4. Related Statutes or rules: There are no related statutes or rules.
Plain language analysis and summary
The proposed rule:
1) Eliminates the term “limited scope plan" from provisions governing defined network and preferred provider plans. The commissioner's intent is to eliminate the application to limited scope plans of certain rules promulgated in Clearinghouse Rule 05-059
2) Changes the provision governing improper utilization practices so as prohibit improper practices but not deem the insurer a defined network plan.
3) Eliminates specific requirements relating to network location, hours, waiting times and availability of after hours care but retains the requirement that access must be reasonably prompt consistent with normal practices and standards in the area.
4) Makes it clear that coverage of emergency medical services at in-network cost sharing is not required after the point that the provider has met its obligation to treat the enrollee under federal law.
Comparison with federal regulation
There is no federal regulation that addresses the activities regulated by the proposed rule.
Comparison of adjacent states
Iowa: Iowa statute §514C.16, requires a carrier which provides coverage for emergency services to be responsible for charges for emergency services furnished outside any contractual provider network or preferred provider network for covered individuals. Iowa Administrative Code s. 191-27.4 (1)(a), requires a health benefit plan which provides for incentives for covered persons to use the health care services of a preferred provider to contain a provision that if a covered person receives emergency services specified in the preferred provider arrangement and cannot reasonably reach a preferred provider, emergency services rendered during the course of the emergency will be reimbursed as though the covered person had been treated by a preferred provider, subject to any restrictions which may govern payment by a preferred provider for emergency services. Iowa statute §514B and Administrative Code 191-40.21, require HMOs to reimburse a provider of emergency services after a review of the care and may not deny reimbursement solely on the grounds that the services were provided by non-contracted providers.
Iowa statute §514F.3 requires the commissioner of insurance to adopt rules for preferred provider contracts and organizations and to adopt rules related to preferred provider arrangements. Iowa statute §514K.1 requires HMOs, organized delivery systems or an insurer using a preferred provider arrangement to provide to its enrollees written information that at a minimum must include the following; a description of the plan's benefits and exclusions, enrollee cost-sharing requirements, list of participating providers, disclosure of drug formularies, explanation for accessing emergency care services, policy for addressing investigational or experimental treatments, methodologies used to compensate providers, performance measures as determined by the commissioner and information on how to access internal and external grievance procedures. In addition the Iowa department must annually publish a consumer guide providing a comparison by plan on performance measures, network composition, and other key information to enable consumers to better understand plan differences.
Iowa Administrative Code 191-27.3 (1), requires preferred provider arrangements to establish the amount and manner of payment to a preferred provider, the mechanisms designed to minimize cost of the health benefits plan and ensure reasonable access to covered services under the preferred provider arrangement. Iowa Administrative Code 191-27.4 (1) (b), requires preferred provider plans to contain a provision that clearly identifies the differentials in benefit levels for health care services of preferred providers and non-preferred providers. Iowa Administrative Code 191-27.4 (2), requires that if a health benefit plan provides difference in benefit levels payable to preferred providers compared to other providers, such difference shall not unfairly deny payment for covered services and shall be no greater than necessary to provide a reasonable incentive for covered persons to use the preferred provider.
Illinois: Illinois statutory code 215 ILCS 5/370o, requires any preferred provider contract to provide the enrollee emergency care coverage regardless of whether the emergency care is provided by a preferred or non-preferred provider and the coverage shall be at the same benefit level as if the service or treatment had been rendered by a plan provider. Section 215 ILCS 5/370i, sec. (a) prohibits policies from containing provisions that would unreasonably restrict the access and availability of health care services for the enrollee. Section 215 ILCS 134/40, sec. 40 (d) requires a health care plan to pay for services of a specialist with the enrollee only responsible for the services as though the services were provided by an in-network provider when the plan does not have the specialist that the enrollee needs for the care of an on-going specific condition. The primary care physician arranges for the enrollee to see a specialist that is within a reasonable distance and travel time and the primary provider notifies the plan of the referral.
