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.
609.01 Annotation
Under this section, an HMO enrollee has no personal liability for the costs of covered health care received. A hospital only has recourse against the HMO and may not assert its lien rights under this section against insurance proceeds paid by a tortfeasor's insurer to the HMO enrollee. Dorr v. Sacred Heart Hospital,
228 Wis. 2d 425,
597 N.W.2d 462 (Ct. App. 1999).
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) and
(4m), 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. 609.22 (4m),
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 and point-of-service option plan required. 609.10(1)(ac)(ac) In this section, "point-of-service option plan" means a health maintenance organization or preferred provider plan that permits an enrollee to obtain covered health care services from a provider that is not a participating provider of the health maintenance organization or preferred provider plan under all of the following conditions:
609.10(1)(ac)1.
1. The nonparticipating provider holds a license or certificate that authorizes or qualifies the provider to provide the health care services.
609.10(1)(ac)2.
2. The health maintenance organization or preferred provider plan is required to pay the nonparticipating provider only the amount that the health maintenance organization or preferred provider plan would pay a participating provider for those health care services.
609.10(1)(ac)3.
3. The enrollee is responsible for any additional costs or charges related to the coverage.
609.10(1)(am)
(am) Except as provided in
subs. (2) to
(4), an employer that offers any of its employees a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employees a standard plan that provides at least substantially equivalent coverage of health care expenses and a point-of-service option plan, as provided in
pars. (b) and
(c).
609.10(1)(b)
(b) At least once annually, the employer shall provide the employees the opportunity to enroll in the health care plans under
par. (am).
609.10(1)(c)
(c) The employer shall provide the employees adequate notice of the opportunity to enroll in the health care plans under
par. (am) and shall provide the employees complete and understandable information concerning the differences among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan.
Effective date note
NOTE: Section 609.10 (title) and (1) are shown as affected eff. 4-1-01 by
1999 Wis. Act 9. Prior to 4-1-01 they read:
Effective date text
609.10 Standard plan required.
(1) (a) Except as provided in subs. (2) to (4), an employer that offers any of its employees a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employees a standard plan, as provided in pars. (b) and (c), that provides at least substantially equivalent coverage of health care expenses.
609.10 Note
(b) At least once annually, the employer shall provide the employees the opportunity to enroll in the health care plans under par. (a).
609.10 Note
(c) The employer shall provide the employees adequate notice of the opportunity to enroll in the health care plans under par. (a) and shall provide the employees 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 employees indicate that they wish to enroll in the standard plan under
sub. (1) (am), the employer need not offer the standard plan on that occasion.
609.10(3)
(3) Subsection (1) does not apply to an employer that does any of the following:
609.10(3)(b)
(b) Offers its employees a health maintenance organization or a preferred provider plan only through an insurer that is a cooperative association organized under
ss. 185.981 to
185.985 or only through an insurer that is restricted under
s. 609.03 (3).
Effective date note
NOTE: Sub. (3) is shown as affected eff. 4-1-01 by
1999 Wis. Act 9. Prior to 4-1-01 it reads:
Effective date text
(3) Subsection (1) does not apply to an employer that employs fewer than 25 full-time employees.
609.10(4)
(4) Nothing in
sub. (1) requires an employer to offer a particular health care plan to an employee if the health care plan determines that the employee 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(6)
(6) The commissioner shall promulgate rules necessary for the administration of the requirement to offer point-of-service option plans under
sub. (1) (am).
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.
Effective date note
NOTE: Sub. (3) is shown as amended eff. 4-1-01 by
1999 Wis. Act 9. Prior to 4-1-01 it reads:
Effective date text
(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 employees offered a health maintenance organization or a preferred provider plan that provides comprehensive services under
s. 609.10 (1) (am) 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 among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan, as defined in
s. 609.10 (1) (ac), including differences among providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization.
Effective date note
NOTE: Sub. (4) is shown as amended eff. 4-1-01 by
1999 Wis. Act 9. Prior to 4-1-01 it reads:
Effective date text
(4) To ensure that employees 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.
609.22
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(4m)
(4m) Obstetric and gynecologic services. 609.22(4m)(a)(a) A managed care plan that provides coverage of obstetric or gynecologic services may not require a female enrollee of the managed care plan to obtain a referral for covered obstetric or gynecologic benefits provided by a participating provider who is a physician licensed under
ch. 448 and who specializes in obstetrics and gynecology, regardless of whether the participating provider is the enrollee's primary provider. Notwithstanding
sub. (4), the managed care plan may not require the enrollee to obtain a standing referral under the procedure established under
sub. (4) (a) for covered obstetric or gynecologic benefits.
609.22(4m)(b)
(b) A managed care plan under
par. (a) may not do any of the following:
609.22(4m)(b)1.
1. Penalize or restrict the coverage of a female enrollee on account of her having obtained obstetric or gynecologic services in the manner provided under
par. (a).
609.22(4m)(b)2.
2. Penalize or restrict the contract of a participating provider on account of his or her having provided obstetric or gynecologic services in the manner provided under
par. (a).
609.22(4m)(c)
(c) A managed care plan under
par. (a) shall provide written notice of the requirement under
par. (a) in every policy or group certificate issued by the managed care plan.
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:
