Wis. Admin. Code Office of the Commissioner of Insurance Ins 8.72

Current through May 28, 2024

Section Ins 8.72 - Basic benefits

Subject to the limitations and restrictions under s. Ins 8.75 and copayments and coinsurance under s. Ins 8.77, each plan shall provide coverage for all of the following, if medically necessary:

(1)Professional services by a health care provider acting within the scope and limitations of his or her license or certificate or a person acting under the direction of a health care provider, including all of the following:

(a) Office, outpatient, inpatient and emergency room visits including treatment rendered during those visits.

(b) Surgical services including postoperative care following inpatient or outpatient surgery.

(c) Services of an assistant surgeon if necessary to perform surgery.

(d) Anesthesia services.

(2) Hospital care, including all of the following:

(a) Semi-private room, board and ancillary services and supplies that are generally provided to hospital inpatients.

(b) Confinement in an intensive care or coronary care unit of a hospital.

(c) Outpatient medical care and treatment.

(d) Medical care and treatment provided in a hospital emergency room.

(3)Medical care and treatment provided in an ambulatory surgery center, as defined in 42 CFR 416.2.

(4)Outpatient x-ray, laboratory and other diagnostic tests.

(5)Confinement in a skilled nursing home licensed under subch. I of ch. 50, Stats.

(6)Services provided by a home health agency licensed under s. 50.49, Stats.

(7)Care provided by a hospice licensed under subch. VI of ch. 50, Stats.

(8)Local ground licensed ambulance services.

(9)Physical therapy.

(10)Rental and purchase of durable medical equipment and supplies.

(11)Prescription drugs.

(12)Reconstructive surgery which is either of the following:

(a) Incidental to or following surgery necessitated by illness or injury.

(b) Caused by a congenital disease or anomaly of a covered dependent child which results in a functional defect.

(13) Sterilization.

(14) Maternity services including all of the following:

(a) Prenatal services normally associated with pregnancy.

(b) Delivery services normally associated with a vaginal or caesarean section delivery.

(c) Routine nursery care from the moment of birth until the infant is discharged from the hospital.

(15) Complications of pregnancy.

(16) Inpatient, outpatient and transitional treatment for nervous and mental disorders and alcoholism and other drug abuse, subject to s. Ins 8.75(3).

(17)Preventive services appropriate to the age and sex of the covered person including all of the following:

(a) Routine physical examinations and health screening tests.

(b) Immunizations for poliomyelitis, diphtheria, pertussis, typhoid, measles, mumps and rubella.

(c) Vaccinations for hemophilus influenza, type B.

(d) Diphtheria and tetanus boosters.

(e) Influenza and pneumonia vaccinations.

(f) Tuberculosis skin tests.

(18) Organ transplants that are covered by medicare.

(19)Services provided by a dentist for the repair of accidental dental injuries.

Wis. Admin. Code Office of the Commissioner of Insurance Ins 8.72

Cr. Register, June, 1993, No. 450, eff. 7-1-93; corrections in (3) and (6) made under s. 13.93(2m) (b) 7, Stats., Register October 2002 No. 562.

Amended by, correction in (7) made under s. 13.92(4) (b) 7., Stats., Register March 2017 No. 735, eff. 4/1/2017