The information required to be provided to consumers is contained in s. 215 ILCS 134/15, that requires annual reporting of participating health care providers in the plan's service area and in addition to basic terms of the plan, includes disclosure of out-of-area coverage, if any, financial responsibility of enrollees including co-payments, deductibles, premium and any other out-of-pocket expenses, continuity of care, appeal rights and mandated benefits. Illinois Administrative Code s. 5420.40, requires disclosure so that a person can compare the attributes of various health care plans based upon a description of coverage. This disclosure includes that 2 appendices are completed that detail specific co-payments, coinsurance, deductibles, and other cost-sharing provisions for services that must be included with the policy for consumer information.
In addition to the worksheets that provide consumers with detailed information, Illinois statutory code s. 215ILCS 5/356z.2, also requires an insurer that issues or renews a individual or group accident and health policy and arranges, contracts with or administers contracts with providers whereby the beneficiary are provided an incentive to use the services of such provider must include the following disclosure of limited benefits in its contracts and evidence of coverage:
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a non-participating provider for a covered service in non-emergency situations, benefit payments to such non-participating provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy's fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical are where the services are performed), or other method as defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-participating providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill. Participating providers have agreed to accept discounted payment for services with no additional billing to the member other than co-insurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll free telephone number on your identification card. (Emphasis in original.)
Illinois statute s. 215 ILCS 134/80 requires that health care plans have procedures for quality assessment program including in s. (3) and (4) that require plans have a procedure for remedial action to correct quality problems that have been verified in accordance with the written plan's methodology and criteria, including written procedures for taking appropriate corrective action and follow-up measures implemented to evaluate the effectiveness of the action plan.
Illinois Administrative Code s. 5420.50 requires that all provider agreements contain provisions providing for advance notice from providers when terminating from the plan and requirements that the plan notify affected enrollees on a timely basis. The notice provided to the enrollee must contain information on how enrollees are to select a new health care provider.
Minnesota: Minnesota statute s. 62A.049, prohibits an accident and sickness policy from requiring prior authorization in cases of emergency confinement or emergency treatment. The enrollee or authorized representative must notify the insurer as soon as reasonably possible. Section 62Q.55 requires managed care organizations including preferred provider organization, to provide enrollees with available and accessible emergency services. Services shall be covered whether provided by participating or nonparticipating providers and whether provided within or outside the health plan's service area. Section 62D.20 and s. 4685.0700, Minnesota Administrative Code, require HMOs to provide out-of-area services including for emergency care.
Minnesota statute s. 62Q.49 (subd. 2) (a), requires all health plans to clearly specify how the cost of health care used to calculate any co-payments, coinsurance or lifetime benefits will be affected by the contracting in which health care providers agree to accept discounted charges. Further any marketing or summary materials must be disclosed prominently and clearly explain the provisions relating to co-payments, coinsurance or maximum lifetime benefits.
Minnesota statute s. 62Q.58, requires that if an enrollee receives services from a nonparticipating specialist because a participating specialist is not available, the services must be provided at no additional cost to the enrollee beyond what the enrollee would otherwise pay for services received from a participating specialist.
Minnesota statute s. 62Q.746, permits the department to request and the health plan to provide the following information including how the plan determines who are eligible to participating in the network, the number of full-time equivalent physicians, by specialty, non-physician providers and allied health providers used to provide services and summary data that is broken down by type of provider reflecting actual utilization of network and non-network practitioners and allied professionals by enrollees of the plan.
Michigan statute s. 500.3406
k, requires an expense-incurred hospital, medical or surgical policy that provides coverage for emergency health services, including an HMO plan, to provide coverage for medically necessary services provided to an enrollee for the sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity, that the absence of immediate care could reasonably be expected to result in serious jeopardy to health without prior authorization.
Insurers that contract with providers are governed by the Prudent Purchaser Act of 1984 including preferred provider organization (MCL 550.50 et seq.). The organization that contracts with providers shall annually report to the commissioner basic utilization of the providers (MCL 550.56). Under MCL 550.53, organizations that contract with providers to control costs and utilization may limit the number of providers to the number necessary to assure reasonable levels of access to health care services, located within reasonable distance.
Summary of factual data and analytical methodologies
The information OCI used in support of this proposed rule includes the information described in the analysis of Clearinghouse Rule 05-059
. However more specifically it includes the information provided by representatives of the insurance industry, preferred provider organizations, and providers in a series of meetings, and in responses to OCI's requests for comments and information, concerning the topics addressed by the proposed rule.
