Chapter 609

609.92   Hospitals, individual practice associations and providers of physician services.

609.925   Election to be subject to restrictions.

609.93   Scope of election by an individual practice association or clinic.

609.935   Notices of election and termination.

609.94   Summary of restrictions.

609.95   Minimum covered liabilities.

609.96   Initial capital and surplus requirements.

609.97   Compulsory and security surplus.

609.98   Special deposit.

Ch. 609 Cross-reference Cross-reference: See definitions in ss. 600.03 and 628.02.

Ch. 609 Cross-reference Cross-reference: See also ch. Ins 9, Wis. adm. code.

609.001 609.001 Joint ventures; legislative findings.

609.001(1) (1) The legislature finds that increased development of health maintenance organizations, preferred provider plans and limited service health organizations may have the effect of putting small, independent health care providers at a competitive disadvantage with larger health care providers. In order to avoid monopolistic situations and to provide competitive alternatives, it may be necessary for those small, independent health care providers to form joint ventures. The legislature finds that these joint ventures are a desirable means of health care cost containment to the extent that they increase the number of entities with which a health maintenance organization, preferred provider plan or limited service health organization may choose to contract and to the extent that the joint ventures do not violate state or federal antitrust laws.

609.001(2) (2) The legislature finds that competition in the health care market will be enhanced by allowing employers and organizations which otherwise act independently to join together in a manner consistent with the state and federal antitrust laws for the purpose of purchasing health care coverage for employees and members. These joint ventures will allow purchasers of health care coverage to obtain volume discounts when they negotiate with insurers and health care providers. These joint ventures should result in an improved business climate in this state because of reduced costs for health care coverage.

609.001 History History: 1985 a. 29.

609.01 609.01 Definitions. In this chapter:

609.01(1b) (1b) “Defined network plan” means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with, or employed by the insurer offering the health benefit plan.

609.01(1c) (1c) “Emergency medical condition” has the meaning given in s. 632.85 (1) (a).

609.01(1d) (1d) “Enrollee” means, with respect to a defined network plan, preferred provider plan, or limited service health organization, a person who is entitled to receive health care services under the plan.

609.01(1g) (1g) 

609.01(1g)(a) (a) Except as provided in par. (b), “health benefit plan” means any hospital or medical policy or certificate.

609.01(1g)(b) (b) “Health benefit plan” does not include any of the following:

609.01(1g)(b)1. 1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.

609.01(1g)(b)2. 2. Coverage issued as a supplement to liability insurance.

609.01(1g)(b)3. 3. Liability insurance, including general liability insurance and automobile liability insurance.

609.01(1g)(b)4. 4. Worker’s compensation or similar insurance.

609.01(1g)(b)5. 5. Automobile medical payment insurance.

609.01(1g)(b)6. 6. Credit-only insurance.

609.01(1g)(b)7. 7. Coverage for on-site medical clinics.

609.01(1g)(b)8. 8. Other similar insurance coverage, as specified in regulations issued by the federal department of health and human services, under which benefits for medical care are secondary or incidental to other insurance benefits.

609.01(1g)(b)9. 9. If provided under a separate policy, certificate or contract of insurance, or if otherwise not an integral part of the policy, certificate or contract of insurance: limited-scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those benefits; and such other similar, limited benefits as are specified in regulations issued by the federal department of health and human services under section 2791 of P.L. 104-191.

609.01(1g)(b)10. 10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply:

609.01(1g)(b)10.a. a. The benefits are provided under a separate policy, certificate or contract of insurance.

609.01(1g)(b)10.b. b. There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.

609.01(1g)(b)10.c. c. Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.

609.01(1g)(b)11. 11. Other insurance exempted by rule of the commissioner.

609.01(1j) (1j) “Health care costs” means consideration for the provision of health care, including consideration for services, equipment, supplies and drugs.

609.01(1m) (1m) “Health care plan” has the meaning given under s. 628.36 (2) (a) 1.

