517 and request a copy of Fact Sheet on Continuation and Conversion in Health Insurance Policies that describes both state and federal law. A copy is also available on OCI's Web site at http://oci.wi.gov/pub_list/pi-023.htm.

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 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.

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