Ins 9.01(6) (6) “Health benefit plan” has the meaning provided under s. 632.745 (11), Stats.

Ins 9.01(7) (7) “HMO” or “health maintenance organization” means a health care plan as defined in s. 609.01 (2), Stats.

Ins 9.01(8) (8) “Health maintenance organization insurer” has the meaning provided under s. 600.03 (23c), Stats.

Ins 9.01(9) (9) “Hospital emergency facility” means any hospital facility that offers services for emergency medical conditions as described in s. 632.85 (1) (a), Stats., within its capability to do so and in accordance with s. DHS 124.24, or the licensure requirements of the jurisdiction in which the hospital resides.

Ins 9.01(9m) (9m) “Intermediate entity” means a provider network, a provider association, a provider leasing arrangement or other similar entity that contracts with providers for the rendering of health care services, items or supplies to enrollees of a defined network plan, preferred provider plan or limited service health organization and also contracts with the insurer offering a defined network plan, preferred provider plan or limited service health organization.

Ins 9.01(10) (10) “IPA” or “individual practice association” has the meaning provided under s. 600.03 (23g), Stats.

Ins 9.01(11) (11) “Limited service health organization” means a health care plan as defined in s. 609.01 (3), Stats.

Ins 9.01(13) (13) “OCI complaint” means any written complaint received by the office of the commissioner of insurance by, or on behalf of, an enrollee of an insurer offering a defined network plan, preferred provider plan or limited service health organization.

Ins 9.01(14) (14) “Office” means the “office of the commissioner of insurance.”

Ins 9.01(14m) (14m) “Participating” has the meaning provided under s. 609.01 (3m), Stats., and includes a provider as being under contract with the insurer when the provider is under contract with an intermediate entity.

Ins 9.01(15) (15) “Preferred provider plan” has the meaning provided under s. 609.01 (4), Stats.

Ins 9.01(16) (16) “Primary provider” has the meaning provided under s. 609.01 (5), Stats.

Ins 9.01(17) (17) “Silent provider network” means one or more participating providers that provide services covered under a defined network plan where all of the following apply:

Ins 9.01(17)(a) (a) The insurer does not include any incentives or penalties in the defined network plan related to utilization or failure to utilize the provider.

Ins 9.01(17)(b) (b) The only direct or indirect compensation arrangement the insurer has with the provider provides for compensation that is:

Ins 9.01(17)(b)1. 1. On a fee for service basis and not on a risk sharing basis, including, but not limited to, capitation, withholds, global budgets, or target expected expenses or claims;

Ins 9.01(17)(b)2. 2. The compensation arrangement provides for compensation that is not less than 80% of the provider’s usual fee or charge.

Ins 9.01(17)(c) (c) The insurer, in any arrangement described under par. (b), requires that the reduction in fees will be applied with respect to cost sharing portions of expenses incurred under the defined network plan to the extent the provider submits the claim directly to the insurer.

Ins 9.01(17)(d) (d) The provider is not directly or indirectly managed, owned, or employed by the insurer.

Ins 9.01(17)(e) (e) The insurer does not disclose, market, advertise, provide a telephone service or number relating to, or include in policyholder or enrollee material information relating to, the availability of the compensation arrangement described under par. (b), or the names or addresses of the provider or an entity that maintains a compensation arrangement described under par. (b), except to the extent required by law in processing of explanation of benefits. The insurer may not indirectly cause or permit a prohibited disclosure and may not make any such disclosure in the course of utilization review or pre-authorization functions.

Ins 9.01 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; correction in (12) made under s. 13.93 (2m) (b) 7., Stats., Register February 2006 No. 602; CR 05-059: renum. (12) to be (3m), am. (3), (3m), (5), (13), (17) (a) and (c), cr. (9m), (10m) and (14m) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (5), (9m) and (13), r. (10m) Register December 2006 No. 612, eff. 1-1-07; correction in (9) made under s. 13.92 (4) (b) 7., Stats., Register February 2013 No. 686; CR 19-036: am. (3m) Register December 2019 No. 768, eff. 1-1-20; correction in (3m) made under s. 35.17, Stats., Register December 2019 No. 768.

Ins 9.015 Ins 9.015 Scope. This chapter applies to all insurers offering a defined network plan, a preferred provider plan or a limited service health organization plan except to an insurer offering a preferred provider plan that also meets the subject matter of s. 632.745 (11) (b) 9., Stats.

Ins 9.015 History History: CR 06-083: cr. Register December 2006 No. 612, eff. 1-1-07.

subch. II of ch. Ins 9 Subchapter II — Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations

Ins 9.02 Ins 9.02 Purpose. This subchapter establishes financial standards for health maintenance organizations and limited service health organizations doing business in Wisconsin. These requirements are in addition to any other statutory or administrative rule requirements that apply to health maintenance organizations and limited service health organizations.

Ins 9.02 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.03 Ins 9.03 Scope. This subchapter applies to all insurers writing health maintenance organization or limited service health organization business in this state.

Ins 9.03 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.04 Ins 9.04 Financial requirements. The following are the minimum financial requirements for compliance with this section unless a different amount is ordered by the commissioner: