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Mandated Benefits in Health Insurance in Wisconsin

Many employers modify their health plans at the beginning of the year, so this may be a good time to review your health insurance plan to verify that you are aware of all of the benefits in your plan.

All health insurance policies differ in the amount and types of treatment that are covered. However, all health insurance policies sold in Wisconsin are required to cover certain medical treatments and other medical services. These required benefits are often referred to as "mandated benefits." Some mandated benefits are only required in group health insurance policies and some are required in both group and individual health insurance policies. To simplify the explanation, let's focus on two of those mandated benefits: coverage of diabetic equipment and supplies, and coverage of chiropractic treatment.

Health insurance policies that cover the treatment of diabetes are required to cover diabetic equipment and supplies. This includes coverage of disposable supplies, such as syringes, and test strips, and coverage of durable medical equipment such as glucometers and insulin infusion pumps. In addition, coverage is required for insulin and for diabetic self-management education programs. A recent change in the law will require coverage of any prescription medication used in the treatment of diabetes, even if the policy does not cover other prescription drugs. This change applies to all health insurance policies that are issued or renewed on or after January 1, 2003. There may be cost-sharing requirements, such as deductibles or copayments that apply to this benefit. You may also be required to obtain pre-authorization for some supplies or be required to follow other procedures. You should review your benefits booklet to see how your plan covers equipment and supplies necessary for treatment of this disease.

Another important Wisconsin mandate requires coverage of the services of certain non-physician providers. For over 10 years, policies have been required to cover services provided by a chiropractor if the policy covers treatment of the medical condition by a p physician. This applies even if the specific treatment plan recommended by a chiropractor is no the same type of treatment that would be recommended by a physician for the condition. It may limit coverage to treatment that is medically necessary to treat your illness or injury, and it is not required to cover treatment intended to maintain your health. Although HMO plans may require you to use the services of a chiropractor who participates in the HMO plans, they may not require you to obtain a referral from your primary care physician or to obtain other permission from the plan. The insurance policy may also require you to pay the same deductibles and copayment amounts that you would pay for treatment from a physician.

If you would like more information on the mandated benefits in Wisconsin, the Office of the Commissioner of Insurance (OCI) publishes a pamphlet that contains a brief description of all current mandated benefits. It's called the Fact Sheet on Mandated Benefits in Health Insurance Policies and may be obtained on OCI's Web site at: http://oci.wi.gov/pub_list/pi-019.htm or by contacting the OCI by telephone at 1-800-236-8517, by electronic mail at information@oci.state.wi.us , or by paper mail at OCI, P.O. Box 7873, Madison, WI 53707-7873

Article written and published by:

Barbara Belling
Managed Care Specialist
Office of the Commissioner of Insurance

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