AB768-ASA1,434,1615
1. If the plan under which the enrollee has coverage has an open enrollment
16period, the most recent open enrollment period.
AB768-ASA1,434,1917
2. If the plan under which the enrollee has coverage has no open enrollment
18period, the time of the enrollee's enrollment or most recent coverage renewal,
19whichever is later.
AB768-ASA1,434,2220
(b) Except as provided in par. (d), a managed care plan shall provide the
21coverage required under par. (a) with respect to the services of a provider who is a
22primary care physician for the following period of time:
AB768-ASA1,434,2423
1. For an enrollee of a plan with no open enrollment period, until the end of the
24current plan year.
AB768-ASA1,435,3
12. For an enrollee of a plan with an open enrollment period, until the end of the
2plan year for which it was represented that the provider was, or would be, a
3participating provider.
AB768-ASA1,435,84
(c) Except as provided in par. (d), if an enrollee is undergoing a course of
5treatment with a participating provider who is not a primary care physician and
6whose participation with the plan terminates, the managed care plan shall provide
7the coverage under par. (a) with respect to the services of the provider for the
8following period of time:
AB768-ASA1,435,129
1. Except as provided in subd. 2., for the remainder of the course of treatment
10or for 90 days after the provider's participation with the plan terminates, whichever
11is shorter, except that the coverage is not required to extend beyond the period
12specified in par. (b) 1. or 2., whichever applies.
AB768-ASA1,435,1513
2. If maternity care is the course of treatment and the enrollee is a woman who
14is in the 2nd or 3rd trimester of pregnancy when the provider's participation with the
15plan terminates, until the completion of postpartum care for the woman and infant.
AB768-ASA1,435,1716
(d) The coverage required under this section need not be provided or may be
17discontinued if any of the following applies:
AB768-ASA1,435,1918
1. The provider no longer practices in the managed care plan's geographic
19service area.
AB768-ASA1,435,2120
2. The insurer issuing the managed care plan terminates or terminated the
21provider's contract for misconduct on the part of the provider.
AB768-ASA1,435,2422
(e) 1. An insurer issuing a managed care plan shall include in its provider
23contracts provisions addressing reimbursement to providers for services rendered
24under this section.
AB768-ASA1,436,3
12. If a contract between a managed care plan and a provider does not address
2reimbursement for services rendered under this section, the insurer shall reimburse
3the provider according to the most recent contracted rate.
AB768-ASA1,436,6
4(2) Medical necessity provisions. This section does not preclude the
5application of any provisions related to medical necessity that are generally
6applicable under the plan.
AB768-ASA1,436,11
7(3) Hold harmless requirements. A provider that receives or is due
8reimbursement for services provided to an enrollee under this section is subject to
9s. 609.91 with respect to the enrollee, regardless of whether the provider is a
10participating provider in the enrollee's plan and regardless of whether the enrollee's
11plan is a health maintenance organization.
AB768-ASA1,436,16
13609.30 Provider disclosures. (1)
Plan may not contract. A managed care
14plan may not contract with a participating provider to limit the provider's disclosure
15of information, to or on behalf of an enrollee, about the enrollee's medical condition
16or treatment options.
AB768-ASA1,436,22
17(2) Plan may not penalize or terminate. A participating provider may discuss,
18with or on behalf of an enrollee, all treatment options and any other information that
19the provider determines to be in the best interest of the enrollee. A managed care
20plan may not penalize or terminate the contract of a participating provider because
21the provider makes referrals to other participating providers or discusses medically
22necessary or appropriate care with or on behalf of an enrollee.
AB768-ASA1,437,2
24609.32 Quality assurance. (1) Standards. A managed care plan shall
25develop comprehensive quality assurance standards that are adequate to identify,
1evaluate and remedy problems related to access to, and continuity and quality of,
2care. The standards shall include at least all of the following:
AB768-ASA1,437,33
(a) An ongoing, written internal quality assurance program.
