AB768-ASA1,425,43
609.01
(1c) "Emergency medical condition" has the meaning given in s. 632.85
4(1) (a).
AB768-ASA1,425,86
609.01
(1d) "Enrollee" means, with respect to a managed care plan, preferred
7provider plan or limited service health organization, a person who is entitled to
8receive health care services under the plan.
AB768-ASA1,425,1110
609.01
(1g) (a) Except as provided in par. (b), "health benefit plan" means any
11hospital or medical policy or certificate.
AB768-ASA1,425,1212
(b) "Health benefit plan" does not include any of the following:
AB768-ASA1,425,1413
1. Coverage that is only accident or disability income insurance, or any
14combination of the 2 types.
AB768-ASA1,425,1515
2. Coverage issued as a supplement to liability insurance.
AB768-ASA1,425,1716
3. Liability insurance, including general liability insurance and automobile
17liability insurance.
AB768-ASA1,425,1818
4. Worker's compensation or similar insurance.
AB768-ASA1,425,1919
5. Automobile medical payment insurance.
AB768-ASA1,425,2020
6. Credit-only insurance.
AB768-ASA1,425,2121
7. Coverage for on-site medical clinics.
AB768-ASA1,425,2422
8. Other similar insurance coverage, as specified in regulations issued by the
23federal department of health and human services, under which benefits for medical
24care are secondary or incidental to other insurance benefits.
AB768-ASA1,426,6
19. If provided under a separate policy, certificate or contract of insurance, or if
2otherwise not an integral part of the policy, certificate or contract of insurance:
3limited-scope dental or vision benefits; benefits for long-term care, nursing home
4care, home health care, community-based care, or any combination of those benefits;
5and such other similar, limited benefits as are specified in regulations issued by the
6federal department of health and human services under section 2791 of P.L.
104-191.
AB768-ASA1,426,87
10. Hospital indemnity or other fixed indemnity insurance or coverage only for
8a specified disease or illness, if all of the following apply:
AB768-ASA1,426,109
a. The benefits are provided under a separate policy, certificate or contract of
10insurance.
AB768-ASA1,426,1311
b. There is no coordination between the provision of such benefits and any
12exclusion of benefits under any group health plan maintained by the same plan
13sponsor.
AB768-ASA1,426,1614
c. Such benefits are paid with respect to an event without regard to whether
15benefits are provided with respect to such an event under any group health plan
16maintained by the same plan sponsor.
AB768-ASA1,426,1717
11. Other insurance exempted by rule of the commissioner.
AB768-ASA1,426,2419
609.01
(2) "Health maintenance organization" means a health care plan
20offered by an organization established under ch. 185, 611, 613 or 614 or issued a
21certificate of authority under ch. 618 that makes available to its
enrolled
22participants enrollees, in consideration for predetermined periodic fixed payments,
23comprehensive health care services performed by providers
selected by the
24organization participating in the plan.
AB768-ASA1,427,6
1609.01
(3) "Limited service health organization" means a health care plan
2offered by an organization established under ch. 185, 611, 613 or 614 or issued a
3certificate of authority under ch. 618 that makes available to its
enrolled
4participants enrollees, in consideration for predetermined periodic fixed payments,
5a limited range of health care services performed by providers
selected by the
6organization participating in the plan.
AB768-ASA1,427,128
609.01
(3c) "Managed care plan" means a health benefit plan that requires an
9enrollee of the health benefit plan, or creates incentives, including financial
10incentives, for an enrollee of the health benefit plan, to use providers that are
11managed, owned, under contract with or employed by the insurer offering the health
12benefit plan.
AB768-ASA1,427,1814
609.01
(3m) "Participating" means, with respect to a physician or other
15provider, under contract with a managed care plan, preferred provider plan or
16limited service health organization to provide health care services, items or supplies
17to enrollees of the managed care plan, preferred provider plan or limited service
18health organization.
AB768-ASA1,427,2020
609.01
(3r) "Physician" has the meaning given in s. 448.01 (5).
AB768-ASA1,428,222
609.01
(4) "Preferred provider plan" means a health care plan offered by an
23organization established under ch. 185, 611, 613 or 614 or issued a certificate of
24authority under ch. 618 that makes available to its
enrolled participants enrollees,
25for consideration other than predetermined periodic fixed payments, either
1comprehensive health care services or a limited range of health care services
2performed by providers
selected by the organization
participating in the plan.
AB768-ASA1,428,54
609.01
(4m) "Primary care physician" means a physician specializing in family
5medical practice, general internal medicine or pediatrics.
AB768-ASA1,428,107
609.01
(5) "Primary provider" means a participating primary care physician,
8or other participating provider authorized by the managed care plan, preferred
9provider plan or limited service health organization to serve as a primary provider,
10who coordinates and may provide ongoing care to an enrollee.
AB768-ASA1,428,1312
609.01
(6) "Specialist physician" means a physician who is not a primary care
13physician.
