In addition to the federal regulations regarding health insurance, the state of Wisconsin has myriad laws and requirements concerning what type of benefits and coverage needs to be made available to its residents. These mandates canvas a range of policy, provider and coverage minimum specifics to ensure that Wisconsin health plans are providing policy holders essential support.
General Requirements Regarding Treatment Coverage
In the state of Wisconsin, all health insurance plans are required to cover certain aspects of every patient's treatment, such as a patient's emergency care, without prior claim authorization. All plans must also include a clearly defined and easily accessible communication structure for patients to submit questions or complaints and receive a speedy acknowledgment or reply. Similarly, when a complaint is filed with a plan provider, the plan provider must alert the state government and file a report outlining the nature of the issue and its resolution.
Wisconsin Health Plan Mandates
Wisconsin mandates that all individual or group plans offers coverage and benefits for individuals, including adopted children, handicapped children, pregnant women and infants. Wisconsin health insurance law also specifies that conditions such as alcoholism, drug abuse, kidney disease, mental disorders and diabetes be covered. Wisconsin law dictates that nursing home care, home aide care, primary physician care and dental care are made accessible to policy holders and covered at least partially under basic health benefits.
Gender-Specific Requirements
The state government mandates that health plans in Wisconsin must include several female-oriented benefits and care provisions for policy holders. For example, all policies must include benefits concerning screening for various types of cancer in women, such as breast and cervical cancer. Similarly, health insurance plans in Wisconsin must cover a woman's access to an OB/GYN for both need-specific care and primary care. However, unlike many other states, Wisconsin does not mandate that contraceptives must be covered by health insurance plans, nor does it mandate coverage be given to individuals who suffer from depression or an eating disorder.
Health Insurance Risk-Sharing Plan
As part of its health insurance policy, the Wisconsin state government established the Health Insurance Risk-Sharing Plan (HIRSP) for residents in 1979 with the goal of making coverage accessible to individuals who encounter difficulty finding an appropriate plan in the private insurance market due to pre-existing medical conditions or job loss. HIRSP is a state funded program that requires potential policy holders to fill out an application regarding medical history and financial circumstance. Once accepted, policy holders receive coverage on health maintenance visits, hospital visits and prescription drugs.
Insurance Regulations for Small Businesses
Wisconsin health insurance law offers specific regulations as to what a small business employer is required to offer employees. Small business employers must offer benefits and coverage to employees who become pregnant, adopt a child under the age of 18 or develop a genetically determined illness. Small business employers are not required to cover employs with pre-existing conditions in the first 12 months of their employment. Wisconsin health insurance law defines a small business as an entity that employs between two and 50 people. There are no state mandated regulations for self-employed individuals.
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