619.01(1)(b)2.
2. Establish procedures that will create minimum interference with the voluntary market;
619.01(1)(b)3.
3. Spread the burden imposed by the facility equitably and efficiently within the industry; and
619.01(1)(b)4.
4. Establish procedures for applicants and participants to have grievances reviewed by an impartial body.
619.01(1)(c)1.1. Each plan, except a health care liability insurance plan, a foster home protection insurance plan, a treatment foster home protection insurance plan or a group home protection insurance plan, shall require participation by all insurers doing any business in this state of the types covered by the specific plan and all agents licensed to represent such insurers in this state for the specified types of business, except that the commissioner may exclude classes of persons for administrative convenience or because it is not equitable or practicable to require them to participate in the plan.
619.01(1)(c)2.
2. Each health care liability insurance plan shall require participation by all insurers insuring persons in this state against liability resulting from personal injuries. Any deficit in a health care liability insurance plan in any year shall be recouped by actuarially sound rate increases which take into account any plan surplus and are applicable prospectively. Each plan shall maintain a surplus determined by the commissioner acting under
ss. 623.11 and
623.12.
619.01(1)(c)3.
3. No county, town, village or city shall be required to participate in any municipal liability risk-sharing plan promulgated or approved by the commissioner under this section or be assessed for the cost of any such plan in which it is not participating.
619.01(1)(c)4.
4. A foster home protection insurance plan shall require participation by all insurers insuring persons in this state under policies described in
subchs. I or
III of ch. 632 and all agents licensed to represent such insurers in this state except that the commissioner may exclude classes of persons for administrative convenience or because it is not equitable or practicable to require them to participate in the plan.
619.01(1)(c)4m.
4m. A treatment foster home protection insurance plan shall require participation by all insurers insuring persons in this state under policies described in
subchs. I or
III of ch. 632 and all agents licensed to represent such insurers in this state except that the commissioner may exclude classes of persons for administrative convenience or because it is not equitable or practicable to require them to participate in the plan.
619.01(1)(c)5.
5. A group home protection insurance plan shall require participation by all insurers insuring persons in this state under policies described in
subchs. I or
III of ch. 632 and all agents licensed to represent such insurers in this state except that the commissioner may exclude classes of persons for administrative convenience or because it is not equitable or practicable to require them to participate in the plan.
619.01(1)(d)
(d)
Voluntary participation. The plan may provide for optional participation by insurers not required to participate under
par. (c).
619.01(1)(e)
(e)
Classifications and rates. Each plan shall provide for the method of classifying risks and making and filing rates applicable thereto.
619.01(2)
(2) Basis of participation. The plan shall specify the basis of participation of insurers and agents and the conditions under which risks must be accepted.
619.01(3)
(3) Duty to provide service. Every participating insurer and agent shall provide to any person seeking coverages of kinds available in the plans the services prescribed in the plans, including full information on the requirements and procedures for obtaining coverage under the plans whenever the business is not placed in the voluntary market.
619.01(4)
(4) Commissions. The plan shall specify what commission rates shall be paid for business placed in the plans.
619.01(5)
(5) Provision of marketing facilities. If the commissioner finds that the lack of cooperating insurers or agents in an area makes the functioning of the plan difficult, the commissioner may order that the plan set up branch service offices or take other appropriate steps to ensure that service is available.
619.01(6)
(6) Transition. The existing assigned risk plan set up under s.
204.51 (2), 1967 stats., and the existing rejected risk plan set up under s.
205.15, 1967 stats., shall continue unless changed in accordance with this chapter.
619.01(7)
(7) Health care liability policy limits. 619.01(7)(a)(a)
Primary coverage plans. Health care liability insurance plans established under this paragraph shall provide minimum coverage to insureds in the amount of not less than $200,000 for each occurrence and $600,000 for all occurrences in any one policy year for occurrences before July 1, 1987, $300,000 for each occurrence and $900,000 for all occurrences in any one policy year for occurrences on or after July 1, 1987 and before July 1, 1988, and $400,000 for each occurrence and $1,000,000 for all occurrences in any one policy year for occurrences on or after July 1, 1988, for the protection of persons who are legally entitled to recover damages from the insured for errors, omissions or neglect in the performance of the insured's professional services. If an insured has excess limits liability coverage or such coverage is available to the insured, the coverage provided under such plans shall be equal to the minimum level of such excess limits coverage. If the insured does not have excess limits liability coverage and such coverage is not available to the insured, the commissioner may establish minimum levels of coverage higher than the minimum limits specified in this paragraph for such plans.
619.01(7)(b)
(b)
Supplemental liability coverage plans. Health care liability insurance plans of the kind authorized under
par. (a) may be established by the commissioner under this paragraph to provide coverage to supplement primary coverage provided by insurers authorized under
ch. 611 or
618.Such plans may be in an amount no greater than $100,000 for each occurrence and $300,000 for all occurrences in any one policy year, but the total combined primary and supplemental coverage may not exceed the limits established by
s. 655.23 (4).
619.01(8)
(8) Health care liability policy provisions. Health care liability insurance plans established under this chapter may include liability coverages normally incidental to health care liability insurance if such coverage is not readily available in the voluntary market.
619.01(8m)
(8m) Premium assessment. Health care liability plans established under this chapter shall pay a fee equal to 2% of net premiums collected to the department of administration for services from state agencies not otherwise charged to the plan.
619.01(9)
(9) Foster home protection insurance. In this section "foster home protection insurance" means insurance coverage to protect persons who receive a license to operate a foster home under
s. 48.62 (1) (a) against the unique risks, determined by the commissioner, to which such persons are exposed. If the persons have insurance which covers any of these risks, the foster home protection insurance may insure against any or all of the other risks, and may provide additional or excess limits coverage for any or all of these risks.
619.01(9m)
(9m) Treatment foster home protection insurance. In this section "treatment foster home protection insurance" means insurance coverage to protect persons who receive a license to operate a treatment foster home under
s. 48.62 (1) (b) against the unique risks, determined by the commissioner, to which such persons are exposed. If the persons have insurance that covers any of these risks, the treatment foster home protection insurance may insure against any or all of the other risks, and may provide additional or excess limits coverage for any or all of these risks.
619.01(10)
(10) Group home protection insurance. In this section "group home protection insurance" means insurance coverage to protect persons who receive a license to operate a group home as provided in
s. 48.625 against the unique risks, determined by the commissioner, to which such persons are exposed. If the persons have insurance which covers any of these risks, the group home protection insurance may insure against any or all of the other risks, and may provide additional or excess limits coverage for any or all of these risks.
619.02
619.02
State contribution for federally reinsured losses. 619.02(1)(1)
Assessment of insurers. The commissioner is authorized to assess each insurance company authorized to do business in this state an aggregate amount sufficient to provide a fund to reimburse the U.S. secretary of housing and urban development in the manner set forth in sec. 1223 (a) (1) of the national housing act as amended by sec. 1103 of the urban property protection and reinsurance act of 1968,
P.L. 90-448, 82 Stat. 476. The assessment shall be on those lines reinsured during the current year in this state by the U.S. secretary of housing and urban development pursuant to such act. The assessment shall be in the proportion that the premiums earned during the preceding calendar year by each such company in this state bear to the aggregate premiums earned on those lines in this state by all insurers. The fund may be provided in whole or in part from appropriations by the legislature.
619.02(2)
(2) Recoupment. Rates used by an insurer shall not be deemed excessive because they contain an amount reasonably calculated to recoup assessments made under this section.
619.03
619.03
Voluntary risk-sharing plans. Insurers doing business within this state are authorized to prepare voluntary plans providing any specified kind, line or class of insurance coverage or subdivision or combination thereof for all or any part of this state in which such insurance is not readily available in the voluntary market and in which the public interest requires the availability of such coverage. Voluntary risk-sharing plans shall be submitted to the commissioner and if approved may be put into operation.
619.03 History
History: 1979 c. 102;
1991 a. 315.
619.04
619.04
Mandatory health care liability risk-sharing plans. 619.04(1)(1) The commissioner shall promulgate rules establishing a plan of health care liability coverage for health care providers as defined in
s. 655.001 (8).
619.04(3)
(3) The plan shall operate subject to the supervision and approval of a board of governors consisting of 3 representatives of the insurance industry appointed by and to serve at the pleasure of the commissioner, a person to be named by the state bar association, a person to be named by the Wisconsin academy of trial lawyers, 2 persons to be named by the Wisconsin medical society, a person to be named by the Wisconsin hospital association, the commissioner or a designated representative employed by the office of the commissioner and 4 public members at least 2 of whom are not attorneys or physicians and are not professionally affiliated with any hospital or insurance company, appointed by the governor for staggered 3-year terms. The commissioner or the commissioner's representative shall be the chairperson of the board of governors. Board members shall be compensated at the rate of $50 per diem plus actual and necessary travel expenses.
619.04(5)
(5) The plan shall offer professional health care liability coverage in a standard policy form. The plan shall include, but not be limited to, the following:
619.04(5)(a)
(a) Rules for the classification of risks and rates which reflect past and prospective loss and expense experience in different areas of practice.
619.04(5)(b)
(b) A rating plan which takes into consideration the loss and expense experience of the individual health care provider which resulted in the payment of money, by the plan or other sources, for damages arising out of the rendering of health care by the health care provider or an employe of the health care provider, except that an adjustment to a health care provider's premiums may not be made under this paragraph prior to the receipt of the recommendation of the patients compensation fund peer review council under
s. 655.275 (5) (a) and the expiration of the time period provided, under
s. 655.275 (7), for the health care provider to comment or prior to the expiration of the time period under
s. 655.275 (5) (a).
619.04(5)(c)
(c) Provisions as to rates for insureds who are semiretired or part-time professionals.
619.04(5m)(a)(a) Every rule under
sub. (5) (b) shall provide for an automatic increase in a health care provider's premiums, except as provided in
par. (b), if the loss and expense experience of the plan and other sources with respect to the health care provider or an employe of the health care provider exceeds either a number of claims paid threshold or a dollar volume of claims paid threshold, both as established in the rule. The rule shall specify applicable amounts of increase corresponding to the number of claims paid and the dollar volume of awards in excess of the respective thresholds.
619.04(5m)(b)
(b) The rule shall provide that the automatic increase does not apply if the board determines that the performance of the patients compensation fund peer review council in making recommendations under
s. 655.275 (5) (a) adequately addresses the consideration set forth in
sub. (5) (b).
619.04(6)(a)(a) If the plan accumulates funds in excess of the surplus required under
s. 619.01 (1) (c) 2. and incurred liabilities, including reserves for claims incurred but not yet reported, the board of governors shall return those excess funds to the insureds by means of refunds or prospective rate decreases.
619.04(6)(b)
(b) The board of governors shall annually determine whether excess funds have accumulated.
619.04(6)(c)
(c) If it determines that excess funds have accumulated, the board of governors shall specify the method and formula for distributing the excess funds.
619.04(9)
(9) Neither the state nor the board of governors shall be liable for any obligation of the plan or of the patients compensation fund under
s. 655.27. The board of governors and members of any committee or subcommittee thereof shall be immune from civil liability for acts or omissions while performing their duties under this section and
s. 655.27.
619.04(10)
(10) If the commissioner makes a finding under
s. 619.01 (1) (a) with respect to health care providers other than those described in
sub. (1), the commissioner may, with the approval of the board established under
sub. (3), promulgate rules permitting those health care providers to obtain coverage under
s. 619.01 from the plan established under this section.
619.04(11)
(11) Upon dissolution of the plan under this section, any assets in excess of incurred liabilities shall be paid to the general fund.
MANDATORY HEALTH INSURANCE
RISK-SHARING PLAN
619.10
619.10
Definitions. In this subchapter:
619.10(1)
(1) "Administering carrier" means the insurer designated under
s. 619.16.
619.10(1m)
(1m) "Alternative plan" means a health maintenance organization, as defined in
s. 609.01 (2), or a preferred provider plan, as defined in
s. 609.01 (4).
619.10(2)
(2) "Board" means the board of governors established under
s. 619.15.
619.10(3)
(3) "Eligible person" means a resident of this state who qualifies under
s. 619.12 whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.
619.10(3m)
(3m) "Health care coverage revenue" means any of the following:
619.10(3m)(b)
(b) Subscriber contract charges received for health care coverage.
619.10(3m)(c)
(c) Health maintenance organization, limited service health organization or preferred provider plan charges received for health care coverage.
619.10(3m)(d)
(d) The sum of benefits paid and administrative costs incurred for health care coverage under a medical reimbursement plan.
619.10(4)
(4) "Health insurance" means surgical, medical, hospital, major medical and other health service coverage provided on an expense-incurred basis and fixed indemnity policies. "Health insurance" does not include ancillary coverages such as income continuation, short-term, accident only, credit insurance, automobile medical payment coverage, coverage issued as a supplement to liability coverage, loss of time or accident benefits.
619.10(4m)
(4m) "HIV" means any strain of human immunodeficiency virus, which causes acquired immunodeficiency syndrome.
619.10(5)
(5) "Insurer" means any person or association of persons, including a health maintenance organization, limited service health organization or preferred provider plan offering or insuring health services on a prepaid basis, including, but not limited to, policies of health insurance issued by a currently licensed insurer, nonprofit hospital or medical service plans under
ch. 613, cooperative medical service plans under
s. 185.981, or other entity whose primary function is to provide diagnostic, therapeutic or preventive services to a defined population in return for a premium paid on a periodic basis. "Insurer" includes any person providing health services coverage for individuals on a self-insurance basis without the intervention of other entities, as well as any person providing health insurance coverage under a medical reimbursement plan to persons. "Insurer" does not include a plan under
ch. 613 which offers only dental care.
619.10(7)
(7) "Medicare" means coverage under both part A and part B of Title XVIII of the federal social security act,
42 USC 1395 et seq., as amended.
619.10(8)
(8) "Plan" means the health care insurance plan established under this subchapter.
619.10(9)
(9) "Resident" means a person who has been legally domiciled in this state for a period of at least 30 days. For purposes of this subchapter, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin or filing a Wisconsin income tax return. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state. A person with a developmental disability or another disability which prevents the person from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in this state by living in this state for 30 days.
619.11
619.11
Establishment of plan. The commissioner shall promulgate rules establishing a plan of health insurance coverage for an eligible person which satisfies the requirements of this chapter.
619.11 History
History: 1979 c. 313.
619.11 Annotation
Employe retirement income security act preempts any state law that relates to employe benefit plans. General Split Corp. v. Mitchell, 523 F Supp. 427 (1981).
619.12
619.12
Eligibility determination. 619.12(1)
(1) Except as provided in
subs. (1m) and
(2), the board or administering carrier shall certify as eligible a person who is covered by medicare because he or she is disabled under
42 USC 423, a person who submits evidence that he or she has tested positive for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV, and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:
619.12(1)(a)
(a) A notice of rejection of coverage from one or more insurers.
619.12(1)(am)
(am) A notice of cancellation of coverage from one or more insurers.
619.12(1)(b)
(b) A notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.
619.12(1)(c)
(c) A notice of increase in premium exceeding the premium then in effect for the insured person by 50% or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.
619.12(1)(d)
(d) A notice of premium for a policy not yet in effect from 2 or more insurers which exceeds the premium applicable to a person considered a standard risk by 50% or more for the types of coverage provided by the plan.
619.12(1m)
(1m) The board or administering carrier may not certify a person as eligible under circumstances requiring notice under
sub. (1) (a) to
(d) if the required notices were issued by one of the following:
619.12(1m)(a)
(a) An insurance intermediary who is not acting as an administrator, as defined in
s. 633.01.
619.12(1m)(b)
(b) The administering carrier, unless the notice was issued to a person who had applied for insurance coverage from the administering carrier.
619.12(2)(b)1.1. Except as provided in
subd. 2., no person who is covered under the plan and voluntarily terminates the coverage under the plan, is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan.
619.12(2)(b)2.
2. Subdivision 1. does not apply to any person who terminates coverage under the plan because he or she is receiving, or is eligible to receive, medical assistance benefits.
619.12(2)(c)
(c) No person on whose behalf the plan has paid out $500,000 or more is eligible for coverage under the plan.
619.12(2)(d)
(d) No person who is 65 years of age or older is eligible for coverage under the plan.