AB768-ASA1,428,1815
609.05
(1) Except as provided in subs. (2) and (3), a
health maintenance
16organization, limited service health organization
or
, preferred provider plan
or 17managed care plan shall permit its
enrolled participants enrollees to choose freely
18among
selected participating providers.
AB768-ASA1,428,2320
609.05
(2) A health care plan under sub. (1) Subject to s. 609.22 (4), a limited
21service health organization, preferred provider plan or managed care plan may
22require an
enrolled participant enrollee to designate a primary provider and to
23obtain health care services from the primary provider when reasonably possible.
AB768-ASA1,429,6
1609.05
(3) Except as provided in ss. 609.65 and 609.655, a
health care plan
2under sub. (1) limited service health organization, preferred provider plan or
3managed care plan may require an
enrolled participant enrollee to obtain a referral
4from the primary provider designated under sub. (2) to another
selected 5participating provider prior to obtaining health care services from
the other selected 6that participating provider.
AB768-ASA1,429,138
609.10
(1) (a) Except as provided in subs. (2) to (4), an employer that offers any
9of its employes a health maintenance organization or a preferred provider plan that
10provides comprehensive health care services shall also offer the employes a standard
11plan, as provided in pars. (b) and (c), that provides at least substantially equivalent
12coverage of health care expenses
and that is not a health maintenance organization
13or a preferred provider plan.
AB768-ASA1,429,1715
609.15
(1) (intro.) Each
health maintenance organization, limited service
16health organization
and, preferred provider plan
and managed care plan shall do all
17of the following:
AB768-ASA1,429,2219
609.15
(1) (a) Establish and use an internal grievance procedure that is
20approved by the commissioner and that complies with sub. (2) for the resolution of
21enrolled participants' enrollees' grievances with the
health care limited service
22health organization, preferred provider plan or managed care plan.
AB768-ASA1,430,3
1609.15
(1) (b) Provide
enrolled participants enrollees with complete and
2understandable information describing the internal grievance procedure under par.
3(a).
AB768-ASA1,430,65
609.15
(2) (a) The opportunity for an
enrolled participant enrollee to submit
6a written grievance in any form.
AB768-ASA1,430,128
609.15
(2) (b) Establishment of a grievance panel for the investigation of each
9grievance submitted under par. (a), consisting of at least one individual authorized
10to take corrective action on the grievance and at least one
enrolled participant 11enrollee other than the grievant, if an
enrolled participant enrollee is available to
12serve on the grievance panel.
AB768-ASA1,430,19
14609.17 Reports of disciplinary action. Every
health maintenance
15organization, limited service health organization
and
, preferred provider plan
and
16managed care plan shall notify the medical examining board or appropriate
17affiliated credentialing board attached to the medical examining board of any
18disciplinary action taken against a
selected participating provider who holds a
19license or certificate granted by the board or affiliated credentialing board.
AB768-ASA1,430,23
21609.20 (title)
Rules for preferred provider
and managed care plans. 22(intro.) The commissioner shall promulgate rules
applicable relating to preferred
23provider plans
and managed care plans for all of the following purposes:
AB768-ASA1,431,2
1609.20
(1) To ensure that
enrolled participants enrollees are not forced to travel
2excessive distances to receive health care services.
AB768-ASA1,431,54
609.20
(2) To ensure that the continuity of patient care for
enrolled participants 5is not disrupted enrollees meets the requirements under s. 609.24.
AB768-ASA1,431,147
609.20
(4) To ensure that employes offered a
health maintenance organization
8or a preferred provider plan that provides comprehensive services under s. 609.10
9(1) (a) are given adequate notice of the opportunity to enroll
and, as well as complete
10and understandable information under s. 609.10 (1) (c) concerning the differences
11between the
health maintenance organization or preferred provider plan and the
12standard plan, including differences between providers available and differences
13resulting from special limitations or requirements imposed by an institutional
14provider because of its affiliation with a religious organization.
AB768-ASA1,431,18
16609.22 Access standards. (1) Providers. A managed care plan shall include
17a sufficient number, and sufficient types, of providers to meet the anticipated needs
18of its enrollees, with respect to covered benefits.
AB768-ASA1,431,21
19(2) Adequate choice. A managed care plan shall ensure that, with respect to
20covered benefits, each enrollee has adequate choice among participating providers
21and that the providers are accessible and qualified.
AB768-ASA1,432,3
22(3) Primary provider selection. A managed care plan shall permit each
23enrollee to select his or her own primary provider from a list of participating primary
24care physicians and any other participating providers that are authorized by the
25managed care plan to serve as primary providers. The list shall be updated on an
1ongoing basis and shall include a sufficient number of primary care physicians and
2any other participating providers authorized by the plan to serve as primary
3providers who are accepting new enrollees.
