The national Medical Plans guide covers plan types (indemnity, HMO, PPO, POS, HDHP with HSA), cost sharing and the federal ACA rules. This guide covers the Wisconsin rules: the long list of mandated benefits in Wis. Stat. 632.895 and nearby sections, dependent coverage, grievances and independent review, and suitability and replacement rules for individual health sales.

Plan types

• A point-of-service plan combines HMO-style gatekeeping and networks with PPO-style out-of-network options (609.10(1)(ac)).
• Fixed indemnity coverage pays a set amount per event instead of actual expenses (632.895(1)(c)).
• Coordination of benefits keeps combined payments from more than one plan from exceeding the actual covered expense (Ins 3.40).

Dependent coverage

• Adult children may stay covered until age 26 (632.885(2)(a)).
• A child who is a full-time student and is called to active duty in the guard or reserves may stay covered past 26, while under 27 (632.885(2)(b)).
• A child who can't support themselves because of an intellectual disability or physical handicap, and is chiefly dependent on the insured, stays covered (632.88).
• Newborns are covered from birth, including congenital defects. The plan may require notice and premium within 60 days (632.895(5)).
• The children of a covered child are covered until that covered child turns 18 (632.895(5m)).
• Adopted children are covered from the earlier of placement or the final adoption order, with no preexisting-condition exclusion (632.896).

Mandated benefits (Wis. Stat. 632.895 and related)

• A plan can't exclude care at a licensed facility out of state within 75 miles of the insured's home (632.75(4)).
• A dependent covered as a full-time student keeps coverage during a medically necessary leave of absence (632.895(15)).

Grievances and independent review

• An insurer's grievance panel includes someone authorized to act and, if available, at least one insured other than the grievant (632.83).
• Independent review (632.835):
  • The request is filed within 4 months after the grievance decision.
  • The amount denied must exceed $250.
  • The decision binds both sides, except that preexisting-condition and rescission decisions don't bind the insured.

Selling individual health coverage

• An agent may recommend a policy only after reasonable inquiry gives grounds to believe it isn't unsuitable (Ins 3.27(7)).
• An outline of coverage is given when the application is taken (Ins 3.27(8)(b)).
• Replacement (Ins 3.29):
  • The application asks about replacement.
  • The applicant signs a notice at application.
  • The notice warns about new preexisting-condition limits and waiting periods, issue at a higher age, and renewal terms.
• The free look for individual health policies is 10 days (632.73). See the Wisconsin Individual Accident and Health Provisions guide.

Common exam traps

• Adult children stay covered to 26, and a student called to active duty to 27.
• A covered child's own children are covered until the covered child turns 18.
• The newborn premium may be required within 60 days.
• Home care is at least 40 visits. Skilled nursing is 30 days. Kidney coverage is $30,000.
• Chiropractic needs no referral.
• Independent review requires more than $250 in dispute and a request within 4 months.