Ins 6.93 Note Note: A copy of a sample navigator and navigator entity bond form OCI 11-093, required in sub. (4) (b), may be obtained at no cost from the Office of the Commissioner of Insurance at 125 S. Webster Street, Madison WI 53703, or at the Office's web address: oci.wi.gov.
Ins 6.93(5) (5)Investigation and review.
Ins 6.93(5)(a) (a) The commissioner, or designated examiner, may investigate and review all navigator entities under ss. 601.43 and 601.44, Stats. The method and timing of the reviews shall be determined by the commissioner in each case and may consist of any of the following:
Ins 6.93(5)(a)1. 1. Consideration of information available from state, federal, or local agencies, private organizations or agencies, or interested persons.
Ins 6.93(5)(a)2. 2. Investigation upon receipt of a complaint from any person.
Ins 6.93(5)(a)3. 3. Any other information the commissioner deems relevant to the investigation.
Ins 6.93(5)(b) (b) If, after the investigation the commissioner suspends, denies or revokes the registration, written notification shall be given with reasons for such action. The suspension, denial or revocation constitutes an order pursuant to s. 601.62 (3) (a), Stats., and the navigator entity may request a hearing before the commissioner under that section.
Ins 6.93 History History: EmR1314: emerg. cr. eff. 9-10-13; CR 13-113: cr. Register August 2014 No. 704, eff. 9-1-14; correction in (1) (title) made under s. 13.92 (4) (b) 2., Stats., and in (1) (c), (2) made under s. 35.17, Stats., Register August 2014 No. 704.; CR 19-025: am. (1) (a), (2) Register August 2020 No. 776, eff. 9-1-20.
Ins 6.95 Ins 6.95 Registration of certified application counselors, nonnavigator assisters and nonnavigator assister entities.
Ins 6.95(1g)(1g)Registration requirement. Certified application counselors and other nonnavigator assisters shall be employed or supervised by a registered nonnavigator assister entity, or be affiliated with a registered nonnavigator assister entity.
Ins 6.95(1r) (1r)Electronic registration for a nonnavigator assister entity. An entity registering as a nonnavigator assister entity shall provide all of the following information to the commissioner in the form prescribed by the commissioner:
Ins 6.95(1r)(a) (a) The nonnavigator assister entity's name and current mailing address.
Ins 6.95(1r)(b) (b) The name and contact information for the nonnavigator assister entity.
Ins 6.95(1r)(c) (c) The name, business address, and type of nonnavigator assister for each nonnavigator assister it employs, supervises, or is affiliated with.
Ins 6.95(1r)(d) (d) An attestation that each nonnavigator assister is in compliance with applicable state law including any nonnavigator assister who is a certified application counselor and who has complied with s. 628.96 (2), Stats.
Ins 6.95(1r)(e) (e) The nonnavigator assister entity's agreement to provide to the commissioner all supporting documents as requested by the commissioner.
Ins 6.95(2) (2)Certified application counselors and other nonnavigator assisters.
Ins 6.95(2)(a) (a) Certified application counselors under 45 C.F.R. 155.225, and other nonnavigator assisters, are eligible to be registered by a nonnavigator assister entity if either of the following apply:
Ins 6.95(2)(a)1. 1. The application counselor or other nonnavigator assister is designated by the federal government to provide consumer assistance; that designation is not withdrawn; and the person has completed the training and examination requirement under ss. 628.92 (7) and 628.96 (2), Stats.
Ins 6.95(2)(a)2. 2. The application counselor or other nonnavigator assister is an insurance agent who hold an active resident license with the accident and health line of authority and is in compliance with continuing education requirements; complies with s. 628.96 (3), Stats., including competence and trustworthiness, and satisfactorily completes 4 hours of navigator training specific to public assistance programs, including Medicaid, in addition to the completion of any federally required nonnavigator assister training and compliance with federal restrictions and requirements. An insurance agent who meets the requirements of this subdivision is not required to complete prelicensing training or the navigator licensing examination under ss. 628.92 (7) and 628.96 (2), Stats.
Ins 6.95(2)(b) (b) The nonnavigator assister entity shall maintain records that each certified application counselor and other nonnavigator assister registered under par. (a) has completed the annual continuing education training. The nonnavigator assister entity shall provide an attestation of compliance with such requirement to the commissioner in a form prescribed by the commissioner by October 1 of each year. The commissioner will provide guidance on the topics for the continuing education training required under this subsection.