AB768-ASA1,432,10
4(4) Specialist providers. (a) A managed care plan shall allow all enrollees
5under the plan to have access to specialist physicians on a timely basis when
6specialty medical care is warranted, with respect to covered benefits. An enrollee
7shall be allowed to choose among participating specialist physicians, within the
8limitations of the managed care plan, when a referral is made for specialty care, with
9respect to covered benefits. A managed care plan shall clearly disclose to enrollees
10any limitations.
AB768-ASA1,432,1511
(b) If the treatment of a specific condition for which coverage is provided under
12the plan requires the services of a particular type of specialist physician and a
13managed care plan has no participating specialist physicians of that type, the
14managed care plan shall provide enrollees with the specific condition with coverage
15for the services of nonparticipating specialist physicians of that type.
AB768-ASA1,432,2016
(c) 1. If a managed care plan requires a referral to a specialist physician for
17coverage of the specialist physician's services, the managed care plan shall establish
18a procedure by which an enrollee may apply for a standing referral to a specialist
19physician. The procedure must specify the criteria and conditions that must be met
20in order for an enrollee to obtain a standing referral.
AB768-ASA1,433,421
2. A managed care plan may require the enrollee's primary provider to remain
22responsible for coordinating the care of an enrollee who receives a standing referral
23to a specialist physician. A managed care plan may restrict the specialist physician
24from making any secondary referrals without prior approval by the enrollee's
25primary provider. If an enrollee requests primary care services from a specialist
1physician to whom the enrollee has a standing referral, the specialist physician, in
2agreement with the enrollee and the enrollee's primary provider, may provide
3primary care services to the enrollee in accordance with procedures established by
4the managed care plan.
AB768-ASA1,433,75
3. A managed care plan must include information regarding referral
6procedures in policies or certificates provided to enrollees and must provide such
7information to an enrollee or prospective enrollee upon request.
AB768-ASA1,433,9
8(5) Second opinions. A managed care plan shall provide an enrollee with
9coverage for a 2nd opinion from another participating provider.
AB768-ASA1,433,12
10(6) Emergency care. Notwithstanding s. 632.85, if a managed care plan
11provides coverage of emergency services, with respect to covered benefits, the
12managed care plan shall do all of the following:
AB768-ASA1,433,1513
(a) Cover emergency medical services for which coverage is provided under the
14plan and that are obtained without prior authorization for the treatment of an
15emergency medical condition.
AB768-ASA1,433,1916
(b) Cover emergency medical services or urgent care for which coverage is
17provided under the plan and that is provided to an individual who has coverage
18under the plan as a dependent child and who is a full-time student attending school
19outside of the geographic service area of the plan.
AB768-ASA1,433,25
20(7) Telephone access. A managed care plan shall provide telephone access for
21sufficient time during business and evening hours to ensure that enrollees have
22adequate access to routine health care services for which coverage is provided under
23the plan. A managed care plan shall provide 24-hour telephone access to the plan
24or to a participating provider for emergency care, or authorization for care, for which
25coverage is provided under the plan.
AB768-ASA1,434,6
1(8) Access plan for certain enrollees. A managed care plan shall develop an
2access plan to meet the needs, with respect to covered benefits, of its enrollees who
3are members of underserved populations. If a significant number of enrollees of the
4plan customarily use languages other than English, the managed care plan shall
5provide access to translation services fluent in those languages to the greatest extent
6possible.
AB768-ASA1,434,14
8609.24 Continuity of care. (1) Requirement to provide access. (a) Subject
9to pars. (b) and (c) and except as provided in par. (d), a managed care plan shall, with
10respect to covered benefits, provide coverage to an enrollee for the services of a
11provider, regardless of whether the provider is a participating provider at the time
12the services are provided, if the managed care plan represented that the provider
13was, or would be, a participating provider in marketing materials that were provided
14or available to the enrollee at any of the following times:
AB768-ASA1,434,1615
1. If the plan under which the enrollee has coverage has an open enrollment
16period, the most recent open enrollment period.
AB768-ASA1,434,1917
2. If the plan under which the enrollee has coverage has no open enrollment
18period, the time of the enrollee's enrollment or most recent coverage renewal,
19whichever is later.
AB768-ASA1,434,2220
(b) Except as provided in par. (d), a managed care plan shall provide the
21coverage required under par. (a) with respect to the services of a provider who is a
22primary care physician for the following period of time:
AB768-ASA1,434,2423
1. For an enrollee of a plan with no open enrollment period, until the end of the
24current plan year.
AB768-ASA1,435,3
12. For an enrollee of a plan with an open enrollment period, until the end of the
2plan year for which it was represented that the provider was, or would be, a
3participating provider.
AB768-ASA1,435,84
(c) Except as provided in par. (d), if an enrollee is undergoing a course of
5treatment with a participating provider who is not a primary care physician and
6whose participation with the plan terminates, the managed care plan shall provide
7the coverage under par. (a) with respect to the services of the provider for the
8following period of time: