Chapter 609

609.205(4) (4) The commissioner may promulgate any rules necessary to implement this section.

609.205 History History: 2019 a. 185.

609.22 609.22 Access standards.

609.22(1) (1) Providers. A defined network plan shall include a sufficient number, and sufficient types, of qualified providers to meet the anticipated needs of its enrollees, with respect to covered benefits, as appropriate to the type of plan and consistent with normal practices and standards in the geographic area.

609.22(2) (2) Adequate choice. A defined network plan that is not a preferred provider plan shall ensure that, with respect to covered benefits, each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.

609.22(3) (3) Primary provider selection. A defined network plan that is not a preferred provider plan shall permit each enrollee to select his or her own primary provider from a list of participating primary care physicians and any other participating providers that are authorized by the defined network plan to serve as primary providers. The list shall be updated on an ongoing basis and shall include a sufficient number of primary care physicians and any other participating providers authorized by the plan to serve as primary providers who are accepting new enrollees.

609.22(4) (4) Specialist providers.

609.22(4)(a) (a)

609.22(4)(a)1. 1. If a defined network plan that is not a preferred provider plan requires a referral to a specialist for coverage of specialist services, the defined network plan that is not a preferred provider plan shall establish a procedure by which an enrollee may apply for a standing referral to a specialist. The procedure must specify the criteria and conditions that must be met in order for an enrollee to obtain a standing referral.

609.22(4)(a)2. 2. A defined network plan that is not a preferred provider plan may require the enrollee’s primary provider to remain responsible for coordinating the care of an enrollee who receives a standing referral to a specialist. A defined network plan that is not a preferred provider plan may restrict the specialist from making any secondary referrals without prior approval by the enrollee’s primary provider. If an enrollee requests primary care services from a specialist to whom the enrollee has a standing referral, the specialist, in agreement with the enrollee and the enrollee’s primary provider, may provide primary care services to the enrollee in accordance with procedures established by the defined network plan that is not a preferred provider plan.

609.22(4)(a)3. 3. A defined network plan that is not a preferred provider plan must include information regarding referral procedures in policies or certificates provided to enrollees and must provide such information to an enrollee or prospective enrollee upon request.

609.22(4m) (4m) Obstetric and gynecologic services.

609.22(4m)(a) (a) A defined network plan that provides coverage of obstetric or gynecologic services may not require a female enrollee of the defined network plan to obtain a referral for covered obstetric or gynecologic benefits provided by a participating provider who is a physician licensed under ch. 448 and who specializes in obstetrics and gynecology, regardless of whether the participating provider is the enrollee’s primary provider. Notwithstanding sub. (4), the defined network plan may not require the enrollee to obtain a standing referral under the procedure established under sub. (4) (a) for covered obstetric or gynecologic benefits.

609.22(4m)(b) (b) A defined network plan under par. (a) may not do any of the following:

609.22(4m)(b)1. 1. Penalize or restrict the coverage of a female enrollee on account of her having obtained obstetric or gynecologic services in the manner provided under par. (a).

609.22(4m)(b)2. 2. Penalize or restrict the contract of a participating provider on account of his or her having provided obstetric or gynecologic services in the manner provided under par. (a).

609.22(4m)(c) (c) A defined network plan under par. (a) shall provide written notice of the requirement under par. (a) in every policy or group certificate issued by the defined network plan.

609.22(5) (5) Second opinions. A defined network plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.

609.22(6) (6) Emergency care. Notwithstanding s. 632.85, if a defined network plan provides coverage of emergency services, with respect to covered benefits, the defined network plan shall do all of the following:

609.22(6)(a) (a) Cover emergency medical services for which coverage is provided under the plan and that are obtained without prior authorization for the treatment of an emergency medical condition.

609.22(6)(b) (b) Cover emergency medical services or urgent care for which coverage is provided under the plan and that is provided to an individual who has coverage under the plan as a dependent child and who is a full-time student attending school outside of the geographic service area of the plan.

609.22(7) (7) Telephone access. A defined network plan that is not a preferred provider plan shall provide telephone access for sufficient time during business and evening hours to ensure that enrollees have adequate access to routine health care services for which coverage is provided under the plan. A defined network plan that is not a preferred provider plan shall provide 24-hour telephone access to the plan or to a participating provider for emergency care, or authorization for care, for which coverage is provided under the plan.

609.22(8) (8) Access plan for certain enrollees. A defined network plan shall develop an access plan to meet the needs, with respect to covered benefits, of its enrollees who are members of underserved populations. If a significant number of enrollees of the plan customarily use languages other than English, the defined network plan shall provide access to translation services fluent in those languages to the greatest extent possible.

609.22 History History: 1997 a. 237; 1999 a. 9; 2001 a. 16.

609.22 Cross-reference Cross-reference: See