What the statutes mean

Since the late 1980’s chiropractors around the country have referred to the requirement for insurers to pay for chiropractic services as “insurance equality” or the “chiropractic mandate”. In reality, neither phrase accurately describes the law in Wisconsin. Wisconsin’s law is closer to an anti-discrimination statute in that insurance companies are free to eliminate coverage for the spine as long as all health care providers are equally treated. In other words, if an insurer choses to eliminate chiropractic care for the spine, they would also have to forbid medical doctors and osteopaths from treating the spine as well.

While the law provides excellent protection against discrimination, it only covers insurers that are covered under Wisconsin statute. Employers that are self insured are exempted because their insurance plans are governed by federal, not state, law. Federal ERISA laws allow a self insured employer to place restrictions on chiropractic care. It is not the insurance company that is self-insured, it is the employer. If you question restrictions placed on chiropractic care you must call the employer to find out whether they are self insured.

Individuals that buy their own insurance (i.e. are not covered by their employer) are also not covered under Wisconsin law. Individuals have a wide variety of health plans from which to select. If they want chiropractic coverage, they may select an insurance company that will offer them coverage. If they want to discriminate against themselves by selecting a company that does not offer chiropractic coverage, they are free to do so.

An insurance company may not:

• Exclude coverage for treatment by a chiropractor, if the insurer covers treatment of the condition by a licensed physician or osteopath. This is true even if a different nomenclature is used to describe the condition.

• Require an examination or referral from a physician before allowing payment for chiropractic services.

• Refuse to provide coverage to an individual because of prior treatment by a chiropractor.

• Establish underwriting standards that are more restrictive for chiropractic care than for care provided by other health care providers.

• Exclude or restrict coverage of a health condition solely because the condition may be treated by a chiropractor.

An insurer may not refuse to pay for chiropractic services unless a chiropractor or a peer review committee that includes a chiropractor recommends the care be denied.

While insurance companies are not allowed to discriminate they are allowed to:

• Require deductibles and co-insurance as long as they are applied to chiropractors and medical doctors on an equal basis.

• Apply cost containment and/or quality assurance measures to chiropractic services as long as the manner in which they do so is consistent with cost containment or quality assurance measures generally applied to the services performed by medical doctors.

Practical advice

This law prevents discrimination against chiropractors. Chiropractors and their patients have additional protection in Wi. Stat. 632.875 (2). A description of that law is under the heading “Independent Medical Exams”.

Statutory excerpts

632.87(3) (a) No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by a licensed physician or osteopath, even if different nomenclature is used to describe the condition or complaint. Examination by or referral from a physician shall not be a condition precedent for receipt of chiropractic care under this paragraph. This paragraph does not:

632.87(3)(a)1. Prohibit the application of deductibles or coinsurance provisions to chiropractic and physician charges on an equal basis.

632.87(3)(a)2.Prohibit the application of cost containment or quality assurance measures to chiropractic services in a manner that is consistent with cost containment or quality assurance measures generally applicable to physician services and that is consistent with this section.

632.87(3)(b) No insurer, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, may do any of the following:

632.87(3)(b)1. Restrict or terminate coverage for the treatment of a condition or a complaint by a licensed chiropractor within the scope of the chiropractor’s professional license on the basis of other than an examination or evaluation by or a recommendation of a licensed chiropractor or a peer review committee that includes a licensed chiropractor.

632.87(3)(b)2. Refuse to provide coverage to an individual because that individual has been treated by a chiropractor.

632.87(3)(b)3. Establish underwriting standards that are more restrictive for chiropractic care than for care provided by other health care providers.

632.87(3)(b)4. Exclude or restrict health care coverage of a health condition solely because the condition may be treated by a chiropractor.

632.87(3)(c) An exclusion or a restriction that violates par. (b) is void in its entirety.