601.41(9)(b) (b) If the federal government has not developed by July 1, 2003, a uniform claim processing form that must be used by all health care providers for submitting claims to insurers and by all insurers for processing claims submitted by health care providers, the commissioner shall develop, by December 31, 2003, a uniform claim processing form for that purpose.
601.41(10) (10) Uniform application for individual health insurance policies.
601.41(10)(a)(a) The commissioner shall by rule prescribe uniform questions and the format for applications, which may not exceed 10 pages in length, for individual major medical health insurance policies.
601.41(10)(b) (b) After the effective date of the rules promulgated under par. (a), an insurer may use only the prescribed questions and format for individual major medical health insurance policy applications. The commissioner shall publish a notice in the Wisconsin Administrative Register that states the effective date of the rules promulgated under par. (a).
601.41(10)(c) (c) For purposes of this subsection, an individual major medical health insurance policy includes health coverage provided on an individual basis through an association.
601.41(11) (11) Prelicensing training.
601.41(11)(a)(a) In this subsection:
601.41(11)(a)1. 1. “Instruction" means education, training, instruction, or other experience related to an occupation or profession.
601.41(11)(a)2. 2. “License" means a license, certificate, or permit issued by the commissioner under chs. 601 to 655 for an occupation or profession.
601.41(11)(b) (b) In connection with the issuance of a license, the commissioner shall count any relevant instruction that an applicant for a license has obtained in connection with military service, as defined in s. 111.32 (12g), toward satisfying any requirements for instruction for that license, if the applicant demonstrates to the satisfaction of the commissioner that the instruction obtained by the applicant is substantially equivalent to the instruction required for the license.
601.41 Cross-reference Cross-reference: See also Ins, Wis. adm. code.
601.41 Annotation Sub. (4) gives the commissioner the authority to issue not only prohibitory and mandatory orders, but also other orders as are necessary to secure compliance with the law. There is no limitation on the nature of the other orders except that they be necessary to secure compliance with the law. Sub. (4) permitted the order of refunds when the commissioner determined that a company violated the law by selling its contracts without a certificate of authority. Homeward Bound Services, Inc. v. Office of the Insurance Commissioner, 2006 WI App 208, 296 Wis. 2d 481, 724 N.W. 2d 380, 05-1781.
601.41 Annotation Why process consumer complaints? A case study of the office of the commissioner of insurance of Wisconsin. Whitford, Kimball, 1974 WLR 639.
601.415 601.415 Miscellaneous duties. The duties listed in this section are in addition to other duties imposed under chs. 600 to 655. Failure to list a specified power, duty or function of the commissioner in this section does not affect the validity of the power, duty or function.
601.415(1) (1) Joint survey committee on retirement systems. The commissioner or an experienced actuary in the office designated by the commissioner shall serve as a member of the joint survey committee on retirement systems under s. 13.50.
601.415(2) (2) Group insurance board. The commissioner shall serve as a member of the group insurance board under s. 15.165 (2).
601.415(3) (3) Wisconsin retirement board. The commissioner or an experienced actuary in the office designated by the commissioner shall serve as a member of the Wisconsin retirement board under s. 15.165 (3) (b).
601.415(5) (5) Cooperation with department of administration. The commissioner shall cooperate with the department of administration in placing insurance under s. 16.865 (4).
601.415(7) (7) Determination of variable interest rate adjustments. The commissioner shall approve indexes for variable interest rate adjustments under s. 138.055 (4) (c).
601.415(8) (8) Long-Term Care Partnership Program. The commissioner shall provide the certifications required under s. 49.45 (31) (b) 5. and shall cooperate with the department of health services in approving the training program under s. 49.45 (31) (c) for agents who sell long-term care insurance policies.
601.415(9) (9) Consumer credit law. The commissioner shall cooperate with the division of banking in the administration of ch. 424, shall determine the method for computation of refunds under s. 424.205, shall approve forms, schedules of premium rates and charges under s. 424.209 and shall issue rules or orders of compliance to insurers under s. 424.602.
601.415(10) (10) Petroleum product storage remedial action program rules. The commissioner shall promulgate the rules required under s. 292.63 (1m).
