609.01 (1d) "Enrollee" means, with respect to a managed care defined network plan, preferred provider plan, or limited service health organization, a person who is entitled to receive health care services under the plan.
16,3741amp Section 3741amp. 609.01 (3c) of the statutes is renumbered 609.01 (1b) and amended to read:
609.01 (1b) "Managed care Defined network 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.
16,3741amt Section 3741amt. 609.01 (3m) of the statutes is amended to read:
609.01 (3m) "Participating" means, with respect to a physician or other provider, under contract with a managed care defined network plan, preferred provider plan, or limited service health organization to provide health care services, items or supplies to enrollees of the managed care defined network plan, preferred provider plan, or limited service health organization.
16,3741bmg Section 3741bmg. 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 enrollees, without referral and for consideration other than predetermined periodic fixed payments, coverage of either comprehensive health care services or a limited range of health care services, regardless of whether the health care services are performed by participating or nonparticipating providers participating in the plan.
16,3741bmp Section 3741bmp. 609.01 (5) of the statutes is amended to read:
609.01 (5) "Primary provider" means a participating primary care physician, or other participating provider authorized by the managed care defined network 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.
16,3741bmt Section 3741bmt. 609.05 (1) of the statutes is amended to read:
609.05 (1) Except as provided in subs. (2) and (3), a limited service health organization, preferred provider plan, or managed care defined network plan shall permit its enrollees to choose freely among participating providers.
16,3741cmg Section 3741cmg. 609.05 (2) of the statutes is amended to read:
609.05 (2) Subject to s. 609.22 (4) and (4m), a limited service health organization, preferred provider plan, or managed care defined network plan may require an enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.
16,3741cmp Section 3741cmp. 609.05 (3) of the statutes is amended to read:
609.05 (3) Except as provided in ss. 609.22 (4m), 609.65, and 609.655, a limited service health organization, preferred provider plan, or managed care defined network plan may require an enrollee to obtain a referral from the primary provider designated under sub. (2) to another participating provider prior to obtaining health care services from that participating provider.
16,3741cmr Section 3741cmr. 609.10 (5) of the statutes is amended to read:
609.10 (5) The commissioner may establish by rule standards in addition to those any established under s. 609.20 for what constitutes adequate notice and complete and understandable information under sub. (1) (c).
16,3741cmt Section 3741cmt. 609.17 of the statutes is amended to read:
609.17 Reports of disciplinary action. Every limited service health organization, preferred provider plan, and managed care defined network 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 participating provider who holds a license or certificate granted by the board or affiliated credentialing board.
16,3741dmg Section 3741dmg. 609.20 (title) of the statutes is amended to read:
609.20 (title) Rules for preferred provider and managed care defined network plans.
16,3741dmp Section 3741dmp. 609.20 (intro.) of the statutes is renumbered 609.20 (1m) (intro.) and amended to read:
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.
16,3741emt Section 3741emt. 609.20 (3) of the statutes, as affected by 1999 Wisconsin Act 9, is renumbered 609.20 (1m) (c).
16,3741fmg Section 3741fmg. 609.20 (4) of the statutes, as affected by 2001 Wisconsin Act 9, is renumbered 609.20 (1m) (d).
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.
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