Ins 6.95(2)(c) (c) The commissioner may deny registration for a certified application counselor and other nonnavigator assisters, for any of the following:
Ins 6.95(2)(c)1. 1. Failure to possess requisite character, integrity, competency and trustworthiness. In addition to the requirements set forth in s. 628.04, Stats., and s. Ins 6.92 (3)
Ins 6.95(2)(c)2. 2. Commission of any act that would warrant the denial, suspension, or revocation of an insurance license or registration including any of the acts delineated in s. Ins 6.92 (3).
Ins 6.95(2)(c)3. 3. Failure to fully provide required or requested information, to complete requisite training including continuing education, to maintain certification from the federal government as a certified application counselor or nonnavigator assister entity.
Ins 6.95(3) (3)Entity reporting of updates. A nonnavigator assister entity shall comply with s. 628.96 (1), Stats., reporting in an electronic format as prescribed by the commissioner, any updates to the list of nonnavigator assisters that the nonnavigator assister entity provided when it first registered with the commissioner, including additions, deletions, or modifications. The information shall be provided within 30 days of the addition, deletion, or modification to the list of nonnavigator assisters.
Ins 6.95(4) (4)Entity liability. A nonnavigator assister entity assumes legal responsibility, in accordance with s. 628.96 (3), Stat., for the acts of the nonnavigator assisters, on behalf of the entity, that the entity employs, supervises or is formally affiliated with, that are performed in this state and that are within the scope of the apparent authority to act as a nonnavigator assister.
Ins 6.95(5) (5)Revocation of entity registration. The commissioner may deny, suspend or revoke a nonnavigator assister entity registration if the nonnavigator assisters it employs, supervises or is affiliated with, fail to comply with s. Ins 6.92 (3), or the nonnavigator assister entity fails to comply with any provision contained in this section or by failing to comply with requests of the commissioner.
Ins 6.95(6) (6)Investigation and review.
Ins 6.95(6)(a) (a) The commissioner, or designated examiner, may investigate and review all nonnavigator entities under ss. 601.43 and 601.44, Stats. The method and timing of the reviews shall be determined by the commissioner in each case and may consist of any of the following:
Ins 6.95(6)(a)1. 1. Consideration of information available from state, federal, or local agencies, private organizations or agencies, or interested persons.
Ins 6.95(6)(a)2. 2. Investigation upon receipt of a complaint from any person.
Ins 6.95(6)(a)3. 3. Any other information the commissioner deems relevant to the investigation.
Ins 6.95(6)(b) (b) If, after the investigation the commissioner suspends, denies, or revokes the registration, written notification shall be given with reasons for such action. The suspension, denial or revocation constitutes an order pursuant to s. 601.62 (3) (a), Stats., and the nonnavigator entity may request a hearing before the commissioner under that section.
Ins 6.95 History History: EmR1314: emerg. cr. eff. 9-10-13; CR 13-113: cr. Register August 2014 No. 704, eff. 9-1-14; (1g) and (1r) renumbered from (intro.) and (1) under s. 13.92 (4) (b) 1., Stats., (1g) (title) added under s. 13.92 (4) (b) 2., Stats., correction in (2) (intro.) made under s. 13.92 (4) (b) 7. Register August 2014 No. 704.
Ins 6.96 Ins 6.96 Prohibited business practices. In addition to the prohibited acts contained in s. 628.95 (2), Stats., navigators, navigator entities, nonnavigator assisters and nonnavigator assister entities are prohibited from all of the following:
Ins 6.96(1) (1)Providing enrollment or other specific information regarding a health benefit plan that is not offered in the federal exchange.
Ins 6.96(2) (2)Providing a recommendation comparing health benefit plans that may be better or worse for the consumer or employer.
Ins 6.96(3) (3)Making misleading statements to a consumer or employer regarding or otherwise misrepresenting one's qualifications or services.
Ins 6.96(4) (4)Offering a recommendation directly to a consumer or employer regarding a particular health benefit plan concerning deductible, coinsurance, or any substantive benefits, terms, or conditions of the contract.
Ins 6.96(5) (5)Asking or urging a consumer to apply for a particular health benefit plan from a particular insurance company.
Ins 6.96(6) (6)Distributing cards, documents or advertisements regarding a particular health insurer.
Ins 6.96(7) (7)Recommending a particular health benefit plan or insurer.
Ins 6.96(8) (8)Receiving consideration directly or indirectly from any health insurer in connection with the enrollment of individual or employees into a qualified health plan as defined 45 CFR 155.20, as amended.
