Bulletin, July 28, 2021, Kidney Disease Treatment Requirements

Wisconsin Statute § 632.895 (4), requires insurers offering disability insurance that provides hospital treatment coverage on an expense incurred basis to provide coverage for kidney disease treatment.  Insurers subject to the mandate “shall provide coverage for hospital inpatient and outpatient kidney disease treatment, which may be limited to dialysis, transplantation and donor-related services…."  Wisconsin Statute § 632.895 (4) (b), provides that insurers are not required “to duplicate coverage available under the federal Medicare program, nor duplicate any other insurance coverage the insured may have…" exclusive of public assistance under Wis. Stat. Ch. 49.

OCI is aware of insurers limiting coverage for renal disease treatment to that of a secondary payer even when an insured is not enrolled in Medicare. Wisconsin is not a presumptive Medicare eligibility state. The mandate does not allow an insurer to refuse to provide coverage or pay as a secondary payer based on the fact that an insured could have coverage through Medicare. Insurers are mandated to provide coverage for kidney disease treatment regardless of what other coverage options a consumer may have. Insurers that refuse to cover or who otherwise reduce benefits under the policy “as if" the individual had other coverage are in violation of Wisconsin Insurance laws.

Insurers should review their policy forms to ensure they are compliant with the mandate. Insurance policy forms that impose additional restrictions or limitations for the treatment of kidney disease that are not in compliance with the mandate will be disapproved and insurers are prohibited from enforcing these provisions.

Any questions concerning this bulletin should be directed to Sarah Smith at Sarah.Smith2@wisconsin.gov.