609.03(4)
(4) Removing restrictions. An amendment to a certificate of authority or statement of operations that removes the limitation imposed under this section is not effective unless the insurer, on the effective date of the amendment, complies with the capital, surplus and other requirements applicable to the insurer under
chs. 600 to
645.
609.03 History
History: 1989 a. 23.
609.05
609.05
Primary provider and referrals. 609.05(1)
(1) Except as provided in
subs. (2) and
(3), a health maintenance organization, limited service health organization or preferred provider plan shall permit its enrolled participants to choose freely among selected providers.
609.05(2)
(2) A health care plan under
sub. (1) may require an enrolled participant to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.
609.05(3)
(3) Except as provided in
ss. 609.65 and
609.655, a health care plan under
sub. (1) may require an enrolled participant to obtain a referral from the primary provider designated under
sub. (2) to another selected provider prior to obtaining health care services from the other selected provider.
609.10
609.10
Standard plan required. 609.10(1)(a)(a) Except as provided in
subs. (2) to
(4), an employer that offers any of its employes a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employes a standard plan, as provided in
pars. (b) and
(c), that provides at least substantially equivalent coverage of health care expenses and that is not a health maintenance organization or a preferred provider plan.
609.10(1)(b)
(b) At least once annually, the employer shall provide the employes the opportunity to enroll in the health care plans under
par. (a).
609.10(1)(c)
(c) The employer shall provide the employes adequate notice of the opportunity to enroll in the health care plans under
par. (a) and shall provide the employes complete and understandable information concerning the differences between the health maintenance organization or preferred provider plan and the standard plan.
609.10(2)
(2) If, after providing an opportunity to enroll under
sub. (1) (b) and the notice and information under
sub. (1) (c), fewer than 25 employes indicate that they wish to enroll in the standard plan under
sub. (1) (a), the employer need not offer the standard plan on that occasion.
609.10(3)
(3) Subsection (1) does not apply to an employer that employs fewer than 25 full-time employes.
609.10(4)
(4) Nothing in
sub. (1) requires an employer to offer a particular health care plan to an employe if the health care plan determines that the employe does not meet reasonable medical underwriting standards of the health care plan.
609.10(5)
(5) The commissioner may establish by rule standards in addition to those established under
s. 609.20 for what constitutes adequate notice and complete and understandable information under
sub. (1) (c).
609.10 History
History: 1985 a. 29.
609.15
609.15
Grievance procedure. 609.15(1)(1) Each health maintenance organization, limited service health organization and preferred provider plan shall do all of the following:
609.15(1)(a)
(a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with
sub. (2) for the resolution of enrolled participants' grievances with the health care plan.
609.15(1)(b)
(b) Provide enrolled participants with complete and understandable information describing the internal grievance procedure under
par. (a).
609.15(1)(c)
(c) Submit an annual report to the commissioner describing the internal grievance procedure under
par. (a) and summarizing the experience under the procedure for the year.
609.15(2)
(2) The internal grievance procedure established under
sub. (1) (a) shall include all of the following elements:
609.15(2)(a)
(a) The opportunity for an enrolled participant to submit a written grievance in any form.
609.15(2)(b)
(b) Establishment of a grievance panel for the investigation of each grievance submitted under
par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one enrolled participant other than the grievant, if an enrolled participant is available to serve on the grievance panel.
609.15(2)(c)
(c) Prompt investigation of each grievance submitted under
par. (a).
609.15(2)(d)
(d) Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.
609.15(2)(e)
(e) Retention of records pertaining to each grievance for at least 3 years after the date of notification under
par. (d).
609.15 History
History: 1985 a. 29.
609.17
609.17
Reports of disciplinary action. Every health maintenance organization, limited service health organization and preferred provider 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 selected provider who holds a license or certificate granted by the board or affiliated credentialing board.
609.17 History
History: 1985 a. 340;
1993 a. 107.
609.20
609.20
Rules for preferred provider plans. The commissioner shall promulgate rules applicable to preferred provider plans for all of the following purposes:
609.20(1)
(1) To ensure that enrolled participants are not forced to travel excessive distances to receive health care services.