There will be no state or local government fiscal effect.
This rule will not have a significant fiscal effect on the private sector. Its effect will be to limit requirements otherwise applied by rules currently in effect, including Clearinghouse rule 05-059
Initial regulatory flexibility analysis
This rule does not impose any additional requirements on small businesses. Its effect will be to limit requirements otherwise applied by rules currently in effect, including Clearing house rule 05-059.
Notice is hereby further given that pursuant to s. 227.114
, Stats., the proposed rule may have an effect on small businesses. The initial regulatory flexibility analysis is as follows:
a. Types of small businesses affected: Insurers
b. Description of reporting and bookkeeping procedures required: None beyond those currently required.
c. Description of professional skills required: None beyond those currently required.
The OCI small business coordinator is Eileen Mallow and may be reached at phone number (608) 266- 7843 or at email address Eileen.Mallow@oci.state.wi.us
Notice of Hearings
(Environmental Protection - air Pollution Control)
NOTICE IS HEREBY GIVEN that pursuant to ss. 227.11 (2) (a)
and 285.11 (1)
, Stats., interpreting ss. 285.11 (6)
, 285.60 (5m)
and 285.69 (1d)
, Stats., the Department of Natural Resources will hold public hearings on revisions to chs. NR 406
, Wis. Adm. Code, relating to construction permit waiver requests from air contaminant sources. The State Implementation Plan developed under s. 285.11 (6)
, Stats., is revised. Section 285.60 (5m)
, Stats., as created by 2003 Wisconsin Act 118
) requires the Department, by rule, to allow sources who file an air pollution control construction permit application to request a construction permit waiver under certain circumstances. Construction permit waivers would allow a facility to start on-site preparation, including, but not limited to, site clearing, grading, dredging or landfilling prior to receiving a construction permit when necessary to avoid undue hardship. The Department must act on the waiver request within 15 days of receipt of the request. There is a $300 non-refundable fee associated with filing a waiver request.
Section NR 406.03 (2)
contains criteria for allowing a facility to obtain a commence construction waiver. The facility must first submit a complete construction permit application and a waiver request. Section NR 410.03 (1) (bm)
establishes the fee.
NOTICE IS HEREBY FURTHER GIVEN that pursuant to s. 227.114
, Stats., the proposed rule may have an impact on small businesses. The initial regulatory flexibility analysis is as follows:
a. Types of small businesses affected: All air pollution sources that have a permit or are required to obtain a construction permit, except for those sources that need an air construction permit under federal law.
b. Description of reporting and bookkeeping procedures required: No additional reporting or bookkeeping requirements are created.
c. Description of professional skills required: No additional skills are required.
NOTICE IS HEREBY FURTHER GIVEN that the Department has made a preliminary determination that this action does not involve significant adverse environmental effects and does not need an environmental analysis under ch. NR 150
, Wis. Adm. Code. However, based on the comments received, the Department may prepare an environmental analysis before proceeding with the proposal. This environmental review document would summarize the Department's consideration of the impacts of the proposal and reasonable alternatives.
NOTICE IS HEREBY FURTHER GIVEN that pursuant to the Americans with Disabilities Act, reasonable accommodations, including the provision of information material in an alternative format, will be provided for qualified individuals with disabilities upon request. Please contact Robert Eckdale at (608) 266-2856 or by e-mail at Robert.Eckdale@dnr.state.wi.us
with specific information on your request at least 10 days before the date of the scheduled hearing.
NOTICE IS HEREBY FURTHER GIVEN that the hearings will be held on:
Monday, August 7, 2006 at 1:00 p.m.
Pinery Room, Portage County Library
1001 Main Street
Tuesday, August 8, 2006 at 1:00 p.m.
Room 609, GEF #2 State Office Building
101 South Webster Street
The proposed rule and supporting documents, including the fiscal estimate may be viewed and downloaded and comments electronically submitted at the following Internet site: http://adminrules.wisconsin.gov
. (Search the Web site using the Natural Resources Board Order number AM-08-06.) Written comments on the proposed rule may also be submitted via U.S. mail to Mr. Joe Brehm, Bureau of Air Management, P.O. Box 7921, Madison, WI 53707 or by e-mail to Joseph.Brehm@dnr.state.wi.us
. Comments may be submitted until August 18, 2006. Written comments whether submitted electronically or by U.S. mail will have the same weight and effect as oral statements presented at the public hearings. If you do not have Internet access, a personal copy of the proposed rule and fiscal estimate may be obtained from Robert Eckdale, (608) 266-2856, Bureau of Air Management, P.O. Box 7921, Madison, WI 53707.
