609.01 (2) “Health maintenance organization" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers selected by the organization participating in the plan.
237,566ccp
Section 566ccp. 609.01 (3) of the statutes is amended to read:
609.01 (3) “Limited service health organization" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers selected by the organization participating in the plan.
237,566ccr
Section 566ccr. 609.01 (3c) of the statutes is created to read:
609.01 (3c) “Managed care 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.
237,566cct
Section 566cct. 609.01 (3m) of the statutes is created to read:
609.01 (3m) “Participating" means, with respect to a physician or other provider, under contract with a managed care plan, preferred provider plan or limited service health organization to provide health care services, items or supplies to enrollees of the managed care plan, preferred provider plan or limited service health organization.
237,566ccv
Section 566ccv. 609.01 (3r) of the statutes is created to read:
609.01 (3r) “Physician" has the meaning given in s. 448.01 (5).
237,566ccx
Section 566ccx. 609.01 (4) of the statutes is amended to read:
609.01 (4) “Preferred provider plan" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, for consideration other than predetermined periodic fixed payments, either comprehensive health care services or a limited range of health care services performed by providers selected by the organization participating in the plan.
237,566ccz
Section 566ccz. 609.01 (4m) of the statutes is created to read:
609.01 (4m) “Primary care physician" means a physician specializing in family medical practice, general internal medicine or pediatrics.
237,566cdd
Section 566cdd. 609.01 (5) of the statutes is repealed and recreated to read:
609.01 (5) “Primary provider" means a participating primary care physician, or other participating provider authorized by the managed care plan, preferred provider plan or limited service health organization to serve as a primary provider, who coordinates and may provide ongoing care to an enrollee.
237,566cdf
Section 566cdf. 609.01 (6) of the statutes is repealed
and recreated to read:
609.01 (6) “Specialist physician" means a physician who is not a primary care physician.
237,566cdg
Section 566cdg. 609.05 (1) of the statutes is amended to read:
609.05 (1) Except as provided in subs. (2) and (3), a health maintenance organization, limited service health organization or, preferred provider plan or managed care plan shall permit its enrolled participants
enrollees to choose freely among selected participating providers.
237,566cdi
Section 566cdi. 609.05 (2) of the statutes is amended to read:
609.05 (2) A health care plan under sub. (1) Subject to s. 609.22 (4), a limited service health organization, preferred provider plan or managed care plan may require an enrolled participant enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.
237,566cdk
Section 566cdk. 609.05 (3) of the statutes is amended to read:
609.05 (3) Except as provided in ss. 609.65 and 609.655, a health care plan under sub. (1) limited service health organization, preferred provider plan or managed care plan may require an enrolled participant
enrollee to obtain a referral from the primary provider designated under sub. (2) to another selected participating provider prior to obtaining health care services from the other selected that participating provider.
237,566cdm
Section 566cdm. 609.10 (1) (a) of the statutes is amended to read:
609.10 (1) (a) Except as provided in subs. (2) to (4), an employer that offers any of its employes a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employes a standard plan, as provided in pars. (b) and (c), that provides at least substantially equivalent coverage of health care expenses and that is not a health maintenance organization or a preferred provider plan.
237,566cdo
Section 566cdo. 609.15 (1) (intro.) of the statutes is amended to read:
609.15 (1) (intro.) Each health maintenance organization, limited service health organization and
, preferred provider plan and managed care plan shall do all of the following:
237,566cdq
Section 566cdq. 609.15 (1) (a) of the statutes is amended to read:
609.15 (1) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (2) for the resolution of enrolled participants' enrollees' grievances with the
health care limited service health organization, preferred provider plan or managed care plan.
237,566cds
Section 566cds. 609.15 (1) (b) of the statutes is amended to read:
609.15 (1) (b) Provide enrolled participants enrollees with complete and understandable information describing the internal grievance procedure under par. (a).
237,566cdu
Section 566cdu. 609.15 (2) (a) of the statutes is amended to read:
609.15 (2) (a) The opportunity for an enrolled participant enrollee to submit a written grievance in any form.
237,566cdw
Section 566cdw. 609.15 (2) (b) of the statutes is amended to read:
609.15 (2) (b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one enrolled participant enrollee other than the grievant, if an enrolled participant enrollee is available to serve on the grievance panel.
237,566cdy
Section 566cdy. 609.17 of the statutes is amended to read:
609.17 Reports of disciplinary action. Every health maintenance organization, limited service health organization and, preferred provider plan and managed care plan shall notify the medical examining board or appropriate affiliated credentialing board attached to the medical examining board of any disciplinary action taken against a selected participating provider who holds a license or certificate granted by the board or affiliated credentialing board.
237,566cfc
Section 566cfc. 609.20 (intro.) of the statutes is amended to read:
609.20 (title) Rules for preferred provider and managed care plans. (intro.) The commissioner shall promulgate rules applicable relating to preferred provider plans and managed care plans for all of the following purposes:
237,566cfe
Section 566cfe. 609.20 (1) of the statutes is amended to read:
609.20 (1) To ensure that enrolled participants enrollees are not forced to travel excessive distances to receive health care services.
237,566cfg
Section 566cfg. 609.20 (2) of the statutes is amended to read:
609.20 (2) To ensure that the continuity of patient care for enrolled participants is not disrupted enrollees meets the requirements under s. 609.24.
237,566cfi
Section 566cfi. 609.20 (4) of the statutes is amended to read:
609.20 (4) To ensure that employes offered a
health maintenance organization or a preferred provider plan that provides comprehensive services under s. 609.10 (1) (a) are given adequate notice of the opportunity to enroll and, as well as complete and understandable information under s. 609.10 (1) (c) concerning the differences between the health maintenance organization or preferred provider plan and the standard plan, including differences between providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization.
237,566cfk
Section 566cfk. 609.22 of the statutes is created to read:
609.22 Access standards. (1) Providers. A managed care plan shall include a sufficient number, and sufficient types, of providers to meet the anticipated needs of its enrollees, with respect to covered benefits.
(2) Adequate choice. A managed care plan shall ensure that, with respect to covered benefits, each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.
(3) Primary provider selection. A managed care plan shall permit each enrollee to select his or her own primary provider from a list of participating primary care physicians and any other participating providers that are authorized by the managed care plan to serve as primary providers. The list shall be updated on an ongoing basis and shall include a sufficient number of primary care physicians and any other participating providers authorized by the plan to serve as primary providers who are accepting new enrollees.
(4) Specialist providers. (a)
A managed care plan shall allow all enrollees under the plan to have access to specialist physicians on a timely basis when specialty medical care is warranted, with respect to covered benefits. An enrollee shall be allowed to choose among participating specialist physicians, within the limitations of the managed care plan, when a referral is made for specialty care, with respect to covered benefits. A managed care plan shall clearly disclose to enrollees any limitations.
(b) If the treatment of a specific condition for which coverage is provided under the plan requires the services of a particular type of specialist physician and a managed care plan has no participating specialist physicians of that type, the managed care plan shall provide enrollees with the specific condition with coverage for the services of nonparticipating specialist physicians of that type.
(c) 1. If a managed care plan requires a referral to a specialist physician for coverage of the specialist physician's services, the managed care plan shall establish a procedure by which an enrollee may apply for a standing referral to a specialist
physician. The procedure must specify the criteria and conditions that must be met in order for an enrollee to obtain a standing referral.
2. A managed care plan may require the enrollee's primary provider to remain responsible for coordinating the care of an enrollee who receives a standing referral to a specialist
physician. A managed care plan may restrict the specialist physician from making any secondary referrals without prior approval by the enrollee's primary provider. If an enrollee requests primary care services from a specialist
physician to whom the enrollee has a standing referral, the specialist physician, in agreement with the enrollee and the enrollee's primary provider, may provide primary care services to the enrollee in accordance with procedures established by the managed care plan.
3. A managed care plan must include information regarding referral procedures in policies or certificates provided to enrollees and must provide such information to an enrollee or prospective enrollee upon request.
(5) Second opinions. A managed care plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.
(6) Emergency care. Notwithstanding s. 632.85, if a managed care plan provides coverage of emergency services, with respect to covered benefits, the managed care plan shall do all of the following:
(a) Cover emergency medical services for which coverage is provided under the plan and that are obtained without prior authorization for the treatment of an emergency medical condition.
(b) Cover emergency medical services or urgent care for which coverage is provided under the plan and that is provided to an individual who has coverage under the plan as a dependent child and who is a full-time student attending school outside of the geographic service area of the plan.
(7) Telephone access. A managed care plan shall provide telephone access for sufficient time during business and evening hours to ensure that enrollees have adequate access to routine health care services for which coverage is provided under the plan. A managed care plan shall provide 24-hour telephone access to the plan or to a participating provider for emergency care, or authorization for care, for which coverage is provided under the plan.
(8) Access plan for certain enrollees. A managed care plan shall develop an access plan to meet the needs, with respect to covered benefits, of its enrollees who are members of underserved populations. If a significant number of enrollees of the plan customarily use languages other than English, the managed care plan shall provide access to translation services fluent in those languages to the greatest extent possible.
237,566cfm
Section 566cfm. 609.24 of the statutes is created to read:
609.24 Continuity of care.
(1) Requirement to provide access. (a) Subject to pars. (b) and (c) and except as provided in par. (d), a managed care plan shall, with respect to covered benefits, provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the managed care plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times:
1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period.
2. If the plan under which the enrollee has coverage has no open enrollment period, the time of the enrollee's enrollment or most recent coverage renewal, whichever is later.
(b) Except as provided in par. (d), a managed care plan shall provide the coverage required under par. (a) with respect to the services of a provider who is a primary care physician for the following period of time:
1. For an enrollee of a plan with no open enrollment period, until the end of the current plan year.
2. For an enrollee of a plan with an open enrollment period, until the end of the plan year for which it was represented that the provider was, or would be, a participating provider.
(c) Except as provided in par. (d), if an enrollee is undergoing a course of treatment with a participating provider who is not a primary care physician and whose participation with the plan terminates, the managed care plan shall provide the coverage under par. (a) with respect to the services of the provider for the following period of time:
1. Except as provided in subd. 2., for the remainder of the course of treatment or for 90 days after the provider's participation with the plan terminates, whichever is shorter, except that the coverage is not required to extend beyond the period specified in par. (b) 1. or 2., whichever applies.
2. If maternity care is the course of treatment and the enrollee is a woman who is in the 2nd or 3rd trimester of pregnancy when the provider's participation with the plan terminates, until the completion of postpartum care for the woman and infant.
(d) The coverage required under this section need not be provided or may be discontinued if any of the following applies:
1. The provider no longer practices in the managed care plan's geographic service area.
2. The insurer issuing the managed care plan terminates or terminated the provider's contract for misconduct on the part of the provider.
(e) 1. An insurer issuing a managed care plan shall include in its provider contracts provisions addressing reimbursement to providers for services rendered under this section.
2. If a contract between a managed care plan and a provider does not address reimbursement for services rendered under this section, the insurer shall reimburse the provider according to the most recent contracted rate.
(2) Medical necessity provisions. This section does not preclude the application of any provisions related to medical necessity that are generally applicable under the plan.
(3) Hold harmless requirements. A provider that receives or is due reimbursement for services provided to an enrollee under this section is subject to s. 609.91 with respect to the enrollee, regardless of whether the provider is a participating provider in the enrollee's plan and regardless of whether the enrollee's plan is a health maintenance organization.
237,566cfo
Section 566cfo. 609.30 of the statutes is created to read:
609.30 Provider disclosures. (1)
Plan may not contract. A managed care plan may not contract with a participating provider to limit the provider's disclosure of information, to or on behalf of an enrollee, about the enrollee's medical condition or treatment options.
(2) Plan may not penalize or terminate. A participating provider may discuss, with or on behalf of an enrollee, all treatment options and any other information that the provider determines to be in the best interest of the enrollee. A managed care plan may not penalize or terminate the contract of a participating provider because the provider makes referrals to other participating providers or discusses medically necessary or appropriate care with or on behalf of an enrollee.
237,566cfq
Section 566cfq. 609.32 of the statutes is created to read:
609.32 Quality assurance. (1)
Standards. A managed care plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following:
(a) An ongoing, written internal quality assurance program.
(b) Specific written guidelines for quality of care studies and monitoring.
(c) Performance and clinical outcomes-based criteria.
(d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.
(e) A plan for gathering and assessing data.
(f) A peer review process.
(2) Selection and evaluation of providers. (a) A managed care plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider's license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider.