601.415(11) (11) Amendments to Own Risk and Solvency Assessment Guidance Manual. The commissioner shall, in his or her discretion, adopt amendments made after April 18, 2014, by the National Association of Insurance Commissioners to the guidance manual, as defined in s. 622.03 (1). Any such amendments made by the National Association of Insurance Commissioners become effective in this state if adopted by the commissioner by order after giving 30 days' notice to insurers of the changes proposed by the National Association of Insurance Commissioners. If one or more insurers request a hearing on the proposed changes during the 30-day period, the commissioner shall hold a hearing to determine whether the commissioner will, in his or her discretion, adopt one or more of the changes made by the National Association of Insurance Commissioners.
601.415(12) (12) Health Insurance Risk-Sharing Plan. The commissioner shall perform the duties specified to be performed by the commissioner in s. 149.13, 2011 stats., and under 2013 Wisconsin Act 20, section 9122 (1L) (b) 8.
601.415(13) (13) Membership in the National Conference of Insurance Legislators. Annually, from the appropriation account under s. 20.145 (1) (g), the commissioner shall credit to the appropriation account under s. 20.765 (3) (g) an amount sufficient for the payment of annual dues by the legislature for membership in the National Conference of Insurance Legislators.
601.42 601.42 Reports and replies.
601.42(1g)(1g)Reports. The commissioner may require any of the following from any person subject to regulation under chs. 600 to 655:
601.42(1g)(a) (a) Statements, reports, answers to questionnaires and other information, and evidence thereof, in whatever reasonable form the commissioner designates, and at such reasonable intervals as the commissioner chooses, or from time to time.
601.42(1g)(b) (b) Full explanation of the programming of any data storage or communication system in use.
601.42(1g)(c) (c) That information from any books, records, electronic data processing systems, computers or any other information storage system be made available to the commissioner at any reasonable time and in any reasonable manner.
601.42(1g)(d) (d) Statements, reports, answers to questionnaires or other information, or reports, audits or certification from a certified public accountant or an actuary approved by the commissioner, relating to the extent liabilities of a health maintenance organization insurer are or will be liabilities for health care costs for which an enrollee or policyholder of the health maintenance organization is not liable to any person under s. 609.91.
601.42(1r) (1r) Reports by individual practice associations. The commissioner may by rule require that an individual practice association submit to the commissioner information reasonably necessary to determine the financial condition of the individual practice association. The information required under this subsection may include, but is not limited to, financial statements of the individual practice association, except the commissioner may not require members of the individual practice association or other health care providers who contract with the individual practice association to submit individual financial statements.
601.42(2) (2) Forms. The commissioner may prescribe forms for the reports under subs. (1g) and (1r) and specify who shall execute or certify such reports. The forms for the reports required under sub. (1g) shall be consistent, so far as practicable, with those prescribed by other jurisdictions.
601.42(3) (3) Accounting methods. The commissioner may prescribe reasonable minimum standards and techniques of accounting and data handling to ensure that timely and reliable information will exist and will be available to the commissioner.
601.42(4) (4) Replies. Any officer, manager or general agent of any insurer authorized to do or doing an insurance business in this state, any person controlling or having a contract under which the person has a right to control such an insurer, whether exclusively or otherwise, any person with executive authority over or in charge of any segment of such an insurer's affairs, any individual practice association or officer, director or manager of an individual practice association, any insurance agent or other person licensed under chs. 600 to 646, any provider of services under a continuing care contract, as defined in s. 647.01 (2), any independent review organization certified or recertified under s. 632.835 (4) or any health care provider, as defined in s. 655.001 (8), shall reply promptly in writing or in other designated form, to any written inquiry from the commissioner requesting a reply.
601.42(5) (5) Verification. The commissioner may require that any communication made to the commissioner under this section be verified.
601.42(6) (6) Immunity.
601.42(6)(a)(a) In the absence of actual malice, no communication to the commissioner required by law or by the commissioner shall subject the person making it to an action for damages for defamation. This paragraph applies to communications received by the commissioner before May 11, 1990, or on or after June 1, 1994.
601.42(6)(b) (b) In the absence of actual malice, no communication to the commissioner or office required by law or by the commissioner shall subject the person making it to an action for damages for the communication. This paragraph applies to communications received by the commissioner or office on or after May 11, 1990, and before June 1, 1994.
