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.
16,3741qmg
Section 3741qmg. 609.655 (1) (a) 1. of the statutes is amended to read:
609.655 (1) (a) 1. Is covered as a dependent child under the terms of a policy or certificate issued by a managed care defined network plan insurer.
16,3741qmp
Section 3741qmp. 609.655 (1) (a) 2. of the statutes is amended to read:
609.655 (1) (a) 2. Is enrolled in a school located in this state but outside the geographical service area of the managed care defined network plan.
16,3741qmt
Section 3741qmt. 609.655 (2) of the statutes is amended to read:
609.655 (2) If a policy or certificate issued by a
managed care defined network plan insurer provides coverage of outpatient services provided to a dependent student, the policy or certificate shall provide coverage of outpatient services, to the extent and in the manner required under sub. (3), that are provided to the dependent student while he or she is attending a school located in this state but outside the geographical service area of the managed care defined network plan, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) and 609.05 (3).
16,3741rmg
Section 3741rmg. 609.655 (3) (intro.) of the statutes is amended to read:
609.655 (3) (intro.) Except as provided in sub. (5), a managed care defined network plan shall provide coverage for all of the following services:
16,3741rmp
Section 3741rmp. 609.655 (3) (a) of the statutes is amended to read:
609.655 (3) (a) A clinical assessment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems, conducted by a provider described in s. 632.89 (1) (e) 2. or 3. who is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and who may be designated by the managed care defined network plan.
16,3741smg
Section 3741smg. 609.655 (3) (b) (intro.) of the statutes is amended to read:
609.655 (3) (b) (intro.) If outpatient services are recommended in the clinical assessment conducted under par. (a), the recommended outpatient services consisting of not more than 5 visits to an outpatient treatment facility or other provider that is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and that may be designated by the managed care defined network plan, except as follows:
16,3741smp
Section 3741smp. 609.655 (3) (b) 1. of the statutes is amended to read:
609.655 (3) (b) 1. Coverage is not required under this paragraph if the medical director of the managed care defined network plan determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.
16,3741smt
Section 3741smt. 609.655 (4) (a) of the statutes is amended to read:
609.655 (4) (a) Upon completion of the 5 visits for outpatient services covered under sub. (3) (b), the medical director of the managed care defined network plan and the clinician treating the dependent student shall review the dependent student's condition and determine whether it is appropriate to continue treatment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems in reasonably close proximity to the school in which the student is enrolled. The review is not required if the dependent student is no longer enrolled in the school or if the coverage limits under the policy or certificate for treatment of nervous or mental disorders or alcoholism or other drug abuse problems have been exhausted.
16,3741tmg
Section 3741tmg. 609.655 (4) (b) of the statutes is amended to read:
609.655 (4) (b) Upon completion of the review under par. (a), the medical director of the managed care
defined network plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the managed care defined network plan's internal grievance procedure established under s. 632.83.
16,3741tmp
Section 3741tmp. 609.655 (5) (a) of the statutes is amended to read:
609.655 (5) (a) A policy or certificate issued by a managed care defined network plan insurer is required to provide coverage for the services specified in sub. (3) only to the extent that the policy or certificate would have covered the service if it had been provided to the dependent student by a participating provider within the geographical service area of the managed care defined network plan.
16,3741tmt
Section 3741tmt. 609.655 (5) (b) of the statutes is amended to read:
609.655 (5) (b) Paragraph (a) does not permit a managed care defined network plan to reimburse a provider for less than the full cost of the services provided or an amount negotiated with the provider, solely because the reimbursement rate for the service would have been less if provided by a participating provider within the geographical service area of the managed care defined network plan.
16,3741umg
Section 3741umg. 609.70 of the statutes is amended to read:
609.70 Chiropractic coverage. Limited service health organizations, preferred provider plans, and
managed care defined network plans are subject to s. 632.87 (3).
16,3741ump
Section 3741ump. 609.75 of the statutes is amended to read:
609.75 Adopted children coverage. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.896. Coverage of health care services obtained by adopted children and children placed for adoption may be subject to any requirements that the limited service health organization, preferred provider plan, or managed care defined network plan imposes under s. 609.05 (2) and (3) on the coverage of health care services obtained by other enrollees.
16,3741umt
Section 3741umt. 609.77 of the statutes is amended to read:
609.77 Coverage of breast reconstruction. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.895 (13).
16,3741vmg
Section 3741vmg. 609.78 of the statutes is amended to read:
609.78 Coverage of treatment for the correction of temporomandibular disorders. Limited service health organizations, preferred provider plans, and
managed care defined network plans are subject to s. 632.895 (11).
16,3741vmp
Section 3741vmp. 609.79 of the statutes is amended to read:
609.79 Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.895 (12).
16,3741vmt
Section 3741vmt. 609.80 of the statutes is amended to read:
609.80 Coverage of mammograms. Managed care Defined network plans are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be subject to any requirements that the managed care defined network plan imposes under s. 609.05 (2) and (3) on the coverage of other health care services obtained by enrollees.
16,3741wmg
Section 3741wmg. 609.81 of the statutes is amended to read:
609.81 Coverage related to HIV infection. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 631.93. Managed care Defined network plans are subject to s. 632.895 (9).
