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),
98-1772.
609.01 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. Sub. (2) says that an HMO is an entity that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services but does not put in place a general limitation on all sources of funds available to HMOs. Torres v. Dean Health Plan, Inc.
2005 WI App 89,
282 Wis. 2d 725,
698 N.W.2d 107,
03-3274.
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 percent 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.
609.03 Cross-reference
Cross-reference: See also s.
Ins 9.12, Wis. adm. code.
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 defined network 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 defined network 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 defined network 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.
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).
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 any 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 defined network 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 defined network plans. 609.20(1m)(1m)
The commissioner may promulgate rules relating to preferred provider plans and defined network plans for any of the following purposes, as appropriate:
609.20(1m)(a)
(a) To ensure that enrollees are not forced to travel excessive distances to receive health care services.
609.20(1m)(b)
(b) To ensure that the continuity of patient care for enrollees meets the requirements under s.
609.24.
609.20(1m)(d)
(d) 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.
609.20(2m)
(2m) Any rule promulgated under this chapter shall recognize the differences between preferred provider plans and other types of defined network plans, take into account the fact that preferred provider plans provide coverage for the services of nonparticipating providers, and be appropriate to the type of plan to which the rule applies.
609.22
609.22
Access standards. 609.22(1)(1)
Providers. A defined network plan shall include a sufficient number, and sufficient types, of qualified providers to meet the anticipated needs of its enrollees, with respect to covered benefits, as appropriate to the type of plan and consistent with normal practices and standards in the geographic area.
609.22(2)
(2)
Adequate choice. A defined network plan that is not a preferred provider 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 defined network plan that is not a preferred provider 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 defined network 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 defined network plan that is not a preferred provider plan requires a referral to a specialist for coverage of specialist services, the defined network plan that is not a preferred provider 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 defined network plan that is not a preferred provider 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 defined network plan that is not a preferred provider 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 defined network plan that is not a preferred provider plan.
609.22(4)(a)3.
3. A defined network plan that is not a preferred provider 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 defined network plan that provides coverage of obstetric or gynecologic services may not require a female enrollee of the defined network 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 defined network 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 defined network 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 defined network plan under par.
(a) shall provide written notice of the requirement under par.
(a) in every policy or group certificate issued by the defined network plan.
609.22(5)
(5)
Second opinions. A defined network 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 defined network plan provides coverage of emergency services, with respect to covered benefits, the defined network 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 defined network plan that is not a preferred provider 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 defined network plan that is not a preferred provider 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 defined network 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 defined network plan shall provide access to translation services fluent in those languages to the greatest extent possible.
609.22 Cross-reference
Cross-reference: See also s.
Ins 9.38, Wis. adm. code.
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 defined network 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 defined network 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 defined network 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 defined network 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 defined network plan's geographic service area.
609.24(1)(d)2.
2. The insurer issuing the defined network 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 defined network 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 defined network 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(4)
(4)
Notice of provisions. A defined network plan shall notify all plan enrollees of the provisions under this section whenever a participating provider's participation with the plan terminates, or shall, by contract, require a participating provider to notify all plan enrollees of the provisions under this section if the participating provider's participation with the plan terminates.
