Section 3.37. Transitional treatment arrangements.

 

(1)   Purpose. This section implements s. 632.89 (4) (a) , Stats.

(2)   Applicability.

(a) This section applies to group and blanket disability insurance policies issued or renewed on and after November 1, 1992, and prior to December 1, 2010, and group health benefit plans and self-insured governmental plans that elect and are eligible to be exempt pursuant to s. 632.89 (3c) , (3f) or (5) , Stats., that provide coverage for inpatient hospital services or outpatient services, as defined in s. 632.89 (1) (d) or (e) , Stats. Group and blanket disability insurance policies and exempted group health benefit plans and self-insured governmental plans shall cover transitional treatment services and comply with subs. (2m) , (3) , (4) , and (5) .

(b) Policies issued on or after December 1, 2010, by a group health benefit plan and a self-insured governmental health plan that are not otherwise exempt under s. 632.89 (3c) , (3f) or (5) , Stats., shall comply with subs. (2m) , (3m) , (4m) , and (5m) .

(2m)   Definitions. In addition to the definitions in s. 632.89 (1) , Stats., in this section:

(a) "Individual health benefit plan" means an insurance product offered on an individual basis that meets the criteria established for a health benefit plan in s. 632.745 (11) , Stats.

(b) "Eligible employee" has the meaning provided in s. 632.745 (5) , Stats.

(c) "Qualified actuary" means a member in good standing of the American Academy of Actuaries who meets any other requirements that the commissioner may by rule specify as defined in s. 623.06 (1c) , Stats., and in accordance with s. 632.89 (3c) (b) , Stats.

(d) "Self-insured governmental plan" has the meaning of a self-insured health plan as defined at s. 632.89 (1) (em) , Stats.

(e) "Substance use disorder" has the same meaning as "alcoholism and other drug abuse problems" as the phrase appears throughout s. 632.89 , Stats.

(f) "Substantially all" has the meaning as provided in 29 CFR 2590.712 (a).

(g) "Treatment limitations" means the limitations that insurers offering group or individual health benefit plans and self-insured governmental plans may impose on treatment of nervous and mental disorders and substance use disorders as described in s. 632.89 (3) , Stats.

(3)   Covered services. An insurer offering a policy subject to this subsection shall provide at least the amount of coverage required under s. 632.89 (2) (dm) 2. , 2007 Stats., subject to the exclusions or limitations, including deductibles and copayments, that are generally applicable to coverage required under s. 632.89 (2) , 2007 Stats., for all of the following:

(a) Mental health services for adults in a day treatment program compliant with the services identified at s. DHS 61.75 (2) and offered by a provider certified by the department of health services under s. DHS 61.75 .

(b) Mental health services for children and adolescents in a day treatment program compliant with the services identified at s. DHS 40.11 and offered by a provider certified by the department of health services under s. DHS 40.04 .

(c) Services for persons with chronic mental illness provided through a community support program compliant with the services identified at s. DHS 63.11 and certified by the department of health services under s. DHS 63.03 .

(d) Residential treatment programs compliant with the services identified at s. DHS 75.14 (1) , for alcohol or drug dependent persons, or both, certified by the department of health services under s. DHS 75.14 (2) and under supervision as required in s. DHS 75.14 (5) .

(e) Services for substance use disorders provided in a day treatment program compliant with the services identified at s. DHS 75.12 (1) , certified by the department of health services under s. DHS 75.12 (2) and under supervision as required in s. DHS 75.12 (5) .

(f) Intensive outpatient programs for narcotic treatment services for opiate addiction compliant with the services under s. DHS 75.15 (1) and (9) , certified by the department of health services under s. DHS 75.15 (2) and under supervision as required in s. DHS 75.15 (4) .

(g) Coordinated emergency mental health services for persons who are experiencing a mental health crisis or who are in a situation likely to turn into a mental health crisis if support is not provided. Services are provided by a program compliant with s. DHS 34.22 , certified by the department of health services under s. DHS 34.03 , and provided in accordance with subch. III of ch. DHS 34 for the period of time the person is experiencing a mental health crisis until the person is stabilized or referred to other providers for stabilization. Certified emergency mental health service plans shall provide timely notice to third-party payors to facilitate coordination of services for persons who are experiencing or are in a situation likely to turn into a mental health crisis.

(3m)   Covered Services. An insurer offering a group health benefit plan or a self-insured governmental plan subject to this subsection shall provide at least the amount of coverage for services included in s. 632.89 (2) (dm) , Stats., subject to the exclusions or limitations, including deductibles and copayments, that are generally applicable to coverage required under s. 632.89 (3) , Stats., for all of the following:

(a) Mental health services for adults in a day treatment program compliant with the services identified at s. DHS 61.75 (2) and offered by a provider certified by the department of health services under s. DHS 61.75 .

(b) Mental health services for children and adolescents in a day treatment program compliant with the services identified at s. DHS 40.11 and offered by a provider certified by the department of health services under s. DHS 40.04 .

(c) Services for persons with chronic mental illness provided through a community support program compliant with the services identified at s. DHS 63.11 and certified by the department of health services under s. DHS 63.03 .

(d) Residential treatment programs compliant with the services identified at s. DHS 75.14 (1) , for alcohol or drug dependent persons, or both, certified by the department of health services under s. DHS 75.14 (2) and under supervision as required in s. DHS 75.14 (5) .

(e) Services for substance use disorders provided in a day treatment program compliant with the services identified at s. DHS 75.12 (1) , certified by the department of health services under s. DHS 75.12 (2) and under supervision as required in s. DHS 75.12 (5) .

(f) Intensive outpatient programs for narcotic treatment service for opiate addiction compliant with the services under s. DHS 75.15 (1) and (9) , certified by the department of health services under s. DHS 75.15 (2) and under supervision as required in s. DHS 75.15 (4) .

(g) Coordinated emergency mental health services for persons who are experiencing a mental health crisis or who are in a situation likely to turn into a mental health crisis if support is not provided. Services are provided by a program compliant with s. DHS 34.22 , certified by the department of health services under s. DHS 34.03 , and provided in accordance with subch. III of ch. DHS 34 for the period of time the person is experiencing a mental health crisis until the person is stabilized or referred to other providers for stabilization. Certified emergency mental health service plans shall provide timely notice to third-party payors to facilitate coordination of services for persons who are experiencing or are in a situation likely to turn into a mental health crisis.

(4)   Out-of-state services and programs. An insurer offering a group and blanket disability plan or exempt group health benefit plans and self-insured governmental plans may comply with sub. (3) (a) to (g) by providing coverage for services and programs that are substantially similar to those specified in sub. (3) (a) to (g) , if the provider is in compliance with similar requirements of the state in which the provider is located.

(4m)   Out-of-state Services And Programs. An insurer offering a group health benefit plan and self-insured governmental health plan may comply with sub. (3m) (a) to (g) by providing coverage for services and programs that are substantially similar to those specified in sub. (3m) (a) to (g) , if the provider complies with similar requirements of the state in which the provider is located.

(5)   Policy form requirements. An insurer offering a group and blanket disability plan or exempt group health benefit plans and self-insured governmental plans shall specify in each policy form all of the following:

(a) The types of transitional treatment programs and services covered by the policy as specified in sub. (3) .

(b) The method the insurer uses to evaluate a transitional treatment program or service to determine if it is medically necessary and covered under the terms of the policy.

(5m)   Policy Form Requirements. An insurer offering a group health benefits plan and self-insured governmental health plan shall specify in each policy form all of the following:

(a) The types of transitional treatment programs and services covered by the policy as specified in sub. (3m) .

(b) The method the insurer and the self-insured governmental health plan uses to evaluate a transitional treatment program or service to determine if it is medically necessary and covered under the terms of the policy.

Emerg. cr. eff. 9-29-92; cr. Register, February, 1993, No. 446 , eff. 3-1-93; corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, June, 1997, No. 498 ; correction in (3) (c) made under s. 13.93 (2m) (b) 7., Stats., Register, July, 2000, No. 535 ; CR 02-051 : am. (3) (intro.), (b), (d) and (e), cr. (3) (g) Register December 2002 No. 564 , eff. 1-1-03; corrections in (3) (a) to (e) and (g) made under s. 13.92 (4) (b) 6. and 7., Stats., Register October 2008 No. 634 ; EmR1043 : emerg. am. (1) to (4) and (5) (intro.), cr. (2m), (3m), (4m) and (5m) eff. 11-29-10; CR 10-149 : am. (1) to (4) and (5) (intro.), cr. (2m), (3m), (4m) and (5m) Register June 2011 No. 666 , eff. 7-1-11.