Chapter Ins 9

Ins 9.05(6) (6) Quality assurance. A summary of comprehensive quality assurance standards that identify, evaluate and remedy problems related to access to care and continuity and quality of care. The summary shall address all of the following:

Ins 9.05(6)(a) (a) A written internal quality assurance program.

Ins 9.05(6)(b) (b) Written guidelines for quality of care studies and monitoring.

Ins 9.05(6)(c) (c) Performance and clinical outcomes–based criteria.

Ins 9.05(6)(d) (d) Procedures for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

Ins 9.05(6)(e) (e) Plans for gathering and assessing data.

Ins 9.05(6)(f) (f) A peer review process.

Ins 9.05(6)(g) (g) A process to inform enrollees on the results of the insurer’s quality assurance program.

Ins 9.05(6)(h) (h) Any additional information requested by the commissioner.

Ins 9.05(7) (7) Plan administration. A summary of how administrative services will be provided, including the size and qualifications of the administrative staff and the projected cost of administration in relation to premium income. If management authority for a major corporate function is delegated to a person outside the organization, the business plan shall include a copy of the contract. Contracts for delegated management authority shall be filed for approval with the commissioner under ss. 611.67 and 618.22, Stats. The contract shall include all of the following:

Ins 9.05(7)(a) (a) The services to be provided.

Ins 9.05(7)(b) (b) The standards of performance for the manager.

Ins 9.05(7)(c) (c) The method of payment including, any provisions for the administrator to participate in the profit or losses of the plan.

Ins 9.05(7)(d) (d) The duration of the contract.

Ins 9.05(7)(e) (e) Any provisions for modifying, terminating or renewing the contract.

Ins 9.05(8) (8) Financial projections. A summary of: current and projected enrollment; income from premiums by type of payor; other income; administrative and other costs; the projected break even point, including the method of funding the accumulated losses until the break even point is reached; and a summary of the assumptions made in developing projected operating results.

Ins 9.05(9) (9) Financial guarantees. A summary of all financial guarantees by providers, sponsors, affiliates or parents within a holding company system, or any other guarantees which are intended to ensure the financial success of the health maintenance organization insurer. These include hold harmless agreements by providers, insolvency insurance, reinsurance or other guarantees.

Ins 9.05(10) (10) Contracts with enrollees. A summary of benefits to be offered enrollees including any limitations and exclusions and the renewability of all contracts to be written.

Ins 9.05 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.06 Ins 9.06 Changes in the business plan.

Ins 9.06(1) (1) A health maintenance organization insurer or an insurer licensed to write only limited service health organization business shall file a written report of any proposed substantial change in its business plan. The insurer shall file the report at least 30 days prior to the effective date of the change. The office may disapprove the change. The insurer may not enter into any transaction, contract, amendment to a transaction or contract or take action or make any omission that is a substantial change in the insurer’s business plan prior to the effective date of the change or if the change is disapproved. Substantial changes include changes in articles and bylaws, organization type, geographical service areas, provider agreements, provider availability, plan administration, financial projections and guarantees and any other change that might affect the financial solvency of the plan. Any changes in the items listed in s. Ins 9.05 (4) shall be filed under this section.

Ins 9.06(2) (2) A change in the quality assurance plan conducted in accordance with s. Ins 9.40 and s. 609.32, Stats., is not a reportable change in a business plan.

Ins 9.06 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.07 Ins 9.07 Copies of provider agreements.

Ins 9.07(1) (1) Notwithstanding any claim of trade secret or proprietary information, all insurers offering a defined network plan, preferred provider plan or limited service health organization shall, upon request, from the commissioner, make available to the commissioner all executed copies of any provider agreements between the insurer and intermediate entities or individual providers. Any party to a provider agreement may assert that a portion of the contracts contain trade secrets, and the commissioner may withhold that portion to the extent it may be withheld under s. Ins 6.13.

Ins 9.07(2) (2) All health maintenance organization insurers or insurers licensed to write only limited service health organization business shall file with the commissioner, prior to doing business, copies of all executed provider agreements and other contracts covering liabilities of the health maintenance organization. For contracts with providers, a list of providers executing a standard contract and a copy of the form of the contract may be filed instead of copies of the executed contracts.

Ins 9.07 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (1) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (1) Register December 2006 No. 612, eff. 1-1-07.

Ins 9.08 Ins 9.08 Other reporting requirements.

Ins 9.08(1) (1) Annual statement. All insurers authorized to write health maintenance organization business and insurers licensed to write only limited service health organization business shall file with the commissioner by March 1 of each year an annual statement for the preceding year. A health maintenance organization insurer and limited service health organization insurer shall use the current health annual statement blank prepared by the national association of insurance commissioners.

Ins 9.08(1)(a) (a) A health maintenance organization insurer shall include with its annual statement a statement of covered expenses, and a special procedures opinion from a certified public accountant, in the form prescribed by the commissioner as appendix A.

Ins 9.08(1)(b) (b) A health maintenance organization insurer shall file a quarterly report, including a report concerning covered expenses, in a form prescribed by the commissioner within 45 days after the close of each of the first 3 calendar quarters of the year unless the commissioner has notified the insurer that another reporting schedule is appropriate.

Ins 9.08(1)(c) (c) A health maintenance organization insurer shall include with its annual audit financial reports filed under s. Ins 50.05 a statement of covered expenses and an audit opinion concerning the statement. Both the statement and opinion shall be in the form prescribed by the commissioner as appendix B and are due no later than May 1 of each year.

Ins 9.08(1m) (1m) Medicare and Medicaid Health Maintenance Organizations. A health maintenance organization insurer that writes 100 % of its business to Medicare or Medicaid recipients, or a combination of the 2, is not required to include a special procedures opinion from a certified public accountant as required by sub. (1) (a) or an audit opinion concerning the statement of covered expenses as required by sub. (1) (c).

Ins 9.08(2) (2) Quarterly report. An insurer writing health maintenance organization business, other than a health maintenance organization insurer, shall file a quarterly report in a form prescribed by the commissioner within 45 days after the close of each of the first 3 calendar quarters of the year unless the commissioner notifies the insurer that another reporting schedule is appropriate.

Ins 9.08(3) (3) Presumptions.

Ins 9.08(3)(a) (a) If a health maintenance organization insurer fails to file a statement or opinion required under subs. (1) to (3) by the time required, it is presumed, in any action brought by the office within one year of the due date, that the health maintenance organization insurer is in financially hazardous condition and that the percentage of its liabilities for health care costs which are covered liabilities is and continues to be less than 65% for the purpose of s. 609.95, Stats.

Ins 9.08(3)(b) (b) It is presumed that the percentage of liabilities that are covered liabilities of a health maintenance organization insurer is and continues to be not greater than the percentage of covered expenses stated in the report or statement filed under subs. (1) to (3) for the most recent period.

Ins 9.08(3)(c) (c) The health maintenance organization insurer has the burden of refuting a presumption under par. (a) or (b).

Ins 9.08 Note Note: The form described in sub. (1) may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison, WI 53707-7873.

Ins 9.08 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 22-070: am. (1) (intro.), cr. (1m), r. (4) Register June 2023 No. 810, eff. 7-1-23; correction in (1m) made under s. 35.17, Stats., Register June 2023 No. 810.

Ins 9.09 Ins 9.09 Notice of election and termination of hold harmless.

Ins 9.09(1) (1) A notice of election to be exempt from s. 609.91 (1) (b), Stats., or a notice of termination of election to be subject to s. 609.91 (1) (c), Stats., in accord with s. 609.925 (1), Stats., is effective only if filed on the form prescribed by the commissioner and if the form is properly completed.

Ins 9.09(2) (2) A notice of termination of election to be exempt from s. 609.91 (1) (b), Stats., in accord with s. 609.92 (4), Stats., or a notice of termination of election to be subject to s. 609.91 (1) (c), Stats., in accord with s. 609.925 (2), Stats., shall be filed on the form prescribed by the commissioner. Notices described in this subsection that are filed with the commissioner but are not on the prescribed form or are not properly completed are nevertheless effective.

Ins 9.09(3) (3) In accordance with s. 609.93, Stats., a provider may not exercise an election under s. 609.92 or 609.925, Stats., separately from a clinic or 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 or provided through the clinic.

