609.65(2)
(2) If after receiving notice under
sub. (1) (b) 2. the limited service health organization, preferred provider plan, or defined network plan arranges for services to be provided by a provider with whom it has a provider agreement, the limited service health organization, preferred provider plan, or plan is not required to reimburse a provider under
sub. (1) (b) 2. for any services provided after arrangements are made under this subsection.
609.65(3)
(3) A limited service health organization, preferred provider plan, or defined network plan is only required to make available, or make reimbursement for, an examination, evaluation, or treatment under
sub. (1) to the extent that the limited service health organization, preferred provider plan, or defined network plan would have made the medically necessary service available to the enrollee or reimbursed the provider for the service if any referrals required under
s. 609.05 (3) had been made and the service had been performed by a participating provider.
609.655
609.655
Coverage of certain services provided to dependent students. 609.655(1)(a)
(a) "Dependent student" means an individual who satisfies all of the following:
609.655(1)(a)1.
1. Is covered as a dependent child under the terms of a policy or certificate issued by a defined network plan insurer.
609.655(1)(a)2.
2. Is enrolled in a school located in this state but outside the geographical service area of the defined network plan.
609.655(1)(c)
(c) "School" means a technical college; an institution within the University of Wisconsin System; and any institution of higher education that grants a bachelor's or higher degree.
609.655(2)
(2) If a policy or certificate issued by a defined network plan insurer provides coverage of outpatient services provided to a dependent student, the policy or certificate shall provide coverage of outpatient services, to the extent and in the manner required under
sub. (3), that are provided to the dependent student while he or she is attending a school located in this state but outside the geographical service area of the defined network plan, notwithstanding the limitations regarding participating providers, primary providers, and referrals under
ss. 609.01 (2) and
609.05 (3).
609.655(3)
(3) Except as provided in
sub. (5), a defined network plan shall provide coverage for all of the following services:
609.655(3)(a)
(a) A clinical assessment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems, conducted by a provider described in
s. 632.89 (1) (e) 2. or
3. who is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and who may be designated by the defined network plan.
609.655(3)(b)
(b) If outpatient services are recommended in the clinical assessment conducted under
par. (a), the recommended outpatient services consisting of not more than 5 visits to an outpatient treatment facility or other provider that is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and that may be designated by the defined network plan, except as follows:
609.655(3)(b)1.
1. Coverage is not required under this paragraph if the medical director of the defined network plan determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.
609.655(3)(b)2.
2. Coverage is not required under this paragraph for outpatient services provided after the dependent student has terminated his or her enrollment in the school.
609.655(4)(a)(a) Upon completion of the 5 visits for outpatient services covered under
sub. (3) (b), the medical director of the defined network plan and the clinician treating the dependent student shall review the dependent student's condition and determine whether it is appropriate to continue treatment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems in reasonably close proximity to the school in which the student is enrolled. The review is not required if the dependent student is no longer enrolled in the school or if the coverage limits under the policy or certificate for treatment of nervous or mental disorders or alcoholism or other drug abuse problems have been exhausted.
609.655(4)(b)
(b) Upon completion of the review under
par. (a), the medical director of the defined network plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the defined network plan's internal grievance procedure established under
s. 632.83.
609.655(5)(a)(a) A policy or certificate issued by a defined network plan insurer is required to provide coverage for the services specified in
sub. (3) only to the extent that the policy or certificate would have covered the service if it had been provided to the dependent student by a participating provider within the geographical service area of the defined network plan.
609.655(5)(b)
(b) Paragraph (a) does not permit a defined network plan to reimburse a provider for less than the full cost of the services provided or an amount negotiated with the provider, solely because the reimbursement rate for the service would have been less if provided by a participating provider within the geographical service area of the defined network plan.
609.70
609.70
Chiropractic coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.87 (3).
609.75
609.75
Adopted children coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.896. Coverage of health care services obtained by adopted children and children placed for adoption may be subject to any requirements that the limited service health organization, preferred provider plan, or defined network plan imposes under
s. 609.05 (2) and
(3) on the coverage of health care services obtained by other enrollees.
609.76
609.76
Coverage of student on medical leave. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.895 (15).
609.76 History
History: 2007 a. 36.
609.77
609.77
Coverage of breast reconstruction. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.895 (13).
609.77 History
History: 1997 a. 27,
237;
2001 a. 16.
609.78
609.78
Coverage of treatment for the correction of temporomandibular disorders. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.895 (11).
609.78 History
History: 1997 a. 27,
237;
2001 a. 16.
609.79
609.79
Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.895 (12).
609.79 History
History: 1997 a. 27,
237;
2001 a. 16.
609.80
609.80
Coverage of mammograms. Defined network plans are subject to
s. 632.895 (8). Coverage of mammograms under
s. 632.895 (8) may be subject to any requirements that the defined network plan imposes under
s. 609.05 (2) and
(3) on the coverage of other health care services obtained by enrollees.
609.81
609.81
Coverage related to HIV infection. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 631.93. Defined network plans are subject to
s. 632.895 (9).
609.82
609.82
Coverage without prior authorization for emergency medical condition treatment. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.85.
609.82 History
History: 1997 a. 237;
2001 a. 16.
609.83
609.83
Coverage of drugs and devices. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.853.
609.83 History
History: 1997 a. 237;
2001 a. 16.
609.84
609.84
Experimental treatment. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 632.855.
609.84 History
History: 1997 a. 237;
2001 a. 16.
609.85
609.85
Coverage of lead screening. Health maintenance organizations and preferred provider plans are subject to
s. 632.895 (10).
609.85 History
History: 1993 a. 450.
609.88
609.88
Coverage of immunizations. Defined network plans are subject to
s. 632.895 (14).
609.88 History
History: 1999 a. 115;
2001 a. 16.
609.89
609.89
Written reason for coverage denial. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 631.17.
609.89 History
History: 1999 a. 95;
2001 a. 16.
609.90
609.90
Restrictions related to domestic abuse. Limited service health organizations, preferred provider plans, and defined network plans are subject to
s. 631.95.
609.90 History
History: 1999 a. 95;
2001 a. 16.
609.91
609.91
Restrictions on recovering health care costs. 609.91(1)(1)
Immunity of enrollees and policyholders. Except as provided in
sub. (1m), an enrollee or policyholder of a health maintenance organization insurer is not liable for health care costs that are incurred on or after January 1, 1990, and that are covered under a policy or certificate issued by the health maintenance organization insurer, if any of the following applies:
609.91(1)(a)
(a) The health care is provided by a provider who satisfies any of the following:
609.91(1)(a)1.
1. Is an affiliate of the health maintenance organization insurer.
609.91(1)(a)2.
2. Owns at least 5% of the voting securities of the health maintenance organization insurer.
609.91(1)(a)3.
3. Is entitled, alone or with one or more affiliates, to solely select one or more board members of the health maintenance organization insurer, or has an affiliate that is entitled to solely select one or more board members of the health maintenance organization insurer.
609.91(1)(a)4.
4. Is entitled to have one or more board members of the health maintenance organization insurer serve exclusively as a representative of the provider, one or more of the provider's affiliates or the provider and its affiliates, except this subdivision does not apply to an individual practice association or an affiliate of an individual practice association.
609.91(1)(a)5.
5. Is an individual practice association that is represented, or its affiliate is represented, on the board of the health maintenance organization insurer, and at least 3 of the board members of the health maintenance organization represent one or more individual practice associations.
609.91(1)(am)
(am) The health care is provided by a provider under a contract with, or through membership in, a person who satisfies
par. (a) 1.,
2.,
3.,
4. or
5.
609.91(1)(b)
(b) The health care is provided by a provider who is not subject to
par. (a) or
(am) and who does not elect to be exempt from this paragraph under
s. 609.92, and the health care satisfies any of the following:
609.91(1)(b)1.
1. Is provided by a hospital or an individual practice association.
609.91(1)(b)2.
2. Is physician services provided under a contract with the health maintenance organization insurer or by a participating provider of the health maintenance organization insurer.
609.91(1)(b)3.
3. Is services, equipment, supplies or drugs that are ancillary or incidental to services described in
subd. 2. and are provided by the contracting provider or participating provider.
609.91(1)(c)
(c) The health care is provided by a provider who is not subject to
par. (a),
(am) or
(b) with regard to that health care and who elects under
s. 609.925 to be subject to this paragraph.
609.91(1)(d)
(d) The liability is for the portion of health care costs that exceeds the amount that the health maintenance organization insurer has agreed, in a contract with the provider of the health care, to pay the provider for that health care.
609.91(1m)
(1m) Immunity of medical assistance recipients. An enrollee, policyholder or insured under a policy issued by an insurer to the department of health services under
s. 49.45 (2) (b) 2. to provide prepaid health care to medical assistance recipients is not liable for health care costs that are covered under the policy.
609.91(2)
(2) Prohibited recovery attempts. No person may bill, charge, collect a deposit from, seek remuneration or compensation from, file or threaten to file with a credit reporting agency or have any recourse against an enrollee, policyholder or insured, or any person acting on their behalf, for health care costs for which the enrollee, policyholder or insured, or person acting on their behalf, is not liable under
sub. (1) or
(1m).
609.91(3)
(3) Deductibles, copayments and premiums. Subsections (1) to
(2) do not affect the liability of an enrollee, policyholder or insured for any deductibles, copayments or premiums owed under the policy or certificate issued by the health maintenance organization insurer or by the insurer described in
sub. (1m).
609.91(4)
(4) Conditions not affecting the immunity. The immunity of an enrollee, policyholder or insured for health care costs, to the extent of the immunity provided under this section and
ss. 609.92 to
609.935, is not affected by any of the following:
609.91(4)(a)
(a) An agreement, other than a notice of election or termination of election in accordance with
s. 609.92 or
609.925, entered into by the provider, the health maintenance organization insurer, the insurer described in
sub. (1m) or any other person, at any time, whether oral or written and whether implied or explicit, including an agreement that purports to hold the enrollee, policyholder or insured liable for health care costs.
609.91(4)(b)
(b) A breach of or default on an agreement by the health maintenance organization insurer, the insurer described in
sub. (1m) or any other person to compensate the provider, directly or indirectly, for health care costs, including health care costs for which the enrollee, policyholder or insured is not liable under
sub. (1) or
(1m).
609.91(4)(c)
(c) The insolvency of the health maintenance organization insurer or any person contracting with the health maintenance organization insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the health maintenance organization insurer or other person, including delinquency proceedings, as defined in
s. 645.03 (1) (b), under
ch. 645, despite whether the health maintenance organization insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee or policyholder is not liable under
sub. (1).
609.91(4)(cm)
(cm) The insolvency of the insurer described in
sub. (1m) or any person contracting with the insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the insurer or other person, including delinquency proceedings, as defined in
s. 645.03 (1) (b), under
ch. 645, despite whether the insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee, policyholder or insured is not liable under
sub. (1m).
609.91(4)(d)
(d) The inability of the provider or other person who is owed compensation for health care costs to obtain compensation from the health maintenance organization insurer, the insurer described in
sub. (1m) or any other person for health care costs for which the enrollee, policyholder or insured is not liable under
sub. (1) or
(1m).
609.91(4)(e)
(e) The failure of a health maintenance organization insurer to comply with
s. 609.94.
609.91(4)(f)
(f) Any other conditions or agreements, other than a notice of election or termination of election in accordance with
s. 609.92 or
609.925, existing at any time.
609.91 Annotation
Sections 609.01 and 609.91 do not prohibit HMOs from asserting contractual subrogation rights with respect to actual medical expenses incurred by an HMO for medical care covered by the HMO's contract with an enrollee. This section is replete with language immunizing enrollees and limiting their liability, but does not speak to the sources of funds available to HMOs, except to the extent that it limits funds HMOs may obtain from enrollees. Torres v. Dean Health Plan, Inc. 2005 WI App 89,
282 Wis. 2d 725,
698 N.W.2d 107,
03-3274.
609.92
609.92
Hospitals, individual practice associations and providers of physician services. 609.92(1)
(1)
Election of exemption. Except as provided in
s. 609.93, a hospital, an individual practice association or other provider described in
s. 609.91 (1) (b) may elect to be exempt from
s. 609.91 (1) (b) for the purpose of recovering health care costs arising from health care provided by the hospital, individual practice association or other provider, if the conditions under
sub. (2) or
(3), whichever is applicable, are satisfied.
609.92(2)
(2) Care provided under a contract. If the health care is provided under a written contract between a health maintenance organization insurer and the hospital, individual practice association or other provider, all of the following conditions must be met for the hospital, individual practice association or other provider to secure an exemption under
sub. (1):
609.92(2)(a)
(a) The contract must be in effect on the date that the health care is provided, and the health care must be provided in accordance with the terms of the contract.
609.92(2)(b)
(b) The hospital, individual practice association or other provider must, within 30 days after entering into the contract, deliver to the office a written notice stating that the hospital, individual practice association or other provider elects to be exempt from
s. 609.91 (1) (b). The notice shall comply with the rules, if any, promulgated under
s. 609.935.
609.92(3)
(3) Care provided without a contract. If the health care is not provided under a contract that satisfies
sub. (2), all of the following conditions must be met for the hospital, individual practice association or other provider to secure an exemption under
sub. (1):
609.92(3)(a)
(a) The hospital, individual practice association or other provider must deliver to the office a notice stating that the hospital, individual practice association or other provider elects to be exempt from
s. 609.91 (1) (b) with respect to a specified health maintenance organization insurer. The notice shall comply with the rules, if any, promulgated under
s. 609.935.
609.92(3)(b)
(b) If the health care is provided on or after January 1, 1990, and before January 1, 1991, the health care must be provided at least 60 days after the office receives the notice under
par. (a).
