What the statutes mean

While Wisconsin law covers millions of Wisconsin residents, some employers and insurance companies are exempt. The major exemptions are those employers who are self insured and are covered by federal ERISA laws. In addition, members of an Indian tribe (and in some cases employees of indian tribes) are also exempt from Wisconsin laws.

Here are additional exemptions:

• The policyholder is not a Wisconsin corporation or other resident and does not have its principal office in Wisconsin.

• No more than 25% of the certificate holders or insureds are resident in this state;

• Reinsurance. These are the insurance companies of insurance companies and, except for extraordinary circumstances, are not likely to be encountered by you or your staff in the normal processing of a claim.

• Group insurance if both the policyholder and the group exist primarily for purposes other than to procure insurance.

Practical advice

Every year WCA members report hundreds of potential law violations to the WCA. While the association is able to help with most of these violations, we can not do anything if a company is exempt from Wisconsin law. It is not the insurance company that is self insured but rather the employer. Insurance companies sell many different types of coverage including traditional group health plans and managed care plans. When they represent an employer that is self insured they are acting as the administrator of the plan only. That means that they do all of the administrative work of processing claims and the review work to insure that the services were medically necessary. But the employer pays them to do this work and is responsible for all of the costs and risks associated with offering insurance.

If you or your staff is unclear whether or not a company is self insured, you should call the insurance department of the employer and ask if they are self-insured for their group health insurance. If you call the insurance company you may get an inexperienced customer service representative that will give you incorrect information.

A company that is self insured is covered under federal ERISA laws and is exempt from Wisconsin’s statutes and rules. This means that may choose whether or not to offer chiropractic services, may require pre-authorization or pre-certification, may require a referral from a medical doctor, or may set limits on the services provided by a chiropractor.

It is to your advantage to inform your patient of any restrictions imposed by their self insured employer so they are prepared for the possibility that may have to pay for those services that are not allowed under their plan. When a patient expresses frustration with the restrictions, this is your opportunity to ask that they voice their concerns to their employer who has complete control over the terms of their plan.

Statute excerpts

Note: In addition to the exceptions noted in this section of the statute, all companies covered by federal ERISA laws and Indian tribes are also exempted from these laws.

600.01(1)(b) Unless otherwise expressly provided, chs. 600 to 646 do not apply to:

600.01(1)(b)1 Reinsurance.

600.01(1)(b)3. Group or blanket insurance covering risks in this state if:

600.01(1)(b)3.a Both the policyholder and the group exist primarily for purposes other than to procure insurance;

600.01(1)(b)3.am. The relationship or association between the policyholder and the group was not created for purposes of procuring insurance;

600.01(1)(b)3.b. The policyholder is not a Wisconsin corporation or other resident and does not have its principal office in Wisconsin;

600.01(1)(b)3.c. No more than 25% of the certificate holders or insureds are resident in this state;

600.01(1)(b)4. Group or blanket insurance covering risks mainly outside this state if:

600.01(1)(b)4.a Both the policyholder and the group exist primarily for purposes other than to procure insurance;

600.01(1)(b)4.am. The relationship or association between the policyholder and the group was not created for purposes of procuring insurance;

600.01(1)(b)4.b. The policyholder is not a Wisconsin corporation or other resident and does not have its principal office in Wisconsin; and

600.01(1)(b)4.c. Any Wisconsin residents insured under the policy are covered because their principal place of employment is outside the state.