Defined Network PLANS
Joint ventures; legislative findings.
Indication of operations.
Primary provider and referrals.
Standard plan and point-of-service option plan required.
Reports of disciplinary action.
Rules for preferred provider and defined network plans.
Continuity of care.
Clinical decision-making; medical director.
Applicability of requirements to preferred provider plans.
Data systems and confidentiality.
Coverage for court-ordered services for the mentally ill.
Coverage of certain services provided to dependent students.
Adopted children coverage.
Coverage of student on medical leave.
Coverage of breast reconstruction.
Coverage of treatment for the correction of temporomandibular disorders.
Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care.
Coverage of mammograms.
Coverage related to HIV infection.
Coverage without prior authorization for emergency medical condition treatment.
Coverage of drugs and devices.
Coverage of lead screening.
Coverage of immunizations.
Written reason for coverage denial.
Restrictions related to domestic abuse.
Restrictions on recovering health care costs.
Hospitals, individual practice associations and providers of physician services.
Election to be subject to restrictions.
Scope of election by an individual practice association or clinic.
Notices of election and termination.
Summary of restrictions.
Minimum covered liabilities.
Initial capital and surplus requirements.
Compulsory and security surplus.
Ch. 609 Cross-reference
See definitions in ss. 600.03
Ch. 609 Cross-reference
See also ch. Ins 9
, Wis. adm. code.
Joint ventures; legislative findings. 609.001(1)
The legislature finds that increased development of health maintenance organizations, preferred provider plans and limited service health organizations may have the effect of putting small, independent health care providers at a competitive disadvantage with larger health care providers. In order to avoid monopolistic situations and to provide competitive alternatives, it may be necessary for those small, independent health care providers to form joint ventures. The legislature finds that these joint ventures are a desirable means of health care cost containment to the extent that they increase the number of entities with which a health maintenance organization, preferred provider plan or limited service health organization may choose to contract and to the extent that the joint ventures do not violate state or federal antitrust laws.
The legislature finds that competition in the health care market will be enhanced by allowing employers and organizations which otherwise act independently to join together in a manner consistent with the state and federal antitrust laws for the purpose of purchasing health care coverage for employees and members. These joint ventures will allow purchasers of health care coverage to obtain volume discounts when they negotiate with insurers and health care providers. These joint ventures should result in an improved business climate in this state because of reduced costs for health care coverage.
History: 1985 a. 29
In this chapter:
" Defined network plan" means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with, or employed by the insurer offering the health benefit plan.
"Enrollee" means, with respect to a defined network plan, preferred provider plan, or limited service health organization, a person who is entitled to receive health care services under the plan.
Except as provided in par. (b)
, "health benefit plan" means any hospital or medical policy or certificate.
"Health benefit plan" does not include any of the following: