A method by which an applicant to the Plan denied insurance or an insured under the Plan whose insurance is terminated may request the committee to review the denial or termination and by which an insurer subscribing to the Plan may request the committee to review actions or decisions of the Plan which adversely affect the insurer. The method shall specify that requests for review must be made in writing to the Plan and that the decision of the committee in regard to the review may be appealed by the applicant, insured or insurer to the commissioner of insurance as provided for in ch. Ins 5
. A request for review does stay the termination of coverage.
The committee's decision under subd. 1.
shall be in writing and shall include notice of the right to a hearing under ch. Ins 5
if the person files a petition for a hearing with the commissioner of insurance not later than 30 days after the notice is mailed. The notice shall describe the requirements of s. Ins 5.11 (1)
Ins 3.49 Note
A petition under subd. 2. shall be filed as provided in s. Ins 5.17
The office of the commissioner of insurance shall hold a hearing within 30 days after receipt of a complete petition under subd. 2.
, unless the petitioner waives the right to a hearing within 30 days. At the hearing, the petitioner has the burden of proving by a preponderance of the evidence that the committee's decision is erroneous under the policy terms or the plan's rules.
Filing a petition under subd. 2.
does not stay the action of the plan with respect to termination of coverage. The plan shall comply with the final decision and order in the contested case proceeding.
The commissioner shall maintain files of the Plan's approved rules, rates, and forms and such documents must be made available for public inspection at the office of the commissioner of insurance.
Ins 3.49 History
Cr. Register, November, 1984, No. 347
, eff. 12-1-84; renum. (3) (d) to be (3) (d) 1. and am., cr. (3) (d) 2. to 4., Register, March, 1996, No. 483
, eff. 4-1-96.
Reports by individual practice associations. Ins 3.51(1)(1)
For the purpose of this section only:
“Accountant" means an independent certified public accountant who is duly registered to practice and in good standing under the laws of this state or a state with similar licensing requirements.
“Individual practice association" means an individual practice association as defined under s. 600.03 (23g)
, Stats., which contracts with a health maintenance organization insurer or a limited service health organization to provide health care services which are principally physician services.
“Work papers" are the records kept by the accountant of the procedures followed, the tests performed, the information obtained, and conclusions reached pertinent to the examination of the financial statements of the independent practice association. Work papers include, but are not limited to, work programs, analysis, memorandum, letters of confirmation and representation, management letters, abstracts of company documents and schedules or commentaries prepared or obtained by the accountant in the course of the examination of the financial statements of the independent practice association and which support the accountant's opinion.
(2) Filing of annual audited financial reports.
Unless otherwise ordered by the commissioner, an individual practice association shall file an annual audited financial report with the commissioner within 180 days after the end of each individual practice association's fiscal year. This section applies to individual practice associations for fiscal years terminating on or after March 31, 1991. The annual audited financial report shall report the assets, liabilities and net worth; the results of operations; and the changes in net worth for the fiscal year then ended on the accrual basis in conformity with generally accepted accounting practices. The annual audited financial report shall not be presented on the cash basis or the income tax basis or any other basis that does not fully account for all the independent practice association's liabilities incurred as of the end of the fiscal year. The annual audited financial report shall include all of the following:
Notes to the financial statements. These notes shall include those needed for fair presentation and disclosure.
Supplemental data and information which the commissioner may from time to time require to be disclosed.
(3) Scope of audit and report of independent certified public accountant.
Financial statements filed under sub. (2)
shall be audited by an independent certified public accountant. The audit shall be conducted in accordance with generally accepted auditing standards. The commissioner may from time to time require that additional auditing procedures be observed by the accountant in the audit of the financial statements of the independent practice association under this rule.
(4) Availability and maintenance of cpa work papers. Ins 3.51(4)(a)(a)
An independent practice association required to file an audited financial report under this rule shall, if requested by the office, require the accountant to make available to the office all the work papers prepared in the conduct of the audit. The independent practice association shall require that the accountant retain the audit work papers for a period of not less than 5 years after the period reported.
The office may photocopy pertinent audit work papers. These copies are part of the office's work papers. Audit work papers are confidential unless the commissioner determines disclosure is necessary to carry out the functions of the office.
A health maintenance organization insurer contracting with an independent practice association shall include provisions in the contract which are necessary to enable the individual practice association to comply with this section including, but not limited to:
Provisions providing for maintenance of necessary records and systems and segregation of records, accounts and assets; and
Other provisions necessary to ensure that the individual practice association operates as an entity distinct from the insurer.
Ins 3.51 History
Cr. Register, August, 1990, No. 416
, eff. 9-1-90.
The tests listed in sub. (4) (e)
have been specified by the state epidemiologist in part B (4) of a report entitled “Validated positive, medically significant and sufficiently reliable tests to detect the presence of human immunodeficiency virus (HIV), antigen or nonantigenic products of HIV or an antibody to HIV," dated January 24, 1997. The commissioner of insurance, therefore, finds that these tests are sufficiently reliable for use in underwriting individual life, accident and health insurance policies.
The purposes of this section are:
To establish procedures for insurers to use in obtaining informed consent for HIV testing and informing individuals of the results of a positive HIV test.
To restrict the use of certain information on HIV testing in underwriting group life, accident and health insurance policies.
“AIDS service organization" means a state designated organization in this state that provides AIDS prevention and education services to the general public and offers direct care and support services to persons with HIV and AIDS at no cost.
“Medical information bureau, inc." means the nonprofit Delaware incorporated trade association, the members of which are life insurance companies, that operates an information exchange on behalf of its members.
“Wisconsin AIDSline" means the state designated statewide AIDS information and medical referral service.
For use in underwriting an individual life, accident or health insurance policy, an insurer may require that the person to be insured be tested, at the insurer's expense, for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV.
An insurer that requires a test under par. (a)
shall, prior to testing, obtain a signed consent form, in substantially the format specified in Appendix A, either from the person to be tested or from one of the following if the specified condition exists:
The person's parent or guardian, if the person is under 14 years of age.
The person's guardian, if the person is adjudged incompetent under ch. 54
The insurer shall provide a copy of the consent form to the person who signed it and shall maintain a copy of each consent form for at least one year.
The insurer shall provide with the consent form a copy of the document, “Resources for persons with a positive HIV test/The implications of testing positive for HIV." Each insurer shall either obtain copies of the document from the office of the commissioner of insurance or reproduce the document itself. If the document is revised, the insurer shall begin using the revised version no later than 30 days after receiving notice of the revision from the office of the commissioner of insurance.
Ins 3.53 Note
The document referred to in this paragraph is form number OCI 17-001. It may be obtained from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison, Wisconsin 53707-7873.
Tests may be used under par. (a)
only if the tests meet the following criteria:
A single specimen which is repeatedly reactive using any food and drug administration “FDA" licensed enzyme immunoassay “EIA" HIV antibody test and confirmed positive using an FDA licensed HIV antibody confirmatory test.
A single specimen which is repeatedly reactive using any FDA licensed HIV antigen test and an FDA licensed EIA HIV antibody test. A specimen which is repeatedly reactive to an FDA licensed HIV antigen test shall be confirmed through a neutralization assay. A specimen which is repeatedly reactive to an FDA licensed EIA HIV antibody test shall be tested with an FDA licensed HIV antibody confirmatory test.
A single specimen which is tested for the presence of HIV using a molecular amplification method for the detection of HIV nucleic acids consistent with national committee for clinical laboratory standards.
A single specimen which is tested for the presence of HIV using viral culture methods.
A test under par. (e)
shall be performed by a laboratory which meets the requirements of the federal health care financing administration under the clinical laboratory improvement amendments act of 1988.
An insurer that uses an application asking whether the person to be insured has been tested for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV may ask only whether the person has been tested using one or more of the tests specified in par. (e)
Notwithstanding subd. 1.
, the insurer may not require or request the disclosure of any information as to whether the person to be insured has been tested at an anonymous counseling and testing site designated by the state epidemiologist or at a similar facility in another jurisdiction or through the use of an anonymous home test kit, or to reveal the results of such a test.
(5) Positive test result; insurer's obligation. Ins 3.53(5)(a)(a)
If a test under sub. (4) (e)
is positive and, in the normal course of underwriting, affects the issuance or terms of the policy, the insurer shall provide written notice to the person who signed the consent form that the person tested does not meet the insurer's usual underwriting criteria because of a test result. The insurer shall request that the person provide informed consent for disclosure of the test result to a health care provider with whom the person wants to discuss the test result.
If informed consent for disclosure is obtained, the insurer shall provide the designated health care provider with the test result. If the person refuses to give informed consent for disclosure, the insurer shall, upon the person's request, provide the person who signed the consent form with the test result. The insurer shall include with the report of the test result all of the following:
A statement that the person should contact a private health care provider, a public health clinic, an AIDS service organization or the Wisconsin AIDSline for additional medical evaluation or referral for such services.
(6) Confidentiality of test results.
An insurer that requires a person to be tested under sub. (4) (a)
may disclose the test result only as described in the consent form obtained under sub. (4) (b)
or with written consent for disclosure signed by the person tested or a person specified in sub. (4) (b) 1.
(7) Group policies; additional prohibition.
In underwriting group life, accident or health insurance on an individual basis, in addition to the restrictions specified in s. 631.90 (2)
, Stats., an insurer may not use or obtain from any source, including the medical information bureau, inc., any of the following:
The results of a person's test for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV.
Any other information on whether the person has been tested for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV.
Ins 3.53 History
Cr. Register, May, 1987, No. 377
, eff. 6-1-87; r. and recr. Register, April, 1991, No. 424
, eff. 5-1-91; am. (1), (3) (b) and (5) (b) 1., r. (3) (c), (d) and (4) (f), renum. (3) (e) to (i) and (4) (g) and (h) to be (3) (c) to (g) and (4) (f) and (g) and am. (3) (f) and (g), (4) (f) and (g), r. and recr. (4) (e), Register, May, 1998, No. 509
, eff. 6-1-98; correction in (4) (b) 2. made under s. 13.92 (4) (b) 7.
, Stats., Register October 2008 No. 634
Ins 3.53 APPENDIX A
[Insurer name and address]
WISCONSIN NOTICE AND CONSENT FOR HUMAN IMMUNODEFICIENCY TESTING
REQUEST FOR CONSENT FOR TESTING
To evaluate your insurability, ( insurer name ) (Insurer) requests that you be tested to determine the presence of human immunodeficiency virus (HIV) antibody or antigens. By signing and dating this form, you agree that this test may be done and that underwriting decisions may be based on the test results. A licensed laboratory will perform one or more tests approved by the Wisconsin Commissioner of Insurance.
Many public health organizations recommend that, if you have any reason to believe you may have been exposed to HIV, you become informed about the implications of the test before being tested. You may obtain information about HIV and counseling from a private health care provider, a public health clinic, or one of the AIDS service organizations on the attached list. You may also wish to obtain an HIV test from an anonymous counseling and testing site before signing this consent form. The Insurer is prohibited from asking you whether you have been tested at an anonymous counseling and testing site and from obtaining the results of such a test. For further information on these options, contact the Wisconsin AIDSline at 1-800-334-2437.
MEANING OF POSITIVE TEST RESULTS
This is not a test for AIDS. It is a test for HIV and shows whether you have been infected by the virus. A positive test result may have an effect on your ability to obtain insurance. A positive test result does not mean that you have AIDS, but it does mean that you are at a seriously increased risk of developing problems with your immune system. HIV tests are very sensitive and specific. Errors are rare but they can occur. If your test result is positive, you may wish to consider further independent testing from your physician, a public health clinic, or an anonymous counseling and testing site.
HIV testing may be arranged by calling the Wisconsin AIDSline at 1-800-334-2437.
NOTIFICATION OF TEST RESULTS
If your HIV test result is negative, no routine notification will be sent to you. If your HIV test result is other than normal, the Insurer will contact you and ask for the name of a physician or other health care provider to whom you may authorize disclosure and with whom you may wish to discuss the test results.
DISCLOSURE OF TEST RESULTS
All test results will be treated confidentially. The laboratory that does the testing will report the result to the Insurer. If necessary to process your application, the Insurer may disclose your test result to another entity such as a contractor, affiliate, or reinsurer. If your HIV test is positive, the Insurer may report it to the Medical Information Bureau (MIB, Inc.), as described in the notice given to you at the time of application. If your HIV test is negative, no report about it will be made to the MIB, Inc. The organizations described in this paragraph may maintain the test results in a file or data bank. These organizations may not disclose the fact that the test has been done or the result of the test except as permitted by law or authorized in writing by you.
I have read and I understand this notice and consent for HIV testing. I voluntarily consent to this testing and the disclosure of the test result as described above. A photocopy or facsimile of this form will be as valid as the original.