Ins 6.96(9) (9)Using a single appointment for selling, soliciting or advising a consumer or employer about a product other than health benefit plans by a navigator or nonnavigator assister who is also a licensed insurance agent. Insurance agents shall make a separate appointment with the consumer or employer for selling, soliciting, or advising about a product other than a health benefit plan.
Ins 6.96 History History: EmR1314: emerg. cr. eff. 9-10-13; CR 13-113: cr. Register August 2014 No. 704, eff. 9-1-14; correction in (8) made under s. 13.92 (4) (b) 7. Register August 2014 No. 704.
Ins 6.97 Ins 6.97 Navigator, nonnavigator assister, navigator entity, and nonnavigator assister entity records.
Ins 6.97(1)(1)Purpose. This section protects consumers by prescribing minimum standards and techniques of accounting and data handling of navigators, nonnavigator assisters, navigator entities and nonnavigator assister entities to ensure that timely and reliable information will exist, if applicable, and be available to the commissioner. This section implements and interprets ss. 601.42 and 628.34, Stats., by establishing the minimum records that are to be maintained.
Ins 6.97(2) (2)Recordkeeping requirements.
Ins 6.97(2)(a) (a) Records, generally. Beginning October 1, 2013, each navigator, nonnavigator assister, navigator entity or nonnavigator assister entity shall maintain, for at least a 3-year period, unless a specific period is provided elsewhere, all of the following financial, consumer, and employee records arising from or related to the activities of the navigator or nonnavigator assister, as applicable:
Ins 6.97(2)(a)1. 1. Business checking account.
Ins 6.97(2)(a)2. 2. Cash disbursed records.
Ins 6.97(2)(a)3. 3. Cash receipts records.
Ins 6.97(2)(a)4. 4. Personnel records.
Ins 6.97(2)(a)5. 5. Consumer or policyholder records.
Ins 6.97(2)(b) (b) Cash disbursed record. The cash disbursed record shall show the name of the party to whom the payment was made, date of payment, and reason for payment.
Ins 6.97(2)(c) (c) Cash receipts record. The cash receipts record shall show the name of the party who remitted the money, date of receipt, and reason for payment.
Ins 6.97(2)(d) (d) Personnel records. Personnel records shall include dates of employment, supervision, or affiliation; position held; description of principal duties; name and last known address and telephone number of employee, supervisee or affiliated person.
Ins 6.97(3) (3)Place of maintaining records.
Ins 6.97(3)(a) (a) The navigator or navigator entity shall maintain records, if any, required by sub. (2) at the business address of the navigator or the navigator entity, or at another location only if the navigator provides written notice of the other location to the commissioner.
Ins 6.97(3)(b) (b) The nonnavigator assister or nonnavigator assister entity shall maintain records, if any, required by sub. (2), at the business address of the nonnavigator assister entity or at another location only if the nonnavigator assister entity provides written notice of the other location to the commissioner.
Ins 6.97(4) (4)Updating records. The navigator, navigator entity, and nonnavigator assister entity shall maintain financial records, if any, all records of compliance with prelicensing training completion, successful passage of the examination and continuing education completion, compliance with federal training and other federal requirements for the navigators and nonnavigator assisters it employs, supervises, or is affiliated with, as applicable for at least 3 years from the transaction of an insurance business.
Ins 6.97 History History: EmR1314: emerg. cr. eff. 9-10-13; CR 13-113: cr. Register August 2014 No. 704, eff. 9-1-14; (2) (a) (title) added under s. 13.92 (4) (b) 2., Stats., Register August 2014 No. 704.
Ins 6.98 Ins 6.98 Prohibition of uses of designations.
Ins 6.98(1)(1)Prohibited uses of designations. It is an unfair and deceptive trade practice under s. 628.34 (12), Stats., for a person to use terms including “navigator," “navigator entity," “nonnavigator assister," “certified application counselor," “certified," and “nonnavigator assister entity," in such a way as to mislead a purchaser or prospective purchaser that the person has special certification or training in advising or providing services to consumers in connection with the advertising, solicitation, sale, or purchase of a health benefit plan or in the provision of advice as to the advisability of purchasing a health benefit plan, either directly or indirectly, offered in the state either within or outside the exchange. The terms may not be used by a person who is not licensed as a navigator or registered as a nonnavigator assister. The terms may not be used alone or in combination with one or more terms such as “certified," “licensed," “registered," or like words, in the name of a certification or professional designation unless such terms appear in a certification or professional designation and that person has attained the certification or professional designation.