601.42(7) (7) Experts. The commissioner may employ experts to assist the commissioner in an examination or in the review of any transaction subject to approval under chs. 600 to 646. The person that is the subject of the examination, or that is a party to a transaction under review, including the person acquiring, controlling or attempting to acquire the insurer, shall pay the reasonable costs incurred by the commissioner for the expert and related expenses.
601.42 Cross-reference Cross-reference: See also s. 623.02 as to standards for accounting rules.
601.42 Cross-reference Cross-reference: See also ss. Ins 6.61, 6.62, and 6.63, Wis. adm. code.
601.423 601.423 Social and financial impact reports.
601.423(1)(1)Definition. In this section, “health insurance mandate" means a statute of this state that does any of the following:
601.423(1)(am) (am) Requires an insurance policy, plan, or contract to do any of the following:
601.423(1)(am)1. 1. Permit a person insured under the policy, plan or contract to obtain treatment or services from a particular type of health care provider, including, but not limited to, requiring a health maintenance organization, preferred provider plan, limited service health organization or other plan to select a particular type of health care provider for participation in the plan.
601.423(1)(am)2. 2. Provide coverage for the treatment of a particular disease, condition or other health care need.
601.423(1)(am)3. 3. Provide coverage of a particular type of health care treatment or service, or of equipment, supplies or drugs used in connection with a health care treatment or service.
601.423(1)(am)4. 4. Provide coverage for particular persons because of their relation to the insured or legal status with respect to the insured, or for any other reason.
601.423(1)(bm) (bm) Requires a particular benefit design or imposes conditions on cost sharing under an insurance policy, plan, or contract for the treatment of a particular disease, condition, or other health care need, for a particular type of health care treatment or service, or for the provision of equipment, supplies, or drugs used in connection with a health care treatment or service.
601.423(1)(cm) (cm) Imposes limits or conditions on a contract between an insurer and a health care provider, as defined in s. 146.81 (1).
601.423(2) (2) Preparation of report.
601.423(2)(a)(a) Subject to par. (b), the office shall submit a report on the social and financial impact of any health insurance mandate contained in any bill or amendment affecting an insurance policy, plan, or contract, or, if the office decides not to submit a report, a written statement explaining the reason for not preparing the report, to the chief clerk of the house of the legislature in which the bill or amendment is introduced or offered.
601.423(2)(b)1.1. The office shall submit the report or written statement for a bill within 10 working days after receiving the copy of the bill from the legislative reference bureau under s. 13.0966 (2) (b).
601.423(2)(b)2. 2. The office shall submit the report or written statement within 10 working days after receiving a copy of the amendment from the legislative reference bureau under s. 13.0966 (2) (b). The office is not required to prepare or submit a report or written statement for an amendment if, by the end of the next business day after receiving a copy of the amendment from the legislative reference bureau, the amendment has failed adoption or failed to be reported out of committee.
601.423(3) (3) Contents of report.
601.423(3)(a)(a) Social impact factors. Any report prepared under sub. (2) shall assess to the extent possible all of the following social impact factors that are relevant to the type of health insurance mandate created, expanded, or continued by the bill or amendment:
601.423(3)(a)1. 1. The portion of this state's residents who use the treatments or services covered by the health insurance mandate.
601.423(3)(a)2. 2. The extent to which individuals under subd. 1. use these treatments or services.
601.423(3)(a)3. 3. The availability of insurance coverage for these treatments or services.
601.423(3)(a)4. 4. The number of persons who would be eligible for coverage under the health insurance mandate, and the availability of insurance coverage for these persons without the health insurance mandate.
601.423(3)(b) (b) Financial impact factors. Any report prepared under sub. (2) shall assess to the extent possible all of the following financial impact factors that are relevant to the type of health insurance mandate created, expanded, or continued by the bill or amendment:
601.423(3)(b)1. 1. Whether the health insurance mandate may increase or decrease the costs of the treatments or services covered by the health insurance mandate.
601.423(3)(b)2. 2. Whether the health insurance mandate would increase the use of the treatments or services covered by the health insurance mandate.
601.423(3)(b)3. 3. Whether any increased use under subd. 2. would substitute for more expensive treatments or services.
601.423(3)(b)4. 4. The impact of the health insurance mandate on total costs of health care in this state.
601.423(3)(b)5. 5. Whether the health insurance mandate may increase the administrative costs to insurance companies and the premium costs to policyholders.
601.423 History History: 1987 a. 177; 2015 a. 288; 2017 a. 239.
601.43 601.43 Examinations and alternatives.
601.43(1)(1)Power to examine.
601.43(1)(a)(a) Insurers, other licensees and other persons subject to regulation. Whenever the commissioner deems it necessary in order to inform himself or herself about any matter related to the enforcement of chs. 600 to 647, the commissioner may examine the affairs and condition of any licensee or permittee under chs. 600 to 647 or applicant for a license or permit, of any person or organization of persons doing or in process of organizing to do an insurance business in this state, and of any advisory organization serving any of the foregoing in this state.
601.43(1)(b) (b) Collateral examinations. So far as reasonably necessary for an examination under par. (a), the commissioner may examine the accounts, records, documents or evidences of transactions, so far as they relate to the examinee, of any of the following:
601.43(1)(b)1. 1. An officer, manager, general agent, employee, or person who has executive authority over or is in charge of any segment of the examinee's affairs.
601.43(1)(b)2. 2. A person controlling or having a contract under which the person has the right to control the examinee whether exclusively or with others.
601.43(1)(b)3. 3. A person who is under the control of the examinee, or a person who is under the control of a person who controls or has a right to control the examinee whether exclusively or with others.
601.43(1)(b)4. 4. An individual practice association which contracts with the examinee to provide health care services.
601.43(1)(c) (c) Availability of records. On demand every examinee under par. (a) shall make available to the commissioner for examination any of its own accounts, records, documents or evidences of transactions and any of those of the persons listed in par. (b). Failure to do so shall be deemed to be concealment of records under s. 645.41 (8), except that if the examinee is unable to obtain accounts, records, documents or evidences of transactions, failure shall not be deemed concealment if the examinee terminates immediately the relationship with the other person.
601.43(1)(d) (d) Delivery of records to the office. On order of the commissioner any licensee or permittee under chs. 600 to 647 shall bring to the office for examination such records as the order reasonably requires.
601.43(2) (2) Duty to examine.
601.43(2)(a)(a) Insurers and rate service organizations. The commissioner shall examine every domestic insurer and every licensed rate service organization.
601.43(2)(b) (b) On request. Whenever the commissioner is requested by verified petition signed by 25 persons interested as shareholders, policyholders or creditors of an insurer alleging that there are grounds for formal delinquency proceedings, the commissioner shall forthwith examine the insurer as to any matter alleged in the petition. Whenever the commissioner is requested to do so by the board of directors of a domestic insurer, the commissioner shall examine the insurer as soon as reasonably possible.
601.43(2)(c) (c) Specific requirements. The commissioner shall examine insurers as otherwise required by law.
601.43(3) (3) Audits or actuarial or other evaluations. In lieu of all or part of an examination under subs. (1) and (2), or in addition to it, the commissioner may order an independent audit by certified public accountants or an actuarial or other evaluation by actuaries or other experts approved by the commissioner of any person subject to the examination requirement. Any accountant, actuary or other expert selected is subject to rules respecting conflicts of interest promulgated by the commissioner. Any audit or evaluation under this section is subject to s. 601.44, so far as appropriate.
601.43(4) (4) Alternatives to examination. In lieu of all or part of an examination under this section, the commissioner may accept the report of an audit already made by certified public accountants or of an actuarial or other evaluation already made by actuaries or other experts approved by the commissioner, or the report of an examination made by the insurance department of another state or of the examination by another government agency in this state, the federal government or another state.
601.43(5) (5) Purpose and scope of examination. An examination may but need not cover comprehensively all aspects of the examinee's affairs and condition. The commissioner shall determine the exact nature and scope of each examination, and in doing so shall take into account all relevant factors, including but not limited to the length of time the examinee has been doing business, the length of time the examinee has been licensed in this state, the nature of the business being examined, the nature of the accounting records available and the nature of examinations performed elsewhere. The examination of an alien insurer shall be limited to insurance transactions and assets in the United States unless the commissioner orders otherwise after finding that extraordinary circumstances necessitate a broader examination.
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2017-18 Wisconsin Statutes updated through 2019 Wis. Act 50 and through all Supreme Court and Controlled Substances Board Orders filed before and in effect on December 6, 2019. Published and certified under s. 35.18. Changes effective after December 6, 2019, are designated by NOTES. (Published 12-6-19)