Ins 9.09 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.10 Ins 9.10 Receivables from affiliates. A receivable, note or other obligation of an affiliate to a health maintenance organization insurer and limited service health organization insurer shall be valued at zero by the insurer for all purposes including, but not limited to, the purpose of reports or statements filed with the office, unless the commissioner specifically approves a different value. The different value shall be not more than the amount of the receivable, note or other obligation which is fully secured by a security interest in cash or cash equivalents held in a segregated account or trust.

Ins 9.10 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.11 Ins 9.11 Receivables from Individual Practice Association (“IPA”). After December 31, 1990, a health maintenance organization insurer shall value receivables, notes or obligations of individual practice associations as defined under s. 600.03 (23g), Stats., at zero for all purposes including, but not limited to, the purpose of reports or statements filed with the office, unless the receivable, note or obligation is fully secured by a security interest in cash or cash equivalents held in a segregated account or trust.

Ins 9.11 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.12 Ins 9.12 Incidental or immaterial indemnity business in health maintenance organizations.

Ins 9.12(1) (1) Except as provided by sub. (2), insurance business is not incidental or immaterial under s. 609.03 (3) (a) 3., Stats., if a health maintenance organization insurer issues coverage which is not typically included in a health maintenance organization or limited service health organization policy and the insurer does any of the following:

Ins 9.12(1)(a) (a) Markets the policy containing the coverage.

Ins 9.12(1)(b) (b) The total premium for policies containing the coverage exceeds or is projected to exceed 5% of total premium earned in any 12–month period.

Ins 9.12(2) (2) Insurance business is incidental or immaterial under s. 609.03 (3) (a) 3., Stats., if the business is written according to the terms of a specific business plan for issuance of coverage under s. 609.03 (3) (a) 3., Stats., and the business plan is approved in writing by the office. A request for approval to do business under this paragraph including, but not limited to, issuance of policies with point of service coverage, shall include a detailed business plan, a copy of the policy form, a detailed description of how the business will be marketed and premium volume controlled, and other information prescribed by the office. The total premium for policies containing coverages subject to this paragraph and policies issued under sub. (1) may not exceed 10% of premium earned or projected to be earned in any 12–month period.

Ins 9.12(3) (3) If the commissioner approves insurance business as incidental or immaterial the commissioner may also, by order under s. Ins 9.04 (2), require the insurer to maintain more than the minimum compulsory surplus.

Ins 9.12(4) (4) For the purpose of this section, any coverage that covers services by a provider other than a participating provider is not typically included in a health maintenance organization or limited service health organization policy, except coverage of emergency out–of–area services.

Ins 9.12 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.13 Ins 9.13 Summary. A health maintenance organization insurer shall use the form prescribed in appendix C to comply with s. 609.94, Stats.

Ins 9.13 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.14 Ins 9.14 Nondomestic HMO. No certificate of authority may be issued under ch. 618, Stats., to a person to do health maintenance organization or limited service health organization business in this state unless the person is organized and regulated as an insurer and domiciled in the United States.

Ins 9.14 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.15 Ins 9.15 Time period. In accordance with s. 227.116, Stats., the commissioner shall review and make a determination on an application for a certificate of authority within 60 business days after it has been received.

Ins 9.15 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

subch. III of ch. Ins 9 Subchapter III — Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations

Ins 9.20 Ins 9.20 Scope. This subchapter applies to all insurers offering a defined network plan, preferred provider plan or limited service health organization in this state. The insurer shall ensure that the requirements of this subchapter are met by all defined network plans, preferred provider plans or limited service health organizations issued by the insurer. The commissioner may approve an exemption to this subchapter for an insurer to market a defined network plan, preferred provider plan or limited service health organization if the insurer files the plan with the commissioner and the commissioner determines that all of the following conditions are met:

Ins 9.20(1) (1) The coverage involves ancillary coverage with minimal cost controls, such as minimal cost controls involving vision, prescription cards or transplant centers.

Ins 9.20(2) (2) The cost controls are unlikely to significantly affect the pattern of practice.

Ins 9.20(3) (3) The exemption is consistent with the purpose of this subchapter.