609.01(2) (2) “Health maintenance organization” means a health care plan offered by an organization established under ch. 185 or 193, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers participating in the plan.

609.01(3) (3) “Limited service health organization” means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers participating in the plan.

609.01(3m) (3m) “Participating” means, with respect to a physician or other provider, under contract with a defined network plan, preferred provider plan, or limited service health organization to provide health care services, items or supplies to enrollees of the defined network plan, preferred provider plan, or limited service health organization.

609.01(3r) (3r) “Physician” has the meaning given in s. 448.01 (5).

609.01(4) (4) “Preferred provider plan” means a health care plan offered by an organization established under ch. 185, 193, 611, 613, or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, without referral and for consideration other than predetermined periodic fixed payments, coverage of either comprehensive health care services or a limited range of health care services, regardless of whether the health care services are performed by participating or nonparticipating providers.

609.01(4m) (4m) “Primary care physician” means a physician specializing in family medical practice, general internal medicine or pediatrics.

609.01(5) (5) “Primary provider” means a participating primary care physician, or other participating provider authorized by the defined network plan, preferred provider plan, or limited service health organization to serve as a primary provider, who coordinates and may provide ongoing care to an enrollee.

609.01(5m) (5m) “Provider” means a health care professional, a health care facility or a health care service or organization.

609.01(7) (7) “Standard plan” means a health care plan other than a health maintenance organization or a preferred provider plan.

609.01 History History: 1985 a. 29; 1989 a. 23; 1997 a. 237; 2001 a. 16; 2005 a. 441 ss. 107, 108; 2007 a. 96.

609.01 Annotation Under this section, an HMO enrollee has no personal liability for the costs of covered health care received. A hospital only has recourse against the HMO and may not assert its lien rights under this section against insurance proceeds paid by a tortfeasor’s insurer to the HMO enrollee. Dorr v. Sacred Heart Hospital, 228 Wis. 2d 425, 597 N.W.2d 462 (Ct. App. 1999), 98-1772.

609.01 Annotation Sections 609.01 and 609.91 do not prohibit HMOs from asserting contractual subrogation rights with respect to actual medical expenses incurred by an HMO for medical care covered by the HMO’s contract with an enrollee. Sub. (2) says that an HMO is an entity that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services but does not put in place a general limitation on all sources of funds available to HMOs. Torres v. Dean Health Plan, Inc. 2005 WI App 89, 282 Wis. 2d 725, 698 N.W.2d 107, 03-3274.

609.03 609.03 Indication of operations.

609.03(1) (1) Certificate of authority. An insurer may apply to the commissioner for a new or amended certificate of authority that limits the insurer to engaging in only the types of insurance business described in sub. (3).

609.03(2) (2) Statement of operations. If an insurer is a cooperative association organized under ss. 185.981 to 185.985, the insurer may apply to the commissioner for a statement of operations that limits the insurer to engaging in only the types of insurance business described in sub. (3).

609.03(3) (3) Restrictions on operations.

609.03(3)(a) (a) An insurer that has a new or amended certificate of authority under sub. (1) or a statement of operations under sub. (2) may engage in only the following types of insurance business:

609.03(3)(a)1. 1. As a health maintenance organization.

609.03(3)(a)2. 2. As a limited service health organization.

609.03(3)(a)3. 3. In other insurance business that is immaterial in relation to, or incidental to, the insurer’s business under subd. 1. or 2.

609.03(3)(b) (b) The commissioner may, by rule, define “immaterial” or “incidental”, or both, for purposes of par. (a) 3. as a percentage of premiums, except the percentage may not exceed 10 percent of the total premiums written by the insurer.

609.03(4) (4) Removing restrictions. An amendment to a certificate of authority or statement of operations that removes the limitation imposed under this section is not effective unless the insurer, on the effective date of the amendment, complies with the capital, surplus and other requirements applicable to the insurer under chs. 600 to 645.

609.03 History History: 1989 a. 23.

609.03 Cross-reference Cross-reference: See also s. Ins 9.12, Wis. adm. code.

609.05 609.05 Primary provider and referrals.

