609.86 History
History: 2009 a. 14.
609.87
609.87
Coverage of treatment for autism spectrum disorders. Defined network plans are subject to
s. 632.895 (12m).
609.87 History
History: 2009 a. 28.
609.875
609.875
Coverage of colorectal cancer screening. Defined network plans are subject to
s. 632.895 (16m).
609.875 History
History: 2009 a. 346 s.
8;
2011 a. 260 s.
80.
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) or
(1p), 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(1p)
(1p) Immunity for certain medicare recipients. An enrollee, policyholder, or insured under a policy issued by an insurer under Part C of Medicare under
42 USC 1395w-21 to
1395w-28 or Part D of Medicare under
42 USC 1395w-101 to
1395w-152 to provide prepaid health care, fee-for-service health care, or drug benefits to enrollees of Part C or Part D of Medicare 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),
(1m), or
(1p).
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) or
(1p).
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
(1p) 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
(1p) 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),
(1m), or
(1p).
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
(1p) 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) or
(1p).
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
(1p), or any other person for health care costs for which the enrollee, policyholder or insured is not liable under
sub. (1),
(1m), or
(1p).
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).
609.92(3)(c)
(c) If the health care is provided on or after January 1, 1991, the health care must be provided at least 90 days after the office receives the notice under
par. (a).
609.92(4)
(4) Termination of election. A hospital, individual practice association or other provider may terminate its election under
sub. (2) or
(3) by stating the termination date in the notice under
sub. (2) or
(3) or in a separate written termination notice filed with the office. The termination notice shall comply with the rules, if any, promulgated under
s. 609.935. The termination is effective for any health care costs incurred after the termination date specified in the notice or the date on which the notice is filed, whichever is later.
609.92(5)
(5) Provider of physician services. A provider who is not under contract with a health maintenance organization insurer and who is not a participating provider of a health maintenance organization insurer is not subject to
s. 609.91 (1) (b) 2. with respect to health care costs incurred by an enrollee of that health maintenance organization insurer.
609.92 History
History: 1989 a. 23;
1997 a. 237.
609.925
609.925
Election to be subject to restrictions. 609.925(1)(1)
Notice of election. Except as provided in
s. 609.93, a provider described in
s. 609.91 (1) (c) is subject to
s. 609.91 (1) (c) for purposes of recovering health care costs arising from health care provided by the provider, if the provider files with the office a written notice stating that the provider elects to be subject to
s. 609.91 (1) (c) with respect to a specified health maintenance organization insurer. The notice shall comply with the rules, if any, promulgated under
s. 609.935. The notice is effective on the date that it is received by the office or the date specified in the notice, whichever is later.
609.925(2)
(2) Termination of election. A provider may terminate a notice of election under
sub. (1) by stating the termination date in the notice of election or in a separate written termination notice filed with the office. The termination notice shall comply with the rules, if any, promulgated under
s. 609.935. The termination date may not be earlier than 90 days after the office receives notice of termination, whether included in the notice of election or in a separate termination notice.
609.925(3)
(3) Effective period of election. Section 609.91 applies to health care costs incurred on and after the effective date of the notice under
sub. (1) or January 1, 1990, whichever is later, and until the termination date of the notice.
609.925 History
History: 1989 a. 23.
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.
