Wis. Admin. Code Office of the Commissioner of Insurance 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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.