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(1d)
(1d) "Enrollee" means, with respect to a managed care plan, preferred provider plan or limited service health organization, a person who is entitled to receive health care services under the plan.
609.01(1g)(a)(a) Except as provided in
par. (b), "health benefit plan" means any hospital or medical policy or certificate.
609.01(1g)(b)
(b) "Health benefit plan" does not include any of the following:
609.01(1g)(b)1.
1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.
609.01(1g)(b)3.
3. Liability insurance, including general liability insurance and automobile liability insurance.
609.01(1g)(b)8.
8. Other similar insurance coverage, as specified in regulations issued by the federal department of health and human services, under which benefits for medical care are secondary or incidental to other insurance benefits.
609.01(1g)(b)9.
9. If provided under a separate policy, certificate or contract of insurance, or if otherwise not an integral part of the policy, certificate or contract of insurance: limited-scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those benefits; and such other similar, limited benefits as are specified in regulations issued by the federal department of health and human services under section 2791 of
P.L. 104-191.
609.01(1g)(b)10.
10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply:
609.01(1g)(b)10.a.
a. The benefits are provided under a separate policy, certificate or contract of insurance.
609.01(1g)(b)10.b.
b. There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.
609.01(1g)(b)10.c.
c. Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.
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 enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers participating in the plan.
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 enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers participating in the plan.
609.01(3c)
(3c) "Managed care plan" means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with or employed by the insurer offering the health benefit plan.
609.01(3m)
(3m) "Participating" means, with respect to a physician or other provider, under contract with a managed care plan, preferred provider plan or limited service health organization to provide health care services, items or supplies to enrollees of the managed care plan, preferred provider plan or limited service health 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 enrollees, for consideration other than predetermined periodic fixed payments, either comprehensive health care services or a limited range of health care services performed by providers participating in the plan.
609.01(4m)
(4m) "Primary care physician" means a physician specializing in family medical practice, general internal medicine or pediatrics.
609.01(5)
(5) "Primary provider" means a participating primary care physician, or other participating provider authorized by the managed care plan, preferred provider plan or limited service health organization to serve as a primary provider, who coordinates and may provide ongoing care to an enrollee.
609.01(5m)
(5m) "Provider" means a health care professional, a health care facility or a health care service or organization.
609.01(7)
(7) "Standard plan" means a health care plan other than a health maintenance organization or a preferred provider plan.
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. 609.05(1)
(1) Except as provided in
subs. (2) and
(3), a limited service health organization, preferred provider plan or managed care plan shall permit its enrollees to choose freely among participating providers.
609.05(2)
(2) Subject to
s. 609.22 (4), a limited service health organization, preferred provider plan or managed care plan may require an enrollee 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 limited service health organization, preferred provider plan or managed care plan may require an enrollee to obtain a referral from the primary provider designated under
sub. (2) to another participating provider prior to obtaining health care services from that participating 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.
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;
1997 a. 237.
609.15
609.15
Grievance procedure. 609.15(1)(1) Each limited service health organization, preferred provider plan and managed care 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 enrollees' grievances with the limited service health organization, preferred provider plan or managed care plan.
609.15(1)(b)
(b) Provide enrollees 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 enrollee 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 enrollee other than the grievant, if an enrollee 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;
1997 a. 237.
609.17
609.17
Reports of disciplinary action. Every limited service health organization, preferred provider plan and managed care 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 participating provider who holds a license or certificate granted by the board or affiliated credentialing board.
609.20
609.20
Rules for preferred provider and managed care plans. The commissioner shall promulgate rules relating to preferred provider plans and managed care plans for all of the following purposes:
609.20(1)
(1) To ensure that enrollees 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 enrollees meets the requirements under
s. 609.24.
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 health maintenance organization or a preferred provider plan that provides comprehensive services under
s. 609.10 (1) (a) are given adequate notice of the opportunity to enroll, as well as complete and understandable information under
s. 609.10 (1) (c) concerning the differences between the health maintenance organization or 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;
1997 a. 237.
609.22
609.22
Access standards. 609.22(1)(1)
Providers. A managed care plan shall include a sufficient number, and sufficient types, of providers to meet the anticipated needs of its enrollees, with respect to covered benefits.
609.22(2)
(2) Adequate choice. A managed care plan shall ensure that, with respect to covered benefits, each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.
609.22(3)
(3) Primary provider selection. A managed care plan shall permit each enrollee to select his or her own primary provider from a list of participating primary care physicians and any other participating providers that are authorized by the managed care plan to serve as primary providers. The list shall be updated on an ongoing basis and shall include a sufficient number of primary care physicians and any other participating providers authorized by the plan to serve as primary providers who are accepting new enrollees.
609.22(4)(a)1.1. If a managed care plan requires a referral to a specialist for coverage of specialist services, the managed care plan shall establish a procedure by which an enrollee may apply for a standing referral to a specialist. The procedure must specify the criteria and conditions that must be met in order for an enrollee to obtain a standing referral.
609.22(4)(a)2.
2. A managed care plan may require the enrollee's primary provider to remain responsible for coordinating the care of an enrollee who receives a standing referral to a specialist. A managed care plan may restrict the specialist from making any secondary referrals without prior approval by the enrollee's primary provider. If an enrollee requests primary care services from a specialist to whom the enrollee has a standing referral, the specialist, in agreement with the enrollee and the enrollee's primary provider, may provide primary care services to the enrollee in accordance with procedures established by the managed care plan.
