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.
609.22(4)(a)3.
3. A managed care plan must include information regarding referral procedures in policies or certificates provided to enrollees and must provide such information to an enrollee or prospective enrollee upon request.
609.22(5)
(5) Second opinions. A managed care plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.
609.22(6)
(6) Emergency care. Notwithstanding
s. 632.85, if a managed care plan provides coverage of emergency services, with respect to covered benefits, the managed care plan shall do all of the following:
609.22(6)(a)
(a) Cover emergency medical services for which coverage is provided under the plan and that are obtained without prior authorization for the treatment of an emergency medical condition.
609.22(6)(b)
(b) Cover emergency medical services or urgent care for which coverage is provided under the plan and that is provided to an individual who has coverage under the plan as a dependent child and who is a full-time student attending school outside of the geographic service area of the plan.
609.22(7)
(7) Telephone access. A managed care plan shall provide telephone access for sufficient time during business and evening hours to ensure that enrollees have adequate access to routine health care services for which coverage is provided under the plan. A managed care plan shall provide 24-hour telephone access to the plan or to a participating provider for emergency care, or authorization for care, for which coverage is provided under the plan.
609.22(8)
(8) Access plan for certain enrollees. A managed care plan shall develop an access plan to meet the needs, with respect to covered benefits, of its enrollees who are members of underserved populations. If a significant number of enrollees of the plan customarily use languages other than English, the managed care plan shall provide access to translation services fluent in those languages to the greatest extent possible.
609.22 History
History: 1997 a. 237.
609.24
609.24
Continuity of care. 609.24(1)(a)(a) Subject to
pars. (b) and
(c) and except as provided in
par. (d), a managed care plan shall, with respect to covered benefits, provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the managed care plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times:
609.24(1)(a)1.
1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period.
609.24(1)(a)2.
2. If the plan under which the enrollee has coverage has no open enrollment period, the time of the enrollee's enrollment or most recent coverage renewal, whichever is later.
609.24(1)(b)
(b) Except as provided in
par. (d), a managed care plan shall provide the coverage required under
par. (a) with respect to the services of a provider who is a primary care physician for the following period of time:
609.24(1)(b)1.
1. For an enrollee of a plan with no open enrollment period, until the end of the current plan year.
609.24(1)(b)2.
2. For an enrollee of a plan with an open enrollment period, until the end of the plan year for which it was represented that the provider was, or would be, a participating provider.
609.24(1)(c)
(c) Except as provided in
par. (d), if an enrollee is undergoing a course of treatment with a participating provider who is not a primary care physician and whose participation with the plan terminates, the managed care plan shall provide the coverage under
par. (a) with respect to the services of the provider for the following period of time:
609.24(1)(c)1.
1. Except as provided in
subd. 2., for the remainder of the course of treatment or for 90 days after the provider's participation with the plan terminates, whichever is shorter, except that the coverage is not required to extend beyond the period specified in
par. (b) 1. or
2., whichever applies.
609.24(1)(c)2.
2. If maternity care is the course of treatment and the enrollee is a woman who is in the 2nd or 3rd trimester of pregnancy when the provider's participation with the plan terminates, until the completion of postpartum care for the woman and infant.
609.24(1)(d)
(d) The coverage required under this section need not be provided or may be discontinued if any of the following applies:
609.24(1)(d)1.
1. The provider no longer practices in the managed care plan's geographic service area.
609.24(1)(d)2.
2. The insurer issuing the managed care plan terminates or terminated the provider's contract for misconduct on the part of the provider.
609.24(1)(e)1.1. An insurer issuing a managed care plan shall include in its provider contracts provisions addressing reimbursement to providers for services rendered under this section.
609.24(1)(e)2.
2. If a contract between a managed care plan and a provider does not address reimbursement for services rendered under this section, the insurer shall reimburse the provider according to the most recent contracted rate.
609.24(2)
(2) Medical necessity provisions. This section does not preclude the application of any provisions related to medical necessity that are generally applicable under the plan.
609.24(3)
(3) Hold harmless requirements. A provider that receives or is due reimbursement for services provided to an enrollee under this section is subject to
s. 609.91 with respect to the enrollee, regardless of whether the provider is a participating provider in the enrollee's plan and regardless of whether the enrollee's plan is a health maintenance organization.
609.24 History
History: 1997 a. 237.
609.30
609.30
Provider disclosures. 609.30(1)
(1)
Plan may not contract. A managed care plan may not contract with a participating provider to limit the provider's disclosure of information, to or on behalf of an enrollee, about the enrollee's medical condition or treatment options.
609.30(2)
(2) Plan may not penalize or terminate. A participating provider may discuss, with or on behalf of an enrollee, all treatment options and any other information that the provider determines to be in the best interest of the enrollee. A managed care plan may not penalize or terminate the contract of a participating provider because the provider makes referrals to other participating providers or discusses medically necessary or appropriate care with or on behalf of an enrollee.
609.30 History
History: 1997 a. 237.
609.32
609.32
Quality assurance. 609.32(1)(1)
Standards. A managed care plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following:
609.32(1)(a)
(a) An ongoing, written internal quality assurance program.
609.32(1)(b)
(b) Specific written guidelines for quality of care studies and monitoring.
609.32(1)(c)
(c) Performance and clinical outcomes-based criteria.
609.32(1)(d)
(d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.
609.32(2)
(2) Selection and evaluation of providers. 609.32(2)(a)(a) A managed care plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider's license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider.
609.32(2)(b)
(b) A managed care plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider's initial acceptance for participation. The reevaluation shall include all of the following:
609.32(2)(b)2.
2. Assessing the provider's performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.
609.32(2)(c)
(c) A managed care plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.
609.32 History
History: 1997 a. 237.
609.34
609.34
Clinical decision-making; medical director. A managed care plan shall appoint a physician as medical director. The medical director shall be responsible for clinical protocols, quality assurance activities and utilization management policies of the plan.
609.34 History
History: 1997 a. 237.
609.36
609.36
Data systems and confidentiality. 609.36(1)
(1)
Information and data reporting. 609.36(1)(a)(a) A managed care plan shall provide to the commissioner information related to all of the following:
609.36(1)(b)
(b) Subject to
sub. (2), the information and data reported under
par. (a) shall be open to public inspection under
ss. 19.31 to
19.39.
609.36(2)
(2) Confidentiality. A managed care plan shall establish written policies and procedures, consistent with
ss. 51.30,
146.82 and
252.15, for the handling of medical records and enrollee communications to ensure confidentiality.
609.36 History
History: 1997 a. 237.
609.38
609.38
Oversight. The office shall perform examinations of insurers that issue managed care plans consistent with
ss. 601.43 and
601.44. The commissioner shall by rule develop standards for managed care plans for compliance with the requirements under this chapter.