Ins 6.98(2) (2)Penalties. A violation of this section is an unfair and deceptive trade practice under s. 628.34 (12), Stats., and shall subject the violator to ss. 601.41, 601.62, 601.64, 601.65 and 628.10, Stats.
Ins 6.98 History History: EmR1314: emerg. cr. eff. 9-10-13; CR 13-113: cr. Register August 2014 No. 704, eff. 9-1-14.
Ins 6.99 Ins 6.99 Exemption.
Ins 6.99(1)(a) (a) State and local governmental entities or any persons acting on behalf of a state or local governmental entity are exempt from ss. Ins 6.91 to 6.98 provided all of the following are met:
Ins 6.99(1)(a)1. 1. All communications, advertisements, notices, or other marketing materials including verbal communications must identify the entity as working on behalf of the state or local unit of government.
Ins 6.99(1)(a)2. 2. The state or local unit of government, upon request, confirms to the commissioner that the entity is responsible or has an agreement or contract that establishes financial responsibility for the acts of the entity and the individual navigators, and nonnavigator assisters employed, supervised, or affiliated with the entity.
Ins 6.99(1)(a)3. 3. The state or local governmental entity shall not use any term or designation denoting that it is certified as a navigator, nonnavigator assister or related entity unless the person, persons, or entity using the term or designation is in compliance with ss. Ins 6.92 or 6.95 and any other applicable sections.
Ins 6.99(1)(b) (b) Federal governmental entities or any persons acting on behalf of a federal governmental entity through a federal contract are exempt from ss. Ins 6.91 to 6.98 provided all of the following are met:
Ins 6.99(1)(b)1. 1. All communications, advertisements, notices or other marketing materials including verbal communications must identify the entity as working on behalf of the federal government.
Ins 6.99(1)(b)2. 2. The federal government, upon request, confirms to the commissioner that the federal governmental is responsible or has an agreement or contract that establishes financial responsibility for the acts of the entity and the individual navigators, and nonnavigator assisters employed, supervised or affiliated with the entity.
Ins 6.99(1)(b)3. 3. The state or local unit of [federal] governmental entity shall not use any term or designation denoting that it is certified as a navigator, nonnavigator assister or related entity unless the person, persons, or entity using the term or designation is in compliance with ss. Ins 6.92 or 6.95 and any other applicable sections.
Ins 6.99 Note Note: “Federal" shown in brackets should have replaced “state or local unit of". The office intends to correct this error in future rulemaking.
Ins 6.99(1)(c)1.1. Employees of a health care facility, including hospitals, clinics and other health care facilities are exempt from ss. Ins 6.91 to 6.98 if as part of their employment they provide assistance to patients including assistance with enrollment in state or federal assistance programs.
Ins 6.99(1)(c)2. 2. The health care facility, including hospitals, clinics and other health care facilities shall not use any term or designation denoting that it is certified as a navigator, nonnavigator assister or related entity unless the person, persons or entity using the term or designation is in compliance with ss. Ins 6.92 or 6.95 and any other applicable sections.
Ins 6.99 History History: EmR1314: emerg. cr. eff. 9-10-13; CR 13-113: cr. Register August 2014 No. 704, eff. 9-1-14.
APPENDIX I
KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS
PROBLEMS WITH YOUR INSURANCE?—If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.
(INSURER NAME)
(CUSTOMER SERVICE)
(ADDRESS)
(CITY, STATE, ZIP)
(TOLL FREE TELEPHONE NUMBER, if available)
(TELEPHONE NUMBER)
You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin's insurance laws, and file a complaint. You can file a complaint electronically with the OFFICE OF THECOMMISSIONER OF INSURANCE at its website at http://oci.wi.gov/, or by contacting:
Office of the Commissioner of Insurance
Complaints Department
P. O. Box 7873
Madison, WI 53707-7873
1-800-236-8517
608-266-0103.
APPENDIX 2
You may resolve your problem by taking the steps outlined in your HMO grievance procedure. You may also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces
Wisconsin's insurance laws, and file a complaint. You can file a complaint electronically with the OFFICE OF THE
COMMISSIONER OF INSURANCE
at its website at http://oci.wi.gov/, or by writing to:
Office of the Commissioner of Insurance
Complaints Department
P. O. Box 7873
Madison, WI 53707-7873
or you can call 1-800-236-8517 outside of Madison or 266-0103 in Madison, and request a complaint form.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.