609.93
609.93
Scope of election by an individual practice association or clinic. 609.93(1)
(1)
Individual practice association. The election by an individual practice association under
s. 609.92 to be exempt from
s. 609.91 (1) (b) or the failure of the individual practice association to so elect applies to health care costs arising from health care provided by any provider, other than a hospital, under a contract with, or through membership in, the individual practice association. A provider, other than a hospital, may not exercise an election under
s. 609.92 or
609.925 separately from an individual practice association with respect to health care costs arising from health care provided under a contract with, or through membership in, the individual practice association.
609.93(2)(a)(a) The election by a clinic under
s. 609.92 to be exempt from
s. 609.91 (1) (b) with respect to services described in
s. 609.91 (1) (b) 2. and
3. or the failure of the clinic to so elect, or the election by a clinic under
s. 609.925 to be subject to
s. 609.91 (1) (c) or the failure of the clinic to so elect, applies to health care costs arising from health care provided by any provider through the clinic. A provider may not exercise an election under
s. 609.92 or
609.925 separately from the clinic with respect to health care costs provided through the clinic.
609.93(2)(b)
(b) The commissioner may, by rule, specify the types of health care facilities or organizations that qualify as clinics for purposes of this subsection.
609.93 History
History: 1989 a. 23.
609.935
609.935
Notices of election and termination. 609.935(1)
(1)
In accordance with rules. If the commissioner promulgates rules governing the form or manner of filing a notice of election or termination notice under
s. 609.92 or
609.925, a notice of election or termination notice filed after the rules take effect is not effective unless filed in accordance with the applicable rules.
609.935(2)
(2) Effect of certain changes. The effectiveness of a notice of election or termination notice filed with the office under
s. 609.92 or
609.925 is not affected by the renaming, reorganization, merger, consolidation or change in control of the provider, health maintenance organization insurer or any other person. The commissioner may, by rule, require a provider to amend a notice of election or termination notice if any of the events in this subsection or other changes affecting the accuracy of the information occur.
609.935 History
History: 1989 a. 23.
609.94
609.94
Summary of restrictions. 609.94(1)
(1) A health maintenance organization insurer shall deliver a written notice that complies with
sub. (2) to all of the following:
609.94(1)(a)
(a) Each provider that contracts with the health maintenance organization insurer to provide health care services, at the time that the health maintenance organization insurer and provider enter into a contract.
609.94(1)(b)
(b) Each participating provider of the health maintenance organization insurer, at the time that the provider becomes a participating provider.
609.94(2)
(2) The notice shall contain a summary of
ss. 609.91 to
609.935 and
609.97 (1) and a statement that the health maintenance organization insurer files financial statements with the office which are available for public inspection. The commissioner may, by rule, specify a form for providing the notice required under this section. If the commissioner promulgates such a rule, any notice delivered on or after the effective date of the rule shall comply with the form specified by rule.
609.94 History
History: 1989 a. 23;
1997 a. 237.
609.94 Cross-reference
Cross Reference: See also s.
Ins 9.13, Wis. adm. code.
609.95
609.95
Minimum covered liabilities. A health maintenance organization insurer, whether first licensed or organized before, on or after July 1, 1989, shall maintain, on and after January 1, 1990, at least 65% of its liabilities for health care costs as covered liabilities.
609.95 History
History: 1989 a. 23.
609.96
609.96
Initial capital and surplus requirements. 609.96(1)(1)
Minimum capital and permanent surplus. 609.96(1)(a)(a) Except as provided in
par. (b), if a health maintenance organization insurer is first licensed or organized on or after July 1, 1989, the minimum capital or permanent surplus for the health maintenance organization insurer is $750,000.
609.96(1)(b)
(b) The commissioner may require a greater amount or permit a lesser amount than that specified under
sub. (1) by rule promulgated, or order issued, on or after July 1, 1989.
609.96(2)
(2) Initial expendable surplus. A health maintenance organization insurer subject to
sub. (1) shall have an initial expendable surplus, after payment of all organizational expenses, of at least 50% of the minimum capital or minimum permanent surplus required under
sub. (1), or such other percentage as the commissioner specifies by rule promulgated, or order issued, on or after July 1, 1989.
609.96 History
History: 1989 a. 23.
609.97
609.97
Compulsory and security surplus. 609.97(1)
(1)
Amount of compulsory surplus. Except as otherwise provided by rule or order under
sub. (2), a health maintenance organization insurer, whether first licensed or organized before, on or after July 1, 1989, shall maintain a compulsory surplus in an amount determined as follows:
609.97(1)(a)
(a) Beginning on July 1, 1989, and ending on December 31, 1989, the compulsory surplus shall be equal to at least the greater of $200,000 or 3% of the premiums earned by the health maintenance organization insurer in the previous 12 months.
609.97(1)(b)
(b) Beginning on January 1, 1990, and ending on December 31, 1991, the compulsory surplus shall be equal to at least the greater of $500,000 or:
609.97(1)(b)1.
1. If before January 1, 1991, 3% of the premiums earned by the health maintenance organization insurer in the previous 12 months.
609.97(1)(b)2.a.
a. If the percentage of the liabilities of the health maintenance organization insurer that are covered liabilities is less than 90%, 4.5% of the premiums earned by the health maintenance organization insurer in the previous 12 months.
609.97(1)(b)2.b.
b. If the percentage of the liabilities of the health maintenance organization insurer that are covered liabilities is at least 90%, 3% of the premiums earned by the health maintenance organization insurer in the previous 12 months.
609.97(1)(c)
(c) Beginning on January 1, 1992, the compulsory surplus shall be equal to at least the greater of $750,000 or:
609.97(1)(c)1.
1. If the percentage of the liabilities of the health maintenance organization insurer that are covered liabilities is less than 90%, 6% of the premiums earned by the health maintenance organization insurer in the previous 12 months.
609.97(1)(c)2.
2. If the percentage of the liabilities of the health maintenance organization insurer that are covered liabilities is at least 90%, 3% of the premiums earned by the health maintenance organization insurer in the previous 12 months.
609.97(2)
(2) Modification by rule or order. The commissioner may require a greater amount or permit a lesser amount than that specified under
sub. (1) by rule promulgated, or order issued, on or after July 1, 1989. The commissioner may consider the risks and factors described under
s. 623.11 (1) (a) and
(b) in promulgating a rule or issuing an order under this subsection.
609.97(3)
(3) Amount of security surplus. A health maintenance organization insurer, whether first licensed or organized before, on or after July 1, 1989, shall maintain a security surplus in the amount set by the commissioner under
s. 623.12.
609.97 History
History: 1989 a. 23.
609.98
609.98
Special deposit. 609.98(2)(a)(a) Before April 1, 1990, and before April 1 of each following year, a health maintenance organization insurer shall deposit under
s. 601.13 an amount that is at least equal to the lesser of the following:
609.98(2)(a)1.
1. An amount necessary to establish or maintain a deposit equaling 1% of premiums written in this state by the health maintenance organization insurer in the preceding calendar year.
609.98(2)(a)2.
2. With respect to the amount due before April 1, 1990, 0.5% of premiums written in this state by the health maintenance organization insurer in the preceding calendar year, unless otherwise provided by rule or order under
par. (b).
609.98(2)(a)3.
3. With respect to the amount due in the years after 1990, one-third of 1% of the premiums written in this state by the health maintenance organization insurer in the preceding calendar year, unless otherwise provided by rule or order under
par. (b).
609.98(2)(b)
(b) The commissioner may, by rule or order, require that the deposit under
par. (a) be in an amount greater than that provided under
par. (a) 2. or
3., but the commissioner may not require an amount exceeding the amount provided under
par. (a) 1.
609.98(3)
(3) Status of deposit. A deposit under this section is in addition to any deposit otherwise required or permitted by law or the commissioner. An amount deposited under this section is not available for the purpose of determining permanent capital or surplus, compulsory surplus or the financial condition, including insolvency, of the health maintenance organization insurer.
609.98(4)
(4) Release of deposit. A deposit under this section may be released only with the approval of the commissioner under
s. 601.13 (10) and only in any of the following circumstances:
609.98(4)(b)
(b) To the extent that the amount on deposit exceeds 1% of premiums written in this state by the health maintenance organization insurer in the preceding calendar year and the deposit is not necessary to pay an assessment under
s. 646.51 (3) (am).
609.98 History
History: 1989 a. 23;
2003 a. 261.
