609.20 (1m) (intro.) The commissioner shall may promulgate rules relating to preferred provider plans and managed care defined network plans for all any of the following purposes, as appropriate:
16,3741dmt
Section 3741dmt. 609.20 (1) of the statutes is renumbered 609.20 (1m) (a).
16,3741emg
Section 3741emg. 609.20 (2) of the statutes is renumbered 609.20 (1m) (b).
16,3741emp
Section 3741emp. 609.20 (2m) of the statutes is created to read:
609.20 (2m) Any rule promulgated under this chapter shall recognize the differences between preferred provider plans and other types of defined network plans, take into account the fact that preferred provider plans provide coverage for the services of nonparticipating providers, and be appropriate to the type of plan to which the rule applies.
16,3741fmp
Section 3741fmp. 609.22 (1) of the statutes is amended to read:
609.22 (1) Providers. A managed care defined network plan shall include a sufficient number, and sufficient types, of qualified providers to meet the anticipated needs of its enrollees, with respect to covered benefits, as appropriate to the type of plan and consistent with normal practices and standards in the geographic area.
16,3741fmt
Section 3741fmt. 609.22 (2) of the statutes is amended to read:
609.22 (2) Adequate choice. A managed care defined network plan that is not a preferred provider 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.
16,3741gmg
Section 3741gmg. 609.22 (3) of the statutes is amended to read:
609.22 (3) Primary provider selection. A managed care defined network plan that is not a preferred provider 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 defined network 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.
16,3741gmp
Section 3741gmp. 609.22 (4) (a) 1. of the statutes is amended to read:
609.22 (4) (a) 1. If a managed care
defined network plan that is not a preferred provider plan requires a referral to a specialist for coverage of specialist services, the managed care defined network plan
that is not a preferred provider plan shall establish a procedure by which an enrollee may apply for a standing referral to a specialist. The procedure must specify the criteria and conditions that must be met in order for an enrollee to obtain a standing referral.
16,3741gmt
Section 3741gmt. 609.22 (4) (a) 2. of the statutes is amended to read:
609.22 (4) (a) 2. A managed care
defined network plan that is not a preferred provider 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. A managed care defined network plan that is not a preferred provider plan may restrict the specialist from making any secondary referrals without prior approval by the enrollee's primary provider. If an enrollee requests primary care services from a specialist to whom the enrollee has a standing referral, the specialist, 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 defined network plan that is not a preferred provider plan.
16,3741hmg
Section 3741hmg. 609.22 (4) (a) 3. of the statutes is amended to read:
609.22 (4) (a) 3. A managed care
defined network plan that is not a preferred provider 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.
16,3741hmp
Section 3741hmp. 609.22 (4m) (a) of the statutes is amended to read:
609.22 (4m) (a) A managed care defined network plan that provides coverage of obstetric or gynecologic services may not require a female enrollee of the managed care defined network plan to obtain a referral for covered obstetric or gynecologic benefits provided by a participating provider who is a physician licensed under ch. 448 and who specializes in obstetrics and gynecology, regardless of whether the participating provider is the enrollee's primary provider. Notwithstanding sub. (4), the managed care defined network plan may not require the enrollee to obtain a standing referral under the procedure established under sub. (4) (a) for covered obstetric or gynecologic benefits.
16,3741hmt
Section 3741hmt. 609.22 (4m) (b) (intro.) of the statutes is amended to read:
609.22 (4m) (b) (intro.) A managed care defined network plan under par. (a) may not do any of the following:
16,3741img
Section 3741img. 609.22 (4m) (c) of the statutes is amended to read:
609.22 (4m) (c) A managed care defined network plan under par. (a) shall provide written notice of the requirement under par. (a) in every policy or group certificate issued by the managed care defined network plan.
16,3741imp
Section 3741imp. 609.22 (5) of the statutes is amended to read:
609.22 (5) Second opinions. A managed care defined network plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.
16,3741imt
Section 3741imt. 609.22 (6) (intro.) of the statutes is amended to read:
609.22 (6) Emergency care. (intro.) Notwithstanding s. 632.85, if a managed care defined network plan provides coverage of emergency services, with respect to covered benefits, the managed care defined network plan shall do all of the following:
16,3741jmg
Section 3741jmg. 609.22 (7) of the statutes is amended to read:
609.22 (7) Telephone access. A managed care defined network plan that is not a preferred provider 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 defined network plan that is not a preferred provider 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.
