Chapter Ins 9

Ins 9.38(2)(c) (c) Restrictions on changing providers during the contract period.

Ins 9.38(2)(d) (d) Out–of–pocket costs including copayments and deductibles.

Ins 9.38(2)(e) (e) Any restrictions on coverage for dependents who do not reside in the service area.

Ins 9.38(3) (3) Disclosure of mandated benefits. Clear disclosure of all benefit mandates outlined in Wisconsin statutes.

Ins 9.38(4) (4) Disclosure of procedures and emergency care notification. Insurers offering a defined network plan shall do all of the following in a manner consistent with s. 609.22, Stats.:

Ins 9.38(4)(a) (a) Provide a description of the procedure for an enrollee to obtain any required referral, including the right to a standing referral, and notice that any enrollee may request the criteria for the standing referral.

Ins 9.38(4)(b) (b) Provide a description of the procedure for any enrollee to obtain a second opinion from a participating plan provider consistent with s. 609.22 (5), Stats.

Ins 9.38(4)(c) (c) Consistent with s. 609.22 (6), Stats., and s. Ins 9.32 (1) (d), an insurer offering a defined network plan may require enrollees to notify the insurer of emergency room usage, but in no case may the insurer offering a defined network plan require notification less than 48 hours after receiving services or before it is medically feasible for the enrollee to provide the notice, whichever is later. An insurer offering a defined network plan may impose no greater penalty than assessing a deductible that may not exceed the lesser of 50% of covered expenses for emergency treatment or $250.00 for failing to comply with emergency treatment notification requirements.

Ins 9.38 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (intro.), (4) (intro.) and (c) Register February 2006 No. 602, eff. 3-1-06.

Ins 9.39 Ins 9.39 Disenrollment.

Ins 9.39(1) (1) Disclosure. The health maintenance organization or limited service health organization shall clearly disclose in the policy and certificate any circumstances under which the health maintenance organization or limited service health organization may disenroll an enrollee.

Ins 9.39(2) (2) Enrollee disenrollment criteria. Except as provided in s. 632.897, Stats., the health maintenance organization or limited service health organization may only disenroll an enrollee if one of the following occurs:

Ins 9.39(2)(a) (a) The enrollee has failed to pay required premiums by the end of the grace period.

Ins 9.39(2)(b) (b) The enrollee has committed acts of physical or verbal abuse that pose a threat to providers or other members of the organization.

Ins 9.39(2)(c) (c) The enrollee has allowed a nonmember to use the health maintenance or limited service health organization’s certification card to obtain services or has knowingly provided fraudulent information in applying for coverage.

Ins 9.39(2)(d) (d) The enrollee has moved outside of the geographical service area of the organization.

Ins 9.39(2)(e) (e) The enrollee is unable to establish or maintain a satisfactory physician–patient relationship with the physician responsible for the enrollee’s care. Disenrollment of an enrollee under this paragraph shall be permitted only if the health maintenance organization or limited service health organization can demonstrate that it did all of the following:

Ins 9.39(2)(e)1. 1. Provided the enrollee with the opportunity to select an alternate primary care physician.

Ins 9.39(2)(e)2. 2. Made a reasonable effort to assist the enrollee in establishing a satisfactory patient–physician relationship.

Ins 9.39(2)(e)3. 3. Informed the enrollee that he or she may file a grievance on this matter.

Ins 9.39(3) (3) Prohibited disenrollment criteria. Notwithstanding sub. (2), the health maintenance organization or limited service health organization plan may not disenroll an enrollee for reasons related to any of the following:

Ins 9.39(3)(a) (a) The physical or mental condition of the enrollee.

Ins 9.39(3)(b) (b) The failure of the enrollee to follow a prescribed course of treatment.

Ins 9.39(3)(c) (c) The failure of an enrollee to keep appointments or to follow other administrative procedures or requirements.

Ins 9.39(4) (4) Alternative coverage for disenrolled enrollees. An insurer offering a health maintenance organization plan or limited service health organization plan that has disenrolled an enrollee for any reason except failure to pay required premiums shall make arrangements to provide similar alternate insurance coverage to the enrollee. In the case of group certificate holders, the insurance coverage shall be continued until the affected enrollee finds his or her own coverage or until the next opportunity to change insurers, whichever comes first. In the case of an enrollee covered on an individual basis, coverage shall be continued until the anniversary date of the policy or for one year, whichever is earlier.

Ins 9.39 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (4) Register February 2006 No. 602, eff. 3-1-06.

Ins 9.40 Ins 9.40 Required quality assurance and remedial action plans.

Ins 9.40(1) (1) In this section “quality assurance” means the measurement and evaluation of the quality and outcomes of medical care provided.

Ins 9.40(2) (2) 

Ins 9.40(2)(a) (a) By April 1, 2000, an insurer, with respect to a defined network plan that is not a preferred provider plan shall submit a quality assurance plan consistent with the requirements of s. 609.32, Stats., to the commissioner, except as provided in par. (b). The insurers shall submit a quality assurance plan that is consistent with the requirements of s. 609.32, Stats., by April 1 of each subsequent year. The quality assurance plan shall be designed to reasonably assure that health care services provided to enrollees of the defined network plan meet the quality of care standards consistent with prevailing standards of medical practice in the community. The quality assurance plan shall document the procedures used to train employees of the defined network plan in the content of the quality assurance plan.

Ins 9.40(2)(b) (b) Insurers offering a defined network plan that is not also a preferred provider plan or health maintenance organization plan shall submit a quality assurance plan consistent with the requirements of par. (a) and s. 609.32, Stats., to the commissioner by April 1, 2007, and April 1 of each subsequent year.

Ins 9.40(3) (3) Insurers offering a preferred provider plan shall develop procedures for taking effective and timely remedial action to address issues arising from quality problems including access to, and continuity of care from, participating primary care providers. The remedial action plan shall at least contain all of the following:

Ins 9.40(3)(a) (a) Designation of a senior-level staff person responsible for the oversight of the insurer’s remedial action plan.

Ins 9.40(3)(b) (b) A written plan for the oversight of any functions delegated to other contracted entities.

Ins 9.40(3)(c) (c) A procedure for the periodic review of services related to clinical protocols and utilization management performed by the insurer offering a preferred provider plan or by another contracted entity.

Ins 9.40(3)(d) (d) Periodic and regular review of grievances, complaints and OCI complaints.

Ins 9.40(3)(e) (e) A written plan for maintaining the confidentiality of protected information.

Ins 9.40(3)(f) (f) Documentation of timely correction of access to and continuity of care issues identified in the plan. Documentation shall include all of the following:

Ins 9.40(3)(f)1. 1. The date of awareness that an issue exists for which a remedial action plan shall be initiated.

Ins 9.40(3)(f)2. 2. The type of issue that is the focus of the remedial action plan.

Ins 9.40(3)(f)3. 3. The person or persons responsible for developing and managing the remedial action plan.

Ins 9.40(3)(f)4. 4. The remedial action plan utilized in each situation.

Ins 9.40(3)(f)5. 5. The outcome of the remedial action plan.

Ins 9.40(3)(f)6. 6. The established time frame for re-evaluation of the issue to ensure resolution and compliance with the remedial action plan.

Ins 9.40(4) (4) All insurers offering a defined network plan, other than a preferred provider plan, shall establish and maintain a quality assurance committee and a written policy governing the activities of the quality assurance committee that assigns to the committee responsibility and authority for the quality assurance program. All complaints, OCI complaints, appeals and grievances relating to quality of care shall be reviewed by the quality assurance committee.

Ins 9.40(7) (7) No later than April 1, 2001, with respect to an insurer offering a defined network plan that is a health maintenance organization plan, and by April 1, 2008, for insurers offering a defined network plan that is not also a preferred provider plan or health maintenance organization plan, shall do all of the following:

Ins 9.40(7)(a) (a) Include a summary of its quality assurance plan in its marketing materials.

Ins 9.40(7)(b) (b) Include a brief summary of its quality assurance plan and a statement of patient rights and responsibilities with respect to the plan in its certificate of coverage or enrollment materials.

Ins 9.40(8) (8) Beginning April 1, 2000, an insurer offering any defined network plan shall submit an annual certification for each plan with the commissioner no later than April 1 of each year. The certification shall assert the type of plan and be signed by an officer of the company. OCI shall maintain for public review a current list of health benefit plans, categorized by type.

Ins 9.40 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (2), (3), (4), (6), (7) and (8), r. (1) (c) Register February 2006 No. 602, eff. 3-1-06; reprinted to restore dropped copy in (3), Register September 2006 No. 609; CR 17-015: consol. (1) (intro.), (b) and renum. and am., r. (1) (a), (5), (6) Register December 2017 No. 744, eff. 1-1-18.

Ins 9.41 Ins 9.41 Right of the commissioner to request OCI complaints be handled as grievances. An insurer offering a defined network plan, preferred provider plan or limited service health organization shall treat and process an OCI complaint as a grievance at the request of the commissioner. The commissioner will provide a written description of the OCI complaint to the insurer.

Ins 9.41 History History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. Register December 2006 No. 612, eff. 1-1-07.

Ins 9.42 Ins 9.42 Compliance program requirements.

Ins 9.42(1) (1) All insurers offering a defined network plan, preferred provider plan or limited service health organization except to the extent otherwise exempted under this chapter or by statute, are responsible for compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., applicable sections of this subchapter and other applicable sections including but not limited to s. Ins 9.07. Insurers offering a defined network plan, preferred provider plan or limited service health organization, to the extent they are required to comply with those provisions, shall establish a compliance program and procedures to verify compliance. Nothing in this section shall affect the availability of the privilege established under s. 146.38, Stats.

Ins 9.42(2) (2) The insurers shall establish and operate a compliance program that provides reasonable assurance that:

Ins 9.42(2)(a) (a) The insurer is in compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, 632.83, and 632.83, Stats., this subchapter and other applicable sections including but not limited to s. Ins 9.07.

Ins 9.42(2)(b) (b) Any violations of ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter or any applicable sections including but not limited to s. Ins 9.07 are detected and timely corrections are taken by the insurer.

Ins 9.42(3) (3) The insurer’s compliance program shall include regular internal audits, including regular audits of any contractors or subcontractors who perform functions relating to compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter or any applicable sections including but not limited to s. Ins 9.07.

Ins 9.42(4) (4) An insurer that materially relies upon another party to carry out functions under ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter or any applicable sections including but not limited to s. Ins 9.07, shall do all of the following:

Ins 9.42(4)(a) (a) Contractually require the other party to carry out those functions in compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter and other applicable sections including but not limited to s. Ins 9.07.

Ins 9.42(4)(b) (b) Enforce the contractual provisions required under par. (a).

Ins 9.42(4)(c) (c) Include in the insurer’s compliance program provisions to monitor, supervise and audit the performance of the other party in carrying out the functions.

Ins 9.42(4)(d) (d) Maintain management reports and records reasonably necessary to monitor, supervise and audit the other party’s performance.

Ins 9.42(4)(e) (e) Include and enforce contractual provisions requiring the other party to give the office access to documentation demonstrating compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter and other applicable sections including but not limited to s. Ins 9.07 within 15 days of receipt of notice.

Ins 9.42(4)(f) (f) Regularly audit compliance with contract provisions including audits of internal working papers and reports.

Ins 9.42(5) (5) The insurer shall maintain all of the following items in its records:

Ins 9.42(5)(a) (a) Any audits, and associated work papers of audits, conducted during the period of review relating to the business and service operation of the insurer offering a defined network plan, preferred provider plan or limited service health organization.

Ins 9.42(5)(b) (b) All provider directories and provider manuals for the period of review. The directory shall include, as an addendum, a list of all providers that disassociated with the insurer or provider network in the review period.

Ins 9.42(5)(c) (c) A sample copy of the provider agreement, including those with a provider network, for each provider category including hospital, physician, medical clinic, pharmacy, mental health services and chiropractor.

Ins 9.42(5)(d) (d) Copies of contracts for management services, data management and processing, marketing, administrative services and case management.

Ins 9.42(5)(e) (e) A sample copy of each certificate form for the period of review including a copy of sample enrollment forms.

Ins 9.42(6) (6) Except as permitted under sub. (7), an insurer shall maintain a complete record of the following:

Ins 9.42(6)(a) (a) An access plan developed in accordance with s. Ins 9.32 (1) and s. 609.22, Stats., requirements.

Ins 9.42(6)(b) (b) A quality assurance plan developed in accordance with s. Ins 9.40 and s. 609.32, Stats., requirements including means of identification, evaluation and correction of quality assurance problems.

Ins 9.42(6)(c) (c) Credentialing policies and procedures and a credentialing plan.

Ins 9.42(6)(d) (d) Utilization management procedures and policies.

Ins 9.42(6)(e) (e) Minutes from any committee, physician association, or board of directors meeting pertaining to quality assurance, utilization management, and credentialing.

Ins 9.42(7) (7) An insurer that complies with subs. (1) to (5), may permit another party to maintain any record required under sub. (6), but only if both of the following requirements are met:

Ins 9.42(7)(a) (a) The insurer includes and enforces the contractual provision described in sub. (4) (e).

Ins 9.42(7)(b) (b) The insurer produces any required record within 15 days after the office requests the record.

Ins 9.42(8) (8) An insurer shall maintain all of the following documents that relate to a silent provider network and shall make them available at the request of the commissioner:

Ins 9.42(8)(a) (a) Provider and provider network agreements, including addenda addressing reimbursement and discounts.

Ins 9.42(8)(b) (b) A listing of providers participating in additional group or individual discount contracts with the insurer.

Ins 9.42(8)(c) (c) Policy form numbers of those insurance products with silent discounts and associated marketing materials.

Ins 9.42(8)(d) (d) Claims administration guidelines for processing discounts including silent discounts.

Ins 9.42(8)(e) (e) Detailed documentation and explanation of claim system data fields and codes that identify silent discounts, other discount calculations, usual and customary calculations, and billed and paid amounts.

Ins 9.42(9) (9) An insurer offering a preferred provider plan that is not also a defined network plan shall comply with this section to the extent applicable.

Ins 9.42 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; corrections in (1) to (4) made under s. 13.93 (2m) (b) 7., Stats., Register November 2001 No. 551; CR 05-059: am. (1) to (3), (4) (a) and (e), (5) (a), and (6) (a), cr. (9) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (1) and (5) (a) Register December 2006 No. 612, eff. 1-1-07.