609.655 Coverage of certain services provided to dependent students.

(1) In this section:

(a) “Dependent student" means an individual who satisfies all of the following:

1. Is covered as a dependent child under the terms of a policy or certificate issued by a defined network plan insurer.

2. Is enrolled in a school located in this state but outside the geographical service area of the defined network plan.

(b) “Outpatient services" has the meaning given in s. 632.89 (1) (e).

(c) “School" means a technical college; an institution within the University of Wisconsin System; and any institution of higher education that grants a bachelor's or higher degree.

(2) If a policy or certificate issued by a defined network plan insurer provides coverage of outpatient services provided to a dependent student, the policy or certificate shall provide coverage of outpatient services, to the extent and in the manner required under sub. (3), that are provided to the dependent student while he or she is attending a school located in this state but outside the geographical service area of the defined network plan, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) and 609.05 (3).

(3) Except as provided in sub. (5), a defined network plan shall provide coverage for all of the following services:

(a) A clinical assessment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems, conducted by a provider described in s. 632.89 (1) (e) 2., 3., or 4. who is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and who may be designated by the defined network plan.

(b) If outpatient services are recommended in the clinical assessment conducted under par. (a), the recommended outpatient services consisting of not more than 5 visits to an outpatient treatment facility or other provider that is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and that may be designated by the defined network plan, except as follows:

1. Coverage is not required under this paragraph if the medical director of the defined network plan determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.

2. Coverage is not required under this paragraph for outpatient services provided after the dependent student has terminated his or her enrollment in the school.

(4)

(a) Upon completion of the 5 visits for outpatient services covered under sub. (3) (b), the medical director of the defined network plan and the clinician treating the dependent student shall review the dependent student's condition and determine whether it is appropriate to continue treatment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems in reasonably close proximity to the school in which the student is enrolled. The review is not required if the dependent student is no longer enrolled in the school or if the coverage limits under the policy or certificate for treatment of nervous or mental disorders or alcoholism or other drug abuse problems have been exhausted.

(b) Upon completion of the review under par. (a), the medical director of the defined network plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the defined network plan's internal grievance procedure established under s. 632.83.

(5)

(a) A policy or certificate issued by a defined network plan insurer is required to provide coverage for the services specified in sub. (3) only to the extent that the policy or certificate would have covered the service if it had been provided to the dependent student by a participating provider within the geographical service area of the defined network plan.

(b) Paragraph (a) does not permit a defined network plan to reimburse a provider for less than the full cost of the services provided or an amount negotiated with the provider, solely because the reimbursement rate for the service would have been less if provided by a participating provider within the geographical service area of the defined network plan.

History: 1989 a. 121; 1993 a. 399; 1997 a. 237; 1999 a. 155; 2001 a. 16; 2009 a. 28.