AB768-ASA1,437,44
(b) Specific written guidelines for quality of care studies and monitoring.
AB768-ASA1,437,55
(c) Performance and clinical outcomes-based criteria.
AB768-ASA1,437,76
(d) A procedure for remedial action to address quality problems, including
7written procedures for taking appropriate corrective action.
AB768-ASA1,437,88
(e) A plan for gathering and assessing data.
AB768-ASA1,437,99
(f) A peer review process.
AB768-ASA1,437,17
10(2) Selection and evaluation of providers. (a) A managed care plan shall
11develop a process for selecting participating providers, including written policies and
12procedures that the plan uses for review and approval of providers. After consulting
13with appropriately qualified providers, the plan shall establish minimum
14professional requirements for its participating providers. The process for selection
15shall include verification of a provider's license or certificate, including the history
16of any suspensions or revocations, and the history of any liability claims made
17against the provider.
AB768-ASA1,437,2118
(b) A managed care plan shall establish in writing a formal, ongoing process
19for reevaluating each participating provider within a specified number of years after
20the provider's initial acceptance for participation. The reevaluation shall include all
21of the following:
AB768-ASA1,437,2222
1. Updating the previous review criteria.
AB768-ASA1,437,2423
2. Assessing the provider's performance on the basis of such criteria as enrollee
24clinical outcomes, number of complaints and malpractice actions.
AB768-ASA1,438,2
1(c) A managed care plan may not require a participating provider to provide
2services that are outside the scope of his or her license or certificate.
AB768-ASA1,438,7
4609.34 Clinical decision-making; medical director. A managed care plan
5shall appoint a physician as medical director. The medical director shall be
6responsible for clinical protocols, quality assurance activities and utilization
7management policies of the plan.
AB768-ASA1,438,11
9609.36 Data systems and confidentiality. (1) Information and data
10reporting. (a) A managed care plan shall provide to the commissioner information
11related to all of the following:
AB768-ASA1,438,1212
1. The structure of the plan.
AB768-ASA1,438,1313
2. Health care benefits and exclusions.
AB768-ASA1,438,1414
3. Cost-sharing requirements.
AB768-ASA1,438,1515
4. Participating providers.
AB768-ASA1,438,1716
(b) Subject to sub. (2), the information and data reported under par. (a) shall
17be open to public inspection under ss. 19.31 to 19.39.
AB768-ASA1,438,20
18(2) Confidentiality. A managed care plan shall establish written policies and
19procedures, consistent with ss. 51.30, 146.82 and 252.15, for the handling of medical
20records and enrollee communications to ensure confidentiality.
AB768-ASA1,438,25
22609.38 Oversight. The office shall perform examinations of insurers that
23issue managed care plans consistent with ss. 601.43 and 601.44. The commissioner
24shall by rule develop standards for managed care plans for compliance with the
25requirements under this chapter.
AB768-ASA1,439,102
609.65
(1) (intro.) If an
enrolled participant of a health maintenance
3organization, enrollee of a limited service health organization
or, preferred provider
4plan
or managed care plan is examined, evaluated or treated for a nervous or mental
5disorder pursuant to an emergency detention under s. 51.15, a commitment or a
6court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the
7limitations regarding
selected participating providers, primary providers and
8referrals under ss. 609.01 (2) to (4) and 609.05 (3), the
health maintenance
9organization, limited service health organization
or
, preferred provider plan
or
10managed care plan shall do all of the following:
AB768-ASA1,439,1812
609.65
(1) (a) If the provider performing the examination, evaluation or
13treatment has a provider agreement with the
health maintenance organization,
14limited service health organization
or, preferred provider plan
or managed care plan 15which covers the provision of that service to the
enrolled participant enrollee, make
16the service available to the
enrolled participant
enrollee in accordance with the
17terms of the
health care limited service health organization, preferred provider plan
18or managed care plan and the provider agreement.
AB768-ASA1,440,220
609.65
(1) (b) (intro.) If the provider performing the examination, evaluation
21or treatment does not have a provider agreement with the
health maintenance
22organization, limited service health organization
or
, preferred provider plan
or
23managed care plan which covers the provision of that service to the
enrolled
24participant enrollee, reimburse the provider for the examination, evaluation or
25treatment of the
enrolled participant enrollee in an amount not to exceed the
1maximum reimbursement for the service under the medical assistance program
2under subch. IV of ch. 49, if any of the following applies:
AB768-ASA1,440,84
609.65
(1) (b) 1. The service is provided pursuant to a commitment or a court
5order, except that reimbursement is not required under this subdivision if the
health
6maintenance organization, limited service health organization
or, preferred provider
7plan
or managed care plan could have provided the service through a provider with
8whom it has a provider agreement.
AB768-ASA1,440,1410
609.65
(1) (b) 2. The service is provided pursuant to an emergency detention
11under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20
12and the provider notifies the
health maintenance organization, limited service
13health organization
or, preferred provider plan
or managed care plan within 72
14hours after the initial provision of the service.
AB768-ASA1,440,2216
609.65
(2) If after receiving notice under sub. (1) (b) 2. the
health maintenance
17organization, limited service health organization
or
, preferred provider plan
or
18managed care plan arranges for services to be provided by a provider with whom it
19has a provider agreement, the
health maintenance organization, limited service
20health organization
or, preferred provider plan
or managed care plan is not required
21to reimburse a provider under sub. (1) (b) 2. for any services provided after
22arrangements are made under this subsection.
AB768-ASA1,441,824
609.65
(3) A
health maintenance organization, limited service health
25organization
or, preferred provider plan
or managed care plan is only required to
1make available, or make reimbursement for, an examination, evaluation or
2treatment under sub. (1) to the extent that the
health maintenance organization, 3limited service health organization
or, preferred provider plan
or managed care plan 4would have made the medically necessary service available to the
enrolled
5participant enrollee or reimbursed the provider for the service if any referrals
6required under s. 609.05 (3) had been made and the service had been performed by
7a
participating provider
selected by the health maintenance organization, limited
8service health organization or preferred provider plan.
AB768-ASA1,441,1210
609.655
(1) (a) 1. Is covered as a dependent child under the terms of a policy
11or certificate issued by a
health maintenance organization managed care plan
12insurer.
AB768-ASA1,441,1614
609.655
(1) (a) 2. Is enrolled in a school located in this state but outside the
15geographical service area of the
health maintenance organization managed care
16plan.
AB768-ASA1,441,2018
609.655
(1) (c) "School" means a technical college;
a center or an institution
19within the university of Wisconsin system; and any institution of higher education
20that grants a bachelor's or higher degree.
AB768-ASA1,442,522
609.655
(2) If a policy or certificate issued by a
health maintenance
23organization managed care plan insurer provides coverage of outpatient services
24provided to a dependent student, the policy or certificate shall provide coverage of
25outpatient services, to the extent and in the manner required under sub. (3), that are
1provided to the dependent student while he or she is attending a school located in this
2state but outside the geographical service area of the
health maintenance
3organization managed care plan, notwithstanding the limitations regarding
selected 4participating providers, primary providers and referrals under ss. 609.01 (2) and
5609.05 (3).
AB768-ASA1,442,97
609.655
(3) (intro.) Except as provided in sub. (5), a
health maintenance
8organization managed care plan shall provide coverage for all of the following
9services:
AB768-ASA1,442,1611
609.655
(3) (a) A clinical assessment of the dependent student's nervous or
12mental disorders or alcoholism or other drug abuse problems, conducted by a
13provider described in s. 632.89 (1) (e) 2. or 3. who is located in this state and in
14reasonably close proximity to the school in which the dependent student is enrolled
15and who may be designated by the
health maintenance organization managed care
16plan.