Ins 9.20 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: renum. from Ins 9.31 and am. (intro.) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (intro.) Register December 2006 No. 612, eff. 1-1-07.

Ins 9.21 Ins 9.21 Limited exemptions.

Ins 9.21(1) (1) Silent discount. An insurer, with respect to a defined network plan:

Ins 9.21(1)(a) (a) Is exempt from meeting the requirements under ss. 609.22, 609.24, 609.32, 609.34, 609.36 and 632.83, Stats., and ss. Ins 9.31, 9.32 (1), 9.35, 9.37, 9.38, 9.39, 9.40 (1) to (7), 9.42 (1) to (7), if the only owned, employed, or participating provider providing services covered under the plan is a silent provider network.

Ins 9.21(1)(b) (b) Is exempt from meeting the requirements under ss. 609.22, 609.24, 609.32, 609.34, and 609.36, Stats., and ss. Ins 9.32 (1), 9.35, 9.37, 9.38, 9.39, 9.40 (1) to (7), and 9.42 (1) to (7), solely with respect to services provided by the silent provider network, if the plan also covers services by providers that the insurer owns or employs, or another participating provider. An insurer is not exempt from those provisions with respect to a provider that is not a silent provider network.

Ins 9.21(2) (2) De minimus limited exception. Insurers offering a defined network plan are exempt from meeting the requirements under ss. 609.22 (1) to (4) and (8), 609.32 and 609.34, Stats., ss. Ins 9.32 (1), 9.40 (1) to (7), and 9.42 (6) and (7), with respect to a defined network plan, if the insurer meets all of the following requirements.

Ins 9.21(2)(a) (a) The insurer offering a defined network plan provides comprehensive benefits to insureds of at least 80% coverage for in-plan providers.

Ins 9.21(2)(b) (b) The insurer’s only financial incentive to the insureds to utilize participating providers is a co-insurance differential of not more than 10% between in-plan versus off-plan providers. Except for the co-insurance differential of no greater than 10%, all benefits, deductibles and co-payments must be the same regardless of whether the insured obtains benefits, services or supplies from in-plan or off-plan providers.

Ins 9.21(2)(c) (c) The insurer makes no representation regarding quality of care.

Ins 9.21(2)(d) (d) The insurer makes no representation that the defined network plan is a preferred provider plan or that the defined network plan directs or is responsible for the quality of health care services. Nothing in this paragraph prevents an insurer from describing the availability or limits on availability of participating providers or the extent or limits of coverage under the defined network plan if participating or non-participating providers are utilized by an insured.

Ins 9.21(2)(e) (e) The insurer, at the time an application is solicited, does all of the following.

Ins 9.21(2)(e)1. 1. Discloses to a potential applicant, and allows the applicant a reasonable opportunity to review, a directory which reasonably and clearly discloses the availability and location of providers:

Ins 9.21(2)(e)1.a. a. Within reasonable travel distance from the principle location of the place of employment of employees likely to enroll under the plan, if the applicant is an employer; or

Ins 9.21(2)(e)1.b. b. Within reasonable travel distance from the residence of the proposed insured, for any other application.

Ins 9.21(2)(e)2. 2. Obtains on the application, or on an addendum to the application, the applicant’s signed acknowledgement that the applicant:

Ins 9.21(2)(e)2.a. a. Has reviewed the disclosure under subd. 1.;

Ins 9.21(2)(e)2.b. b. Understands that participating providers may or may not be available to provide services and that the insurer is not required to make participating providers available; and

Ins 9.21(2)(e)2.c. c. Understands that the plan will provide reduced benefits if the insured uses a non-participating provider.

Ins 9.21(2)(e)3. 3. Provides to each applicant a copy of the provider directory at the time the policy is issued.

Ins 9.21(2)(e)4. 4. The insurer provides access to translation services for the purpose of providing information concerning benefits, to the greatest extent possible, if a significant number of enrollees of the plan customarily use languages other than English.

Ins 9.21 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; correction in (1) (a) made under s. 13.93 (2m) (b) 7., Stats., Register November 2001 No. 551; CR 05-059: renum. from Ins 9.32 and am. (1) (a) and (b), (2) (a) and (d) Register February 2006 No. 602, eff. 3-1-06.