609.20(2)
(2) To ensure that the continuity of patient care for enrolled participants is not disrupted.
609.20(3)
(3) To define substantially equivalent coverage of health care expenses for purposes of
s. 609.10 (1) (a).
609.20(4)
(4) To ensure that employes offered a preferred provider plan that provides comprehensive services under
s. 609.10 (1) (a) are given adequate notice of the opportunity to enroll and complete and understandable information under
s. 609.10 (1) (c) concerning the differences between the preferred provider plan and the standard plan, including differences between providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization.
609.20 History
History: 1985 a. 29.
609.60
609.60
Optometric coverage. Health maintenance organizations and preferred provider plans are subject to
s. 632.87 (2m).
609.60 History
History: 1985 a. 29.
609.65
609.65
Coverage for court-ordered services for the mentally ill. 609.65(1)(1) If an enrolled participant of a health maintenance organization, limited service health organization or preferred provider 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 selected providers, primary providers and referrals under
ss. 609.01 (2) to
(4) and
609.05 (3), the health maintenance organization, limited service health organization or preferred provider plan shall do all of the following:
609.65(1)(a)
(a) If the provider performing the examination, evaluation or treatment has a provider agreement with the health maintenance organization, limited service health organization or preferred provider plan which covers the provision of that service to the enrolled participant, make the service available to the enrolled participant in accordance with the terms of the health care plan and the provider agreement.
609.65(1)(b)
(b) If the provider performing the examination, evaluation or treatment does not have a provider agreement with the health maintenance organization, limited service health organization or preferred provider plan which covers the provision of that service to the enrolled participant, reimburse the provider for the examination, evaluation or treatment of the enrolled participant 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:
609.65(1)(b)1.
1. The service is provided pursuant to a commitment or a court order, except that reimbursement is not required under this subdivision if the health maintenance organization, limited service health organization or preferred provider plan could have provided the service through a provider with whom it has a provider agreement.
609.65(1)(b)2.
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 health maintenance organization, limited service health organization or preferred provider plan within 72 hours after the initial provision of the service.
609.65(2)
(2) If after receiving notice under
sub. (1) (b) 2. the health maintenance organization, limited service health organization or preferred provider plan arranges for services to be provided by a provider with whom it has a provider agreement, the health maintenance organization, limited service health organization or preferred provider plan is not required to reimburse a provider under
sub. (1) (b) 2. for any services provided after arrangements are made under this subsection.
609.65(3)
(3) A health maintenance organization, limited service health organization or preferred provider plan is only required to make available, or make reimbursement for, an examination, evaluation or treatment under
sub. (1) to the extent that the health maintenance organization, limited service health organization or preferred provider plan would have made the medically necessary service available to the enrolled participant 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 provider selected by the health maintenance organization, limited service health organization or preferred provider plan.
609.655
609.655
Coverage of certain services provided to dependent students. 609.655(1)(a)
(a) "Dependent student" means an individual who satisfies all of the following:
609.655(1)(a)1.
1. Is covered as a dependent child under the terms of a policy or certificate issued by a health maintenance organization.
609.655(1)(a)2.
2. Is enrolled in a school located in this state but outside the geographical service area of the health maintenance organization.
609.655(1)(c)
(c) "School" means a technical college; a center or institution within the university of Wisconsin system; and any institution of higher education that grants a bachelor's or higher degree.
609.655(2)
(2) If a policy or certificate issued by a health maintenance organization 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 health maintenance organization, notwithstanding the limitations regarding selected providers, primary providers and referrals under
ss. 609.01 (2) and
609.05 (3).
609.655(3)
(3) Except as provided in
sub. (5), a health maintenance organization shall provide coverage for all of the following services:
609.655(3)(a)
(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 health maintenance organization.
609.655(3)(b)
(b) 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 health maintenance organization, except as follows:
609.655(3)(b)1.
1. Coverage is not required under this paragraph if the medical director of the health maintenance organization determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.
609.655(3)(b)2.
2. Coverage is not required under this paragraph for outpatient services provided after the dependent student has terminated his or her enrollment in the school.
609.655(4)(a)(a) Upon completion of the 5 visits for outpatient services covered under
sub. (3) (b), the medical director of the health maintenance organization 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.
609.655(4)(b)
(b) Upon completion of the review under
par. (a), the medical director of the health maintenance organization 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 health maintenance organization's internal grievance procedure established under
s. 609.15.
609.655(5)(a)(a) A policy or certificate issued by a health maintenance organization 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 selected provider within the geographical service area of the health maintenance organization.
609.655(5)(b)
(b) Paragraph (a) does not permit a health maintenance organization 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 selected provider within the geographical service area of the health maintenance organization.
609.655 History
History: 1989 a. 121;
1993 a. 399.
609.70
609.70
Chiropractic coverage. Health maintenance organizations, limited service health organizations and preferred provider plans are subject to
s. 632.87 (3).
609.70 History
History: 1987 a. 27.
609.75
609.75
Adopted children coverage. Health maintenance organizations, limited service health organizations and preferred provider 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 health maintenance organization, limited service health organization or preferred provider plan imposes under
s. 609.05 (2) and
(3) on the coverage of health care services obtained by other enrolled participants.
609.75 History
History: 1989 a. 336.
609.80
609.80
Coverage of mammograms. Health maintenance organizations and preferred provider plans are subject to
s. 632.895 (8). Coverage of mammograms under
s. 632.895 (8) may be subject to any requirements that the health maintenance organization or preferred provider plan imposes under
s. 609.05 (2) and
(3) on the coverage of other health care services obtained by enrolled participants.
609.80 History
History: 1989 a. 129.
609.81
609.81
Coverage related to HIV infection. Health maintenance organizations, limited service health organizations and preferred provider plans are subject to
s. 631.93. Health maintenance organizations and preferred provider plans are subject to
s. 632.895 (9).
609.81 History
History: 1989 a. 201;
1989 a. 359 s.
389.
609.85
609.85
Coverage of lead screening. Health maintenance organizations and preferred provider plans are subject to
s. 632.895 (10).
609.85 History
History: 1993 a. 450.
609.91
609.91
Restrictions on recovering health care costs. 609.91(1)(1)
Immunity of enrolled participants and policyholders. Except as provided in
sub. (1m), an enrolled participant or policyholder of a health maintenance organization insurer is not liable for health care costs that are incurred on or after January 1, 1990, and that are covered under a policy or certificate issued by the health maintenance organization insurer, if any of the following applies:
609.91(1)(a)
(a) The health care is provided by a provider who satisfies any of the following:
609.91(1)(a)1.
1. Is an affiliate of the health maintenance organization insurer.
609.91(1)(a)2.
2. Owns at least 5% of the voting securities of the health maintenance organization insurer.
609.91(1)(a)3.
3. Is entitled, alone or with one or more affiliates, to solely select one or more board members of the health maintenance organization insurer, or has an affiliate that is entitled to solely select one or more board members of the health maintenance organization insurer.
609.91(1)(a)4.
4. Is entitled to have one or more board members of the health maintenance organization insurer serve exclusively as a representative of the provider, one or more of the provider's affiliates or the provider and its affiliates, except this subdivision does not apply to an individual practice association or an affiliate of an individual practice association.
609.91(1)(a)5.
5. Is an individual practice association that is represented, or its affiliate is represented, on the board of the health maintenance organization insurer, and at least 3 of the board members of the health maintenance organization represent one or more individual practice associations.
609.91(1)(am)
(am) The health care is provided by a provider under a contract with, or through membership in, a person who satisfies
par. (a) 1.,
2.,
3.,
4. or
5.
609.91(1)(b)
(b) The health care is provided by a provider who is not subject to
par. (a) or
(am) and who does not elect to be exempt from this paragraph under
s. 609.92, and the health care satisfies any of the following:
609.91(1)(b)1.
1. Is provided by a hospital or an individual practice association.