609.05(1) (1) Except as provided in subs. (2) and (3), a limited service health organization, preferred provider plan, or defined network plan shall permit its enrollees to choose freely among participating providers.

609.05(2) (2) Subject to s. 609.22 (4) and (4m), a limited service health organization, preferred provider plan, or defined network plan may require an enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.

609.05(3) (3) Except as provided in ss. 609.22 (4m), 609.65, and 609.655, a limited service health organization, preferred provider plan, or defined network plan may require an enrollee to obtain a referral from the primary provider designated under sub. (2) to another participating provider prior to obtaining health care services from that participating provider.

609.05 History History: 1985 a. 29; 1987 a. 366; 1989 a. 121; 1997 a. 237; 1999 a. 9; 2001 a. 16.

609.10 609.10 Standard plan and point-of-service option plan required.

609.10(1) (1) 

609.10(1)(ac) (ac) In this section, “point-of-service option plan” means a health maintenance organization or preferred provider plan that permits an enrollee to obtain covered health care services from a provider that is not a participating provider of the health maintenance organization or preferred provider plan under all of the following conditions:

609.10(1)(ac)1. 1. The nonparticipating provider holds a license or certificate that authorizes or qualifies the provider to provide the health care services.

609.10(1)(ac)2. 2. The health maintenance organization or preferred provider plan is required to pay the nonparticipating provider only the amount that the health maintenance organization or preferred provider plan would pay a participating provider for those health care services.

609.10(1)(ac)3. 3. The enrollee is responsible for any additional costs or charges related to the coverage.

609.10(1)(am) (am) Except as provided in subs. (2) to (4), an employer that offers any of its employees a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employees a standard plan that provides at least substantially equivalent coverage of health care expenses and a point-of-service option plan, as provided in pars. (b) and (c).

609.10(1)(b) (b) At least once annually, the employer shall provide the employees the opportunity to enroll in the health care plans under par. (am).

609.10(1)(c) (c) The employer shall provide the employees adequate notice of the opportunity to enroll in the health care plans under par. (am) and shall provide the employees complete and understandable information concerning the differences among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan.

609.10(2) (2) If, after providing an opportunity to enroll under sub. (1) (b) and the notice and information under sub. (1) (c), fewer than 25 employees indicate that they wish to enroll in the standard plan under sub. (1) (am), the employer need not offer the standard plan on that occasion.

609.10(3) (3) Subsection (1) does not apply to an employer that does any of the following:

609.10(3)(a) (a) Employs fewer than 25 full-time employees.

609.10(3)(b) (b) Offers its employees a health maintenance organization or a preferred provider plan only through an insurer that is a cooperative association organized under ss. 185.981 to 185.985 or only through an insurer that is restricted under s. 609.03 (3).

609.10(4) (4) Nothing in sub. (1) requires an employer to offer a particular health care plan to an employee if the health care plan determines that the employee does not meet reasonable medical underwriting standards of the health care plan.

609.10(5) (5) The commissioner may establish by rule standards in addition to any established under s. 609.20 for what constitutes adequate notice and complete and understandable information under sub. (1) (c).

609.10(6) (6) The commissioner shall promulgate rules necessary for the administration of the requirement to offer point-of-service option plans under sub. (1) (am).

609.10 History History: 1985 a. 29; 1997 a. 237; 1999 a. 9; 2001 a. 16.

609.17 609.17 Reports of disciplinary action. Every limited service health organization, preferred provider plan, and defined network plan shall notify the medical examining board or appropriate affiliated credentialing board attached to the medical examining board of any disciplinary action taken against a participating provider who holds a license or certificate granted by the board or affiliated credentialing board.

609.17 History History: 1985 a. 340; 1993 a. 107; 1997 a. 237; 2001 a. 16.

609.20 609.20 Rules for preferred provider and defined network plans.

609.20(1m) (1m) The commissioner may promulgate rules relating to preferred provider plans and defined network plans for any of the following purposes, as appropriate: