CHAPTER 609
HEALTH MAINTENANCE ORGANIZATIONS, LIMITED SERVICE
HEALTH ORGANIZATIONS AND PREFERRED PROVIDER PLANS
609.001 Joint ventures; legislative findings.
609.03 Indication of operations.
609.05 Primary provider and referrals.
609.10 Standard plan required.
609.15 Grievance procedure.
609.17 Reports of disciplinary action.
609.20 Rules for preferred provider plans.
609.60 Optometric coverage.
609.65 Coverage for court-ordered services for the mentally ill.
609.655 Coverage of certain services provided to dependent students.
609.70 Chiropractic coverage.
609.75 Adopted children coverage.
609.80 Coverage of mammograms.
609.81 Coverage related to HIV infection.
609.85 Coverage of lead screening.
609.91 Restrictions on recovering health care costs.
609.92 Hospitals, individual practice associations and providers of physician services.
609.925 Election to be subject to restrictions.
609.93 Scope of election by an individual practice association or clinic.
609.935 Notices of election and termination.
609.94 Summary of restrictions.
609.95 Minimum covered liabilities.
609.96 Initial capital and surplus requirements.
609.97 Compulsory and security surplus.
Ch. 609 Cross-reference
Cross-reference: See definitions in ss.
600.03 and
628.02.
609.001
609.001
Joint ventures; legislative findings. 609.001(1)
(1) The legislature finds that increased development of health maintenance organizations, preferred provider plans and limited service health organizations may have the effect of putting small, independent health care providers at a competitive disadvantage with larger health care providers. In order to avoid monopolistic situations and to provide competitive alternatives, it may be necessary for those small, independent health care providers to form joint ventures. The legislature finds that these joint ventures are a desirable means of health care cost containment to the extent that they increase the number of entities with which a health maintenance organization, preferred provider plan or limited service health organization may choose to contract and to the extent that the joint ventures do not violate state or federal antitrust laws.
609.001(2)
(2) The legislature finds that competition in the health care market will be enhanced by allowing employers and organizations which otherwise act independently to join together in a manner consistent with the state and federal antitrust laws for the purpose of purchasing health care coverage for employes and members. These joint ventures will allow purchasers of health care coverage to obtain volume discounts when they negotiate with insurers and health care providers. These joint ventures should result in an improved business climate in this state because of reduced costs for health care coverage.
609.001 History
History: 1985 a. 29.
609.01
609.01
Definitions. In this chapter:
609.01(1)
(1) "Covered liability" means liability of a health maintenance organization insurer for health care costs for which an enrolled participant or policyholder of the health maintenance organization insurer is not liable to any person under
s. 609.91.
609.01(1d)
(1d) "Enrolled participant" means a person entitled to health care services under an individual or group policy issued by a health maintenance organization, limited service health organization or preferred provider plan.
609.01(1j)
(1j) "Health care costs" means consideration for the provision of health care, including consideration for services, equipment, supplies and drugs.
609.01(2)
(2) "Health maintenance organization" 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 enrolled participants, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers selected by the organization.
609.01(3)
(3) "Limited service health organization" 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 enrolled participants, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers selected by the organization.
609.01(4)
(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 enrolled participants, for consideration other than predetermined periodic fixed payments, either comprehensive health care services or a limited range of health care services performed by providers selected by the organization.
609.01(5)
(5) "Primary provider" means a selected provider who is an individual and who is designated by an enrolled participant.
609.01(5m)
(5m) "Provider" means a health care professional, a health care facility or a health care service or organization.
609.01(6)
(6) "Selected provider" means a provider selected by a health maintenance organization, limited service health organization or preferred provider plan to perform health care services for enrolled participants.
609.01(7)
(7) "Standard plan" means a health care plan other than a health maintenance organization or a preferred provider plan.
609.01 History
History: 1985 a. 29;
1989 a. 23.
609.03
609.03
Indication of operations. 609.03(1)
(1)
Certificate of authority. An insurer may apply to the commissioner for a new or amended certificate of authority that limits the insurer to engaging in only the types of insurance business described in
sub. (3).
609.03(2)
(2) Statement of operations. If an insurer is a cooperative association organized under
ss. 185.981 to
185.985, the insurer may apply to the commissioner for a statement of operations that limits the insurer to engaging in only the types of insurance business described in
sub. (3).
609.03(3)(a)(a) An insurer that has a new or amended certificate of authority under
sub. (1) or a statement of operations under
sub. (2) may engage in only the following types of insurance business:
609.03(3)(a)3.
3. In other insurance business that is immaterial in relation to, or incidental to, the insurer's business under
subd. 1. or
2.
609.03(3)(b)
(b) The commissioner may, by rule, define "immaterial" or "incidental", or both, for purposes of
par. (a) 3. as a percentage of premiums, except the percentage may not exceed 10% of the total premiums written by the insurer.
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.