Notice of Hearing
NOTICE IS HEREBY GIVEN that pursuant to ss. 343.14 (2) (er)
, 343.17 (3)
, 343.20 (1m)
and 343.50 (5)
, Stats., and interpreting s. 343.14 (2) (er)
, Stats., the Department of Transportation will hold a public hearing in Room 144-B of the Hill Farms State Transportation Building, 4802 Sheboygan Avenue, Madison, Wisconsin on the 3rd day of August, 2006
, at 1:00 PM, to consider the amendment of ch. Trans 102
, Wisconsin Administrative Code, relating to operator's licenses and identification cards.
An interpreter for the hearing impaired will be available on request for this hearing. Please make reservations for a hearing interpreter at least 10 days prior to the hearing.
Parking for persons with disabilities and an accessible entrance are available.
Analysis Prepared by the Wisconsin Department of Transportation
Explanation of agency authority: 2005 Wisconsin Act 126
requires that a person applying for a driver's license or identification card provide documentary proof of citizenship or legal presence in the United States.
Plain language analysis: 2005 Wisconsin Act 126
requires all persons applying for an original, reissue, reinstatement, renewal or duplicate Wisconsin driver's license or identification card on or after April 1, 2007 to show documentary proof of citizenship or legal presence in this country. Currently, applicants for a driver's license or identification card are required to show proof of identity, name and date of birth, and residency. 2005 Wisconsin Act 126
also requires operator's licenses and identification cards to expire on the date the person's legal presence in the United States is no longer authorized. This rule implements these expiration dates.
Summary of, and preliminary comparison with, existing or proposed federal regulation: This proposed rule making moves Wisconsin towards compliance with the legal presence requirements of the federal REAL ID Act, which takes effect May 11, 2008.
Comparison with Rules in Adjacent States:
Michigan: No legal presence requirement.
Minnesota: Legal presence required.
Illinois: Legal presence required.
Iowa: Legal presence required.
Summary of factual data and analytical methodologies used and how the related findings support the regulatory approach chosen: Not applicable.
Analysis and supporting documentation used to determine effect on small businesses: Some small businesses may be affected, if their employees who are not U.S. citizens do not have legal presence and consequently lose their driving privileges and require driving privileges to attend or perform their jobs. These costs are indeterminable.
Effect on small business: Indeterminable. The Department's Regulatory Review Coordinator may be contacted by e-mail at email@example.com
, or by calling (414) 438-4585.
Fiscal effect and anticipated costs incurred by private sector: Costs incurred by the private sector is indeterminable. This rule does not directly affect business but may affect the work force. The Department estimates that there will be no fiscal impact on the liabilities or revenues of any county, city, village, town, school district, vocational, technical and adult education district, sewerage district, or federally-recognized tribes or bands. The Department estimates that there will be no fiscal impact on state revenues or liabilities.
Agency contact person and place where comments are to be submitted and deadline for submission: The public record on this proposed rule making will be held open until close of business the day of the hearing to permit the submission of comments in lieu of public hearing testimony or comments supplementing testimony offered at the hearing. Any such comments should be submitted to Erin Egan, Department of Transportation, Bureau of Driver Services, Room 255, P. O. Box 7911, Madison, WI 53707-7911. You may also contact Ms. Egan by phone at (608) 266-1449.
Notice of Hearing
University of Wisconsin System
NOTICE IS HEREBY GIVEN that pursuant to ss. 36.09 (1)
, 36.11 (1)
and 36.13 (3)
, Stats., the Board of Regents of the University of Wisconsin System will hold a public hearing in Room 1820 Van Hise Hall, 1220 Linden Drive, in the City of Madison, Wisconsin on August 2, 2006 at 9:00 a.m. to consider the creation of rules relating to the dismissal of faculty and academic staff in special cases. Persons with disabilities requesting an accommodation to attend are asked to contact Judith Temby in advance of the hearing at (608) 262-2324.