16,3741jmp
Section 3741jmp. 609.22 (8) of the statutes is amended to read:
609.22 (8) Access plan for certain enrollees. A managed care defined network 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 defined network plan shall provide access to translation services fluent in those languages to the greatest extent possible.
16,3741jmt
Section 3741jmt. 609.24 (1) (a) (intro.) of the statutes is amended to read:
609.24 (1) (a) (intro.) Subject to pars. (b) and (c) and except as provided in par. (d), a managed care defined network 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 defined network 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:
16,3741kmg
Section 3741kmg. 609.24 (1) (b) (intro.) of the statutes is amended to read:
609.24 (1) (b) (intro.) Except as provided in par. (d), a managed care defined network 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:
16,3741kmp
Section 3741kmp. 609.24 (1) (c) (intro.) of the statutes is amended to read:
609.24 (1) (c) (intro.) 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 defined network plan shall provide the coverage under par. (a) with respect to the services of the provider for the following period of time:
16,3741kmt
Section 3741kmt. 609.24 (1) (d) 1. of the statutes is amended to read:
609.24 (1) (d) 1. The provider no longer practices in the managed care defined network plan's geographic service area.
16,3741Lmg
Section 3741Lmg. 609.24 (1) (d) 2. of the statutes is amended to read:
609.24 (1) (d) 2. The insurer issuing the managed care defined network plan terminates or terminated the provider's contract for misconduct on the part of the provider.
16,3471Lmp
Section 3471Lmp. 609.24 (1) (e) 1. of the statutes is amended to read:
609.24 (1) (e) 1. An insurer issuing a managed care defined network plan shall include in its provider contracts provisions addressing reimbursement to providers for services rendered under this section.
16,3741Lmt
Section 3741Lmt. 609.24 (1) (e) 2. of the statutes is amended to read:
609.24 (1) (e) 2. If a contract between a managed care defined network 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.
16,3741mmb
Section 3741mmb. 609.24 (4) of the statutes is created to read:
609.24 (4) Notice of provisions. A defined network plan shall notify all plan enrollees of the provisions under this section whenever a participating provider's participation with the plan terminates, or shall, by contract, require a participating provider to notify all plan enrollees of the provisions under this section if the participating provider's participation with the plan terminates.
16,3741mmd
Section 3741mmd. 609.30 (1) of the statutes is amended to read:
609.30 (1) Plan may not contract. A managed care defined network 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.
16,3741mmf
Section 3741mmf. 609.30 (2) of the statutes is amended to read:
609.30 (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 defined network 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.
16,3741mmh
Section 3741mmh. 609.32 (1) (intro.) of the statutes is amended to read:
609.32 (1) Standards; other than preferred provider plans. (intro.) A managed care defined network plan that is not a preferred provider 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:
16,3741mmj
Section 3741mmj. 609.32 (1m) of the statutes is created to read:
609.32 (1m) Procedure for remedial action; preferred provider plans. A preferred provider plan shall develop a procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.
16,3741mmn
Section 3741mmn. 609.32 (2) (a) of the statutes is amended to read:
609.32 (2) (a) A managed care defined network 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.
16,3741mmp
Section 3741mmp. 609.32 (2) (b) (intro.) of the statutes is amended to read:
609.32 (2) (b) (intro.) A managed care
defined network plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider's initial acceptance for participation. The reevaluation shall include all of the following:
16,3741mmr
Section 3741mmr. 609.32 (2) (c) of the statutes is amended to read:
609.32 (2) (c) A managed care defined network plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.
16,3741mmt
Section 3741mmt. 609.34 of the statutes is renumbered 609.34 (1) and amended to read:
609.34 (1) A managed care defined network plan that is not a preferred provider plan shall appoint a physician as medical director. The medical director shall be responsible for clinical protocols, quality assurance activities, and utilization management policies of the plan.
16,3741mmx
Section 3741mmx. 609.34 (2) of the statutes is created to read:
609.34 (2) A preferred provider plan may contract for services related to clinical protocols and utilization management. A preferred provider plan or its designee is required to appoint a medical director only to the extent that the preferred provider plan or its designee assumes direct responsibility for clinical protocols and utilization management policies of the plan. The medical director, who shall be a physician, shall be responsible for such protocols and policies of the plan.
16,3741mmy
Section 3741mmy. 609.35 of the statutes is created to read:
609.35 Applicability of requirements to preferred provider plans. Notwithstanding ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1), a preferred provider plan that does not cover the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider is subject to the requirements under ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1).
16,3741mmz
Section 3741mmz. 609.36 (1) (a) (intro.) of the statutes is amended to read:
609.36 (1) (a) (intro.) A managed care
defined network plan shall provide to the commissioner information related to all of the following:
16,3741nmg
Section 3741nmg. 609.36 (2) of the statutes is amended to read:
609.36 (2) Confidentiality. A managed care defined network plan shall establish written policies and procedures, consistent with ss. 51.30, 146.82, and 252.15, for the handling of medical records and enrollee communications to ensure confidentiality.
16,3741nmp
Section 3741nmp. 609.38 of the statutes is amended to read:
609.38 Oversight. The office shall perform examinations of insurers that issue managed care
defined network plans consistent with ss. 601.43 and 601.44. The commissioner shall by rule develop standards for managed care defined network plans for compliance with the requirements under this chapter.
16,3741nmt
Section 3741nmt. 609.65 (1) (intro.) of the statutes is amended to read:
609.65 (1) (intro.) If an enrollee of a limited service health organization, preferred provider plan, or
managed care defined network plan is examined, evaluated
, or treated for a nervous or mental disorder pursuant to an emergency detention under s. 51.15, a commitment or a court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) to (4) and 609.05 (3), the limited service health organization, preferred provider plan, or managed care defined network plan shall do all of the following:
16,3741omg
Section 3741omg. 609.65 (1) (a) of the statutes is amended to read:
609.65 (1) (a) If the provider performing the examination, evaluation, or treatment has a provider agreement with the limited service health organization, preferred provider plan, or managed care defined network plan which covers the provision of that service to the enrollee, make the service available to the enrollee in accordance with the terms of the limited service health organization, preferred provider plan, or managed care defined network plan and the provider agreement.
16,3741omp
Section 3741omp. 609.65 (1) (b) (intro.) of the statutes is amended to read:
609.65 (1) (b) (intro.) If the provider performing the examination, evaluation or treatment does not have a provider agreement with the limited service health organization, preferred provider plan, or managed care defined network plan which covers the provision of that service to the enrollee, reimburse the provider for the examination, evaluation, or treatment of the enrollee in an amount not to exceed the maximum reimbursement for the service under the medical assistance program under subch. IV of ch. 49, if any of the following applies:
16,3741omt
Section 3741omt. 609.65 (1) (b) 1. of the statutes is amended to read:
609.65 (1) (b) 1. The service is provided pursuant to a commitment or a court order, except that reimbursement is not required under this subdivision if the limited service health organization, preferred provider plan, or managed care defined network plan could have provided the service through a provider with whom it has a provider agreement.
16,3741pmg
Section 3741pmg. 609.65 (1) (b) 2. of the statutes is amended to read:
609.65 (1) (b) 2. The service is provided pursuant to an emergency detention under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20 and the provider notifies the limited service health organization, preferred provider plan, or managed care defined network plan within 72 hours after the initial provision of the service.
16,3741pmp
Section 3741pmp. 609.65 (2) of the statutes is amended to read:
609.65 (2) If after receiving notice under sub. (1) (b) 2. the limited service health organization, preferred provider plan, or managed care defined network plan arranges for services to be provided by a provider with whom it has a provider agreement, the limited service health organization, preferred provider plan, or managed care plan is not required to reimburse a provider under sub. (1) (b) 2. for any services provided after arrangements are made under this subsection.
16,3741pmt
Section 3741pmt. 609.65 (3) of the statutes is amended to read:
609.65 (3) A limited service health organization, preferred provider plan, or managed care
defined network plan is only required to make available, or make reimbursement for, an examination, evaluation, or treatment under sub. (1) to the extent that the limited service health organization, preferred provider plan, or managed care defined network plan would have made the medically necessary service available to the enrollee or reimbursed the provider for the service if any referrals required under s. 609.05 (3) had been made and the service had been performed by a participating provider.