AB768-ASA1,442,2318
609.655
(3) (b) (intro.) If outpatient services are recommended in the clinical
19assessment conducted under par. (a), the recommended outpatient services
20consisting of not more than 5 visits to an outpatient treatment facility or other
21provider that is located in this state and in reasonably close proximity to the school
22in which the dependent student is enrolled and that may be designated by the
health
23maintenance organization managed care plan, except as follows:
AB768-ASA1,443,4
1609.655
(3) (b) 1. Coverage is not required under this paragraph if the medical
2director of the
health maintenance organization managed care plan determines that
3the nature of the treatment recommended in the clinical assessment will prohibit the
4dependent student from attending school on a regular basis.
AB768-ASA1,443,156
609.655
(4) (a) Upon completion of the 5 visits for outpatient services covered
7under sub. (3) (b), the medical director of the
health maintenance organization 8managed care plan and the clinician treating the dependent student shall review the
9dependent student's condition and determine whether it is appropriate to continue
10treatment of the dependent student's nervous or mental disorders or alcoholism or
11other drug abuse problems in reasonably close proximity to the school in which the
12student is enrolled. The review is not required if the dependent student is no longer
13enrolled in the school or if the coverage limits under the policy or certificate for
14treatment of nervous or mental disorders or alcoholism or other drug abuse problems
15have been exhausted.
AB768-ASA1,443,2517
609.655
(4) (b) Upon completion of the review under par. (a), the medical
18director of the
health maintenance organization managed care plan shall determine
19whether the policy or certificate will provide coverage of any further treatment for
20the dependent student's nervous or mental disorder or alcoholism or other drug
21abuse problems that is provided by a provider located in reasonably close proximity
22to the school in which the student is enrolled. If the dependent student disputes the
23medical director's determination, the dependent student may submit a written
24grievance under the
health maintenance organization's
managed care plan's 25internal grievance procedure established under s. 609.15.
AB768-ASA1,444,72
609.655
(5) (a) A policy or certificate issued by a
health maintenance
3organization managed care plan insurer is required to provide coverage for the
4services specified in sub. (3) only to the extent that the policy or certificate would
5have covered the service if it had been provided to the dependent student by a
6selected participating provider within the geographical service area of the
health
7maintenance organization managed care plan.
AB768-ASA1,444,149
609.655
(5) (b) Paragraph (a) does not permit a
health maintenance
10organization managed care plan to reimburse a provider for less than the full cost
11of the services provided or an amount negotiated with the provider, solely because
12the reimbursement rate for the service would have been less if provided by a
selected 13participating provider within the geographical service area of the
health
14maintenance organization managed care plan.
AB768-ASA1,444,18
16609.70 Chiropractic coverage. Health maintenance organizations, limited
17Limited service health organizations
and
, preferred provider plans
and managed
18care plans are subject to s. 632.87 (3).
AB768-ASA1,445,2
20609.75 Adopted children coverage.
Health maintenance organizations,
21limited Limited service health organizations
and, preferred provider plans
and
22managed care plans are subject to s. 632.896. Coverage of health care services
23obtained by adopted children and children placed for adoption may be subject to any
24requirements that the
health maintenance organization, limited service health
25organization
or, preferred provider plan
or managed care plan imposes under s.
1609.05 (2) and (3) on the coverage of health care services obtained by other
enrolled
2participants enrollees.
AB768-ASA1,445,7
5609.77 Coverage of breast reconstruction. Health maintenance
6organizations, limited Limited service health organizations
and, preferred provider
7plans
and managed care plans are subject to s. 632.895 (13).
AB768-ASA1,445,13
10609.78 Coverage of treatment for the correction of
11temporomandibular disorders. Health maintenance organizations, limited 12Limited service health organizations
and
, preferred provider plans
and managed
13care plans are subject to s. 632.895 (11).