SB55-ASA1-AA1,1294,2018
609.01
(1d) "Enrollee" means, with respect to a
managed care defined network 19plan, preferred provider plan
, or limited service health organization, a person who
20is entitled to receive health care services under the plan.
SB55-ASA1-AA1,1295,323
609.01
(1b) "
Managed care Defined network plan" means a health benefit plan
24that requires an enrollee of the health benefit plan, or creates incentives, including
1financial incentives, for an enrollee of the health benefit plan, to use providers that
2are managed, owned, under contract with
, or employed by the insurer offering the
3health benefit plan.
SB55-ASA1-AA1,1295,95
609.01
(3m) "Participating" means, with respect to a physician or other
6provider, under contract with a
managed care defined network plan, preferred
7provider plan
, or limited service health organization to provide health care services,
8items or supplies to enrollees of the
managed care
defined network plan, preferred
9provider plan
, or limited service health organization.
SB55-ASA1-AA1,1295,1711
609.01
(4) "Preferred provider plan" means a health care plan offered by an
12organization established under ch. 185, 611, 613
, or 614 or issued a certificate of
13authority under ch. 618 that makes available to its enrollees,
without referral and 14for consideration other than predetermined periodic fixed payments,
coverage of 15either comprehensive health care services or a limited range of health care services
,
16regardless of whether the health care services are performed by
participating or
17nonparticipating providers
participating in the plan.
SB55-ASA1-AA1,1295,2219
609.01
(5) "Primary provider" means a participating primary care physician,
20or other participating provider authorized by the
managed care defined network 21plan, preferred provider plan
, or limited service health organization to serve as a
22primary provider, who coordinates and may provide ongoing care to an enrollee.
SB55-ASA1-AA1,1296,3
1609.05
(1) Except as provided in subs. (2) and (3), a limited service health
2organization, preferred provider plan
, or
managed care defined network plan shall
3permit its enrollees to choose freely among participating providers.
SB55-ASA1-AA1,1296,85
609.05
(2) Subject to s. 609.22 (4) and (4m), a limited service health
6organization, preferred provider plan
, or
managed care defined network plan may
7require an enrollee to designate a primary provider and to obtain health care services
8from the primary provider when reasonably possible.
SB55-ASA1-AA1,1296,1410
609.05
(3) Except as provided in ss. 609.22 (4m), 609.65
, and 609.655, a limited
11service health organization, preferred provider plan
, or
managed care defined
12network plan may require an enrollee to obtain a referral from the primary provider
13designated under sub. (2) to another participating provider prior to obtaining health
14care services from that participating provider.
SB55-ASA1-AA1,1296,1816
609.10
(5) The commissioner may establish by rule standards in addition to
17those any established under s. 609.20 for what constitutes adequate notice and
18complete and understandable information under sub. (1) (c).
SB55-ASA1-AA1,1296,25
20609.17 Reports of disciplinary action. Every limited service health
21organization, preferred provider plan
, and
managed care defined network plan shall
22notify the medical examining board or appropriate affiliated credentialing board
23attached to the medical examining board of any disciplinary action taken against a
24participating provider who holds a license or certificate granted by the board or
25affiliated credentialing board.
SB55-ASA1-AA1,1297,3
2609.20 (title)
Rules for preferred provider and managed care defined
3network plans.
SB55-ASA1-AA1, s. 3741dmp
4Section 3741dmp. 609.20 (intro.) of the statutes is renumbered 609.20 (1m)
5(intro.) and amended to read:
SB55-ASA1-AA1,1297,86
609.20
(1m) (intro.) The commissioner
shall may promulgate rules relating to
7preferred provider plans and
managed care defined network plans for
all any of the
8following purposes
, as appropriate:
SB55-ASA1-AA1,1297,1612
609.20
(2m) Any rule promulgated under this chapter shall recognize the
13differences between preferred provider plans and other types of defined network
14plans, take into account the fact that preferred provider plans provide coverage for
15the services of nonparticipating providers, and be appropriate to the type of plan to
16which the rule applies.
SB55-ASA1-AA1,1297,2522
609.22
(1) Providers. A
managed care defined network plan shall include a
23sufficient number, and sufficient types, of
qualified providers to meet the anticipated
24needs of its enrollees, with respect to covered benefits
, as appropriate to the type of
25plan and consistent with normal practices and standards in the geographic area.
SB55-ASA1-AA1,1298,52
609.22
(2) Adequate choice. A
managed care defined network plan
that is not
3a preferred provider plan shall ensure that, with respect to covered benefits, each
4enrollee has adequate choice among participating providers and that the providers
5are accessible and qualified.
SB55-ASA1-AA1,1298,147
609.22
(3) Primary provider selection. A
managed care defined network plan
8that is not a preferred provider plan shall permit each enrollee to select his or her
9own primary provider from a list of participating primary care physicians and any
10other participating providers that are authorized by the
managed care defined
11network plan to serve as primary providers. The list shall be updated on an ongoing
12basis and shall include a sufficient number of primary care physicians and any other
13participating providers authorized by the plan to serve as primary providers who are
14accepting new enrollees.
SB55-ASA1-AA1,1298,2116
609.22
(4) (a) 1. If a
managed care
defined network plan
that is not a preferred
17provider plan requires a referral to a specialist for coverage of specialist services, the
18managed care defined network plan
that is not a preferred provider plan shall
19establish a procedure by which an enrollee may apply for a standing referral to a
20specialist. The procedure must specify the criteria and conditions that must be met
21in order for an enrollee to obtain a standing referral.
SB55-ASA1-AA1,1299,723
609.22
(4) (a) 2. A
managed care
defined network plan
that is not a preferred
24provider plan may require the enrollee's primary provider to remain responsible for
25coordinating the care of an enrollee who receives a standing referral to a specialist.
1A
managed care defined network plan
that is not a preferred provider plan may
2restrict the specialist from making any secondary referrals without prior approval
3by the enrollee's primary provider. If an enrollee requests primary care services from
4a specialist to whom the enrollee has a standing referral, the specialist, in agreement
5with the enrollee and the enrollee's primary provider, may provide primary care
6services to the enrollee in accordance with procedures established by the
managed
7care defined network plan
that is not a preferred provider plan.
SB55-ASA1-AA1,1299,129
609.22
(4) (a) 3. A
managed care
defined network plan
that is not a preferred
10provider plan must include information regarding referral procedures in policies or
11certificates provided to enrollees and must provide such information to an enrollee
12or prospective enrollee upon request.
SB55-ASA1-AA1,1299,2214
609.22
(4m) (a) A
managed care defined network plan that provides coverage
15of obstetric or gynecologic services may not require a female enrollee of the
managed
16care defined network plan to obtain a referral for covered obstetric or gynecologic
17benefits provided by a participating provider who is a physician licensed under ch.
18448 and who specializes in obstetrics and gynecology, regardless of whether the
19participating provider is the enrollee's primary provider. Notwithstanding sub. (4),
20the
managed care defined network plan may not require the enrollee to obtain a
21standing referral under the procedure established under sub. (4) (a) for covered
22obstetric or gynecologic benefits.
SB55-ASA1-AA1,1299,2524
609.22
(4m) (b) (intro.) A
managed care defined network plan under par. (a)
25may not do any of the following:
SB55-ASA1-AA1,1300,42
609.22
(4m) (c) A
managed care defined network plan under par. (a) shall
3provide written notice of the requirement under par. (a) in every policy or group
4certificate issued by the
managed care defined network plan.
SB55-ASA1-AA1,1300,86
609.22
(5) Second opinions. A
managed care defined network plan shall
7provide an enrollee with coverage for a 2nd opinion from another participating
8provider.
SB55-ASA1-AA1,1300,1210
609.22
(6) Emergency care. (intro.) Notwithstanding s. 632.85, if a
managed
11care defined network plan provides coverage of emergency services, with respect to
12covered benefits, the
managed care defined network plan shall do all of the following:
SB55-ASA1-AA1,1300,2014
609.22
(7) Telephone access. A
managed care defined network plan
that is not
15a preferred provider plan shall provide telephone access for sufficient time during
16business and evening hours to ensure that enrollees have adequate access to routine
17health care services for which coverage is provided under the plan. A
managed care 18defined network plan
that is not a preferred provider plan shall provide 24-hour
19telephone access to the plan or to a participating provider for emergency care, or
20authorization for care, for which coverage is provided under the plan.
SB55-ASA1-AA1,1301,222
609.22
(8) Access plan for certain enrollees. A
managed care defined
23network plan shall develop an access plan to meet the needs, with respect to covered
24benefits, of its enrollees who are members of underserved populations. If a
25significant number of enrollees of the plan customarily use languages other than
1English, the
managed care defined network plan shall provide access to translation
2services fluent in those languages to the greatest extent possible.
SB55-ASA1-AA1,1301,104
609.24
(1) (a) (intro.) Subject to pars. (b) and (c) and except as provided in par.
5(d), a
managed care defined network plan shall, with respect to covered benefits,
6provide coverage to an enrollee for the services of a provider, regardless of whether
7the provider is a participating provider at the time the services are provided, if the
8managed care defined network plan represented that the provider was, or would be,
9a participating provider in marketing materials that were provided or available to
10the enrollee at any of the following times:
SB55-ASA1-AA1,1301,1412
609.24
(1) (b) (intro.) Except as provided in par. (d), a
managed care defined
13network plan shall provide the coverage required under par. (a) with respect to the
14services of a provider who is a primary care physician for the following period of time:
SB55-ASA1-AA1,1301,2016
609.24
(1) (c) (intro.) Except as provided in par. (d), if an enrollee is undergoing
17a course of treatment with a participating provider who is not a primary care
18physician and whose participation with the plan terminates, the
managed care 19defined network plan shall provide the coverage under par. (a) with respect to the
20services of the provider for the following period of time:
SB55-ASA1-AA1,1301,2322
609.24
(1) (d) 1. The provider no longer practices in the
managed care defined
23network plan's geographic service area.
SB55-ASA1-AA1,1302,3
1609.24
(1) (d) 2. The insurer issuing the
managed care defined network plan
2terminates or terminated the provider's contract for misconduct on the part of the
3provider.
SB55-ASA1-AA1,1302,75
609.24
(1) (e) 1. An insurer issuing a
managed care defined network plan shall
6include in its provider contracts provisions addressing reimbursement to providers
7for services rendered under this section.
SB55-ASA1-AA1,1302,129
609.24
(1) (e) 2. If a contract between a
managed care defined network plan and
10a provider does not address reimbursement for services rendered under this section,
11the insurer shall reimburse the provider according to the most recent contracted
12rate.
SB55-ASA1-AA1,1302,1814
609.24
(4) Notice of provisions. A defined network plan shall notify all plan
15enrollees of the provisions under this section whenever a participating provider's
16participation with the plan terminates, or shall, by contract, require a participating
17provider to notify all plan enrollees of the provisions under this section if the
18participating provider's participation with the plan terminates.
SB55-ASA1-AA1,1302,2320
609.30
(1) Plan may not contract. A
managed care defined network plan may
21not contract with a participating provider to limit the provider's disclosure of
22information, to or on behalf of an enrollee, about the enrollee's medical condition or
23treatment options.
SB55-ASA1-AA1,1303,7
1609.30
(2) Plan may not penalize or terminate. A participating provider may
2discuss, with or on behalf of an enrollee, all treatment options and any other
3information that the provider determines to be in the best interest of the enrollee.
4A
managed care defined network plan may not penalize or terminate the contract of
5a participating provider because the provider makes referrals to other participating
6providers or discusses medically necessary or appropriate care with or on behalf of
7an enrollee.
SB55-ASA1-AA1,1303,139
609.32
(1) Standards; other than preferred provider plans. (intro.) A
10managed care defined network plan
that is not a preferred provider plan shall
11develop comprehensive quality assurance standards that are adequate to identify,
12evaluate
, and remedy problems related to access to, and continuity and quality of,
13care. The standards shall include at least all of the following:
SB55-ASA1-AA1,1303,1815
609.32
(1m) Procedure for remedial action; preferred provider plans. A
16preferred provider plan shall develop a procedure for remedial action to address
17quality problems, including written procedures for taking appropriate corrective
18action.
SB55-ASA1-AA1,1304,220
609.32
(2) (a) A
managed care defined network plan shall develop a process for
21selecting participating providers, including written policies and procedures that the
22plan uses for review and approval of providers. After consulting with appropriately
23qualified providers, the plan shall establish minimum professional requirements for
24its participating providers. The process for selection shall include verification of a
1provider's license or certificate, including the history of any suspensions or
2revocations, and the history of any liability claims made against the provider.
SB55-ASA1-AA1,1304,74
609.32
(2) (b) (intro.) A
managed care
defined network plan shall establish in
5writing a formal, ongoing process for reevaluating each participating provider
6within a specified number of years after the provider's initial acceptance for
7participation. The reevaluation shall include all of the following:
SB55-ASA1-AA1,1304,119
609.32
(2) (c) A
managed care defined network plan may not require a
10participating provider to provide services that are outside the scope of his or her
11license or certificate.
SB55-ASA1-AA1,1304,1714
609.34
(1) A
managed care defined network plan
that is not a preferred
15provider plan shall appoint a physician as medical director. The medical director
16shall be responsible for clinical protocols, quality assurance activities
, and
17utilization management policies of the plan.
