Date:February 28, 2000
To:All Insurers Licensed to Write Health Insurance in Wisconsin
From:Randy Blumer, Deputy Commissioner
Subject:Section Ins 3.67, Wis. Adm. Code - Benefit Appeals Under Certain Policies

The purpose of this memorandum is to summarize the requirements of s. Ins 3.67, Wis. Adm. Code, which will become effective for all policies issued or renewed on or after March 1, 2000.

INSURERS SHOULD CAREFULLY REVIEW THIS MEMORANDUM AND THE RULE AS BOTH POLICY FORMS AND OUTLINES OF COVERAGE ARE AFFECTED.

Section 632.853, Wis. Stat., requires health care plans and self-insured health plans that use a formulary or other list of preapproved drugs and devices to have a process to permit a physician to request an individual exception for coverage of a drug or device not normally covered under the plan. Section 632.855, Wis. Stat. requires health care plans and self-insured health plans that limit coverage of experimental treatment to disclose such limitations and an insured's right to appeal a denial of coverage of an experimental treatment, in its policies, certificates and outlines of coverage. Both laws became effective January 1, 1999. Section Ins 3.67, Wis. Adm. Code contains requirements and standards that must be included in the appeal process established pursuant to ss. 632.853 and 632.855, Wis. Stat.

Section Ins 3.67 (1)

This section defines "health care plan" as an insurance contract providing coverage of health care expenses. This definition includes fixed indemnity and specified disease insurance, but does not include coverage ancillary to property and casualty insurance and Medicare + Choice plans. This section also defines "self-insured health plan" as a self-insured health plan of the state or a county, city, village, town or school district.

Section Ins 3.67 (2)

Health care plans and self-insured health plans that use a formulary or other list of preapproved drugs and devices must have a process to permit a physician to request an individual exception for coverage of a drug or device not normally covered under the plan, pursuant to s. 632.853, Wis. Stat.

Section Ins 3.67 (3)

Health care plans and self-insured health plans that limit coverage for experimental treatment must disclose such limitations in its policies and certificates, and have a procedure for handling requests for prior authorization of an experimental procedure. Plans must also have a procedure to allow an insured to appeal a denial of coverage for an experimental treatment, pursuant to s. 632.855, Wis. Stat.

Section Ins 3.67 (4)

Managed care plans must allow an enrollee to appeal a denial of coverage for a drug or device not normally covered under the plan or for an experimental treatment, pursuant to the grievance procedures in s. Ins 9.33, Wis. Adm. Code.

Health care plans that are not managed care plans must establish an appeal process that includes the following requirements:

  • A policyholder, certificate holder or an authorized representative must be allowed the opportunity to appeal a denial of coverage for a drug or device not normally covered under the plan or for an experimental treatment by submitting a written request, in any form, to the insurer.
  • A written description of the appeal process must be given the insured at the time of notice of a denial of coverage.
  • An appeal to allow coverage of a drug or device not normally covered under the plan must be acknowledged, in writing, by the health care plan or self-insured health plan within 5 business days of receiving the appeal.
  • The person who submits an appeal must be notified by the health care plan or self-insured health plan of the results of the appeal within 30 calendar days.
  • An expedited request as defined in s. Ins 3.67 (1), Wis. Adm. Code must be resolved as expeditiously as the health condition requires, but not to exceed 72 hours from the appeal request.
  • A description of the appeal process must be included in every policy, certificate and outline of coverage.
  • An insurer offering health care plans must maintain at its home or principal office all records of appeals under this section, and make such records available to the commissioner upon request.

This bulletin presents a brief summary of the benefit appeal requirements for health care plans and self-insured health plans. A copy of the complete rule can be obtained by sending a written request, along with a large self-addressed, stamped envelope to OCI's Central Files Section, or you may review the rule on OCI's website at http://oci.wi.gov/rules/0900fn00.pdf (opens in new window).

Persons To Contact For Additional Information

If you have questions, please put them in writing and address them to Barbara Belling or Diane Dambach, Health & Life Section, Market Regulation Bureau.