SB55-ASA1-AA1,1301,2016
609.24
(1) (c) (intro.) Except as provided in par. (d), if an enrollee is undergoing
17a course of treatment with a participating provider who is not a primary care
18physician and whose participation with the plan terminates, the
managed care 19defined network plan shall provide the coverage under par. (a) with respect to the
20services of the provider for the following period of time:
SB55-ASA1-AA1,1301,2322
609.24
(1) (d) 1. The provider no longer practices in the
managed care defined
23network plan's geographic service area.
SB55-ASA1-AA1,1302,3
1609.24
(1) (d) 2. The insurer issuing the
managed care defined network plan
2terminates or terminated the provider's contract for misconduct on the part of the
3provider.
SB55-ASA1-AA1,1302,75
609.24
(1) (e) 1. An insurer issuing a
managed care defined network plan shall
6include in its provider contracts provisions addressing reimbursement to providers
7for services rendered under this section.
SB55-ASA1-AA1,1302,129
609.24
(1) (e) 2. If a contract between a
managed care defined network plan and
10a provider does not address reimbursement for services rendered under this section,
11the insurer shall reimburse the provider according to the most recent contracted
12rate.
SB55-ASA1-AA1,1302,1814
609.24
(4) Notice of provisions. A defined network plan shall notify all plan
15enrollees of the provisions under this section whenever a participating provider's
16participation with the plan terminates, or shall, by contract, require a participating
17provider to notify all plan enrollees of the provisions under this section if the
18participating provider's participation with the plan terminates.
SB55-ASA1-AA1,1302,2320
609.30
(1) Plan may not contract. A
managed care defined network plan may
21not contract with a participating provider to limit the provider's disclosure of
22information, to or on behalf of an enrollee, about the enrollee's medical condition or
23treatment options.
SB55-ASA1-AA1,1303,7
1609.30
(2) Plan may not penalize or terminate. A participating provider may
2discuss, with or on behalf of an enrollee, all treatment options and any other
3information that the provider determines to be in the best interest of the enrollee.
4A
managed care defined network plan may not penalize or terminate the contract of
5a participating provider because the provider makes referrals to other participating
6providers or discusses medically necessary or appropriate care with or on behalf of
7an enrollee.
SB55-ASA1-AA1,1303,139
609.32
(1) Standards; other than preferred provider plans. (intro.) A
10managed care defined network plan
that is not a preferred provider plan shall
11develop comprehensive quality assurance standards that are adequate to identify,
12evaluate
, and remedy problems related to access to, and continuity and quality of,
13care. The standards shall include at least all of the following:
SB55-ASA1-AA1,1303,1815
609.32
(1m) Procedure for remedial action; preferred provider plans. A
16preferred provider plan shall develop a procedure for remedial action to address
17quality problems, including written procedures for taking appropriate corrective
18action.
SB55-ASA1-AA1,1304,220
609.32
(2) (a) A
managed care defined network plan shall develop a process for
21selecting participating providers, including written policies and procedures that the
22plan uses for review and approval of providers. After consulting with appropriately
23qualified providers, the plan shall establish minimum professional requirements for
24its participating providers. The process for selection shall include verification of a
1provider's license or certificate, including the history of any suspensions or
2revocations, and the history of any liability claims made against the provider.
SB55-ASA1-AA1,1304,74
609.32
(2) (b) (intro.) A
managed care
defined network plan shall establish in
5writing a formal, ongoing process for reevaluating each participating provider
6within a specified number of years after the provider's initial acceptance for
7participation. The reevaluation shall include all of the following:
SB55-ASA1-AA1,1304,119
609.32
(2) (c) A
managed care defined network plan may not require a
10participating provider to provide services that are outside the scope of his or her
11license or certificate.
SB55-ASA1-AA1,1304,1714
609.34
(1) A
managed care defined network plan
that is not a preferred
15provider plan shall appoint a physician as medical director. The medical director
16shall be responsible for clinical protocols, quality assurance activities
, and
17utilization management policies of the plan.
SB55-ASA1-AA1,1304,2419
609.34
(2) A preferred provider plan may contract for services related to clinical
20protocols and utilization management. A preferred provider plan or its designee is
21required to appoint a medical director only to the extent that the preferred provider
22plan or its designee assumes direct responsibility for clinical protocols and
23utilization management policies of the plan. The medical director, who shall be a
24physician, shall be responsible for such protocols and policies of the plan.
SB55-ASA1-AA1,1305,6
1609.35 Applicability of requirements to preferred provider plans. 2Notwithstanding ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1), a preferred
3provider plan that does not cover the same services when performed by a
4nonparticipating provider that it covers when those services are performed by a
5participating provider is subject to the requirements under ss. 609.22 (2), (3), (4), and
6(7), 609.32 (1), and 609.34 (1).
SB55-ASA1-AA1,1305,98
609.36
(1) (a) (intro.) A
managed care
defined network plan shall provide to the
9commissioner information related to all of the following:
SB55-ASA1-AA1,1305,1411
609.36
(2) Confidentiality. A
managed care defined network plan shall
12establish written policies and procedures, consistent with ss. 51.30, 146.82
, and
13252.15, for the handling of medical records and enrollee communications to ensure
14confidentiality.
SB55-ASA1-AA1,1305,19
16609.38 Oversight. The office shall perform examinations of insurers that
17issue
managed care defined network plans consistent with ss. 601.43 and 601.44.
18The commissioner shall by rule develop standards for
managed care defined network 19plans for compliance with the requirements under this chapter.
SB55-ASA1-AA1,1306,321
609.65
(1) (intro.) If an enrollee of a limited service health organization,
22preferred provider plan
, or
managed care defined network plan is examined,
23evaluated
, or treated for a nervous or mental disorder pursuant to an emergency
24detention under s. 51.15, a commitment or a court order under s. 51.20 or 880.33 (4m)
25or (4r) or ch. 980, then, notwithstanding the limitations regarding participating
1providers, primary providers
, and referrals under ss. 609.01 (2) to (4) and 609.05 (3),
2the limited service health organization, preferred provider plan
, or
managed care 3defined network plan shall do all of the following:
SB55-ASA1-AA1,1306,105
609.65
(1) (a) If the provider performing the examination, evaluation
, or
6treatment has a provider agreement with the limited service health organization,
7preferred provider plan
, or
managed care defined network plan which covers the
8provision of that service to the enrollee, make the service available to the enrollee in
9accordance with the terms of the limited service health organization, preferred
10provider plan
, or
managed care defined network plan and the provider agreement.
SB55-ASA1-AA1,1306,1812
609.65
(1) (b) (intro.) If the provider performing the examination, evaluation
13or treatment does not have a provider agreement with the limited service health
14organization, preferred provider plan
, or
managed care defined network plan which
15covers the provision of that service to the enrollee, reimburse the provider for the
16examination, evaluation
, or treatment of the enrollee in an amount not to exceed the
17maximum reimbursement for the service under the medical assistance program
18under subch. IV of ch. 49, if any of the following applies:
SB55-ASA1-AA1,1306,2420
609.65
(1) (b) 1. The service is provided pursuant to a commitment or a court
21order, except that reimbursement is not required under this subdivision if the limited
22service health organization, preferred provider plan
, or
managed care defined
23network plan could have provided the service through a provider with whom it has
24a provider agreement.
SB55-ASA1-AA1,1307,5
1609.65
(1) (b) 2. The service is provided pursuant to an emergency detention
2under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20
3and the provider notifies the limited service health organization, preferred provider
4plan
, or
managed care defined network plan within 72 hours after the initial
5provision of the service.
SB55-ASA1-AA1,1307,127
609.65
(2) If after receiving notice under sub. (1) (b) 2. the limited service health
8organization, preferred provider plan
, or
managed care defined network plan
9arranges for services to be provided by a provider with whom it has a provider
10agreement, the limited service health organization, preferred provider plan
, or
11managed care plan is not required to reimburse a provider under sub. (1) (b) 2. for
12any services provided after arrangements are made under this subsection.
SB55-ASA1-AA1,1307,2114
609.65
(3) A limited service health organization, preferred provider plan
, or
15managed care defined network plan is only required to make available, or make
16reimbursement for, an examination, evaluation
, or treatment under sub. (1) to the
17extent that the limited service health organization, preferred provider plan
, or
18managed care defined network plan would have made the medically necessary
19service available to the enrollee or reimbursed the provider for the service if any
20referrals required under s. 609.05 (3) had been made and the service had been
21performed by a participating provider.
SB55-ASA1-AA1,1307,2423
609.655
(1) (a) 1. Is covered as a dependent child under the terms of a policy
24or certificate issued by a
managed care defined network plan insurer.
SB55-ASA1-AA1,1308,2
1609.655
(1) (a) 2. Is enrolled in a school located in this state but outside the
2geographical service area of the
managed care defined network plan.
SB55-ASA1-AA1,1308,114
609.655
(2) If a policy or certificate issued by a
managed care defined network 5plan insurer provides coverage of outpatient services provided to a dependent
6student, the policy or certificate shall provide coverage of outpatient services, to the
7extent and in the manner required under sub. (3), that are provided to the dependent
8student while he or she is attending a school located in this state but outside the
9geographical service area of the
managed care defined network plan,
10notwithstanding the limitations regarding participating providers, primary
11providers
, and referrals under ss. 609.01 (2) and 609.05 (3).
SB55-ASA1-AA1,1308,1413
609.655
(3) (intro.) Except as provided in sub. (5), a
managed care defined
14network plan shall provide coverage for all of the following services:
SB55-ASA1-AA1,1308,2016
609.655
(3) (a) A clinical assessment of the dependent student's nervous or
17mental disorders or alcoholism or other drug abuse problems, conducted by a
18provider described in s. 632.89 (1) (e) 2. or 3. who is located in this state and in
19reasonably close proximity to the school in which the dependent student is enrolled
20and who may be designated by the
managed care defined network plan.
SB55-ASA1-AA1,1309,222
609.655
(3) (b) (intro.) If outpatient services are recommended in the clinical
23assessment conducted under par. (a), the recommended outpatient services
24consisting of not more than 5 visits to an outpatient treatment facility or other
25provider that is located in this state and in reasonably close proximity to the school
1in which the dependent student is enrolled and that may be designated by the
2managed care defined network plan, except as follows:
SB55-ASA1-AA1,1309,74
609.655
(3) (b) 1. Coverage is not required under this paragraph if the medical
5director of the
managed care defined network plan determines that the nature of the
6treatment recommended in the clinical assessment will prohibit the dependent
7student from attending school on a regular basis.
SB55-ASA1-AA1,1309,179
609.655
(4) (a) Upon completion of the 5 visits for outpatient services covered
10under sub. (3) (b), the medical director of the
managed care defined network plan and
11the clinician treating the dependent student shall review the dependent student's
12condition and determine whether it is appropriate to continue treatment of the
13dependent student's nervous or mental disorders or alcoholism or other drug abuse
14problems in reasonably close proximity to the school in which the student is enrolled.
15The review is not required if the dependent student is no longer enrolled in the school
16or if the coverage limits under the policy or certificate for treatment of nervous or
17mental disorders or alcoholism or other drug abuse problems have been exhausted.
SB55-ASA1-AA1,1310,219
609.655
(4) (b) Upon completion of the review under par. (a), the medical
20director of the
managed care defined network plan shall determine whether the
21policy or certificate will provide coverage of any further treatment for the dependent
22student's nervous or mental disorder or alcoholism or other drug abuse problems that
23is provided by a provider located in reasonably close proximity to the school in which
24the student is enrolled. If the dependent student disputes the medical director's
25determination, the dependent student may submit a written grievance under the
1managed care defined network plan's internal grievance procedure established
2under s. 632.83.
SB55-ASA1-AA1,1310,84
609.655
(5) (a) A policy or certificate issued by a
managed care defined network 5plan insurer is required to provide coverage for the services specified in sub. (3) only
6to the extent that the policy or certificate would have covered the service if it had been
7provided to the dependent student by a participating provider within the
8geographical service area of the
managed care defined network plan.
SB55-ASA1-AA1,1310,1410
609.655
(5) (b) Paragraph (a) does not permit a
managed care defined network 11plan to reimburse a provider for less than the full cost of the services provided or an
12amount negotiated with the provider, solely because the reimbursement rate for the
13service would have been less if provided by a participating provider within the
14geographical service area of the
managed care defined network plan.
SB55-ASA1-AA1,1310,18
16609.70 Chiropractic coverage. Limited service health organizations,
17preferred provider plans
, and
managed care defined network plans are subject to s.
18632.87 (3).
SB55-ASA1-AA1,1311,2
20609.75 Adopted children coverage. Limited service health organizations,
21preferred provider plans
, and
managed care defined network plans are subject to s.
22632.896. Coverage of health care services obtained by adopted children and children
23placed for adoption may be subject to any requirements that the limited service
24health organization, preferred provider plan
, or
managed care defined network plan
1imposes under s. 609.05 (2) and (3) on the coverage of health care services obtained
2by other enrollees.
SB55-ASA1-AA1,1311,6
4609.77 Coverage of breast reconstruction. Limited service health
5organizations, preferred provider plans
, and
managed care defined network plans
6are subject to s. 632.895 (13).
SB55-ASA1-AA1,1311,11
8609.78 Coverage of treatment for the correction of
9temporomandibular disorders. Limited service health organizations, preferred
10provider plans
, and
managed care
defined network plans are subject to s. 632.895
11(11).
SB55-ASA1-AA1,1311,16
13609.79 Coverage of hospital and ambulatory surgery center charges
14and anesthetics for dental care. Limited service health organizations, preferred
15provider plans
, and
managed care
defined network plans are subject to s. 632.895
16(12).
SB55-ASA1-AA1,1311,22
18609.80 Coverage of mammograms. Managed care Defined network plans
19are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be
20subject to any requirements that the
managed care
defined network plan imposes
21under s. 609.05 (2) and (3) on the coverage of other health care services obtained by
22enrollees.
SB55-ASA1-AA1,1312,2
24609.81 Coverage related to HIV infection. Limited service health
25organizations, preferred provider plans
, and
managed care defined network plans
1are subject to s. 631.93.
Managed care
Defined network plans are subject to s.
2632.895 (9).
SB55-ASA1-AA1,1312,6
4609.82 Coverage without prior authorization for emergency medical
5condition treatment. Limited service health organizations, preferred provider
6plans
, and
managed care defined network plans are subject to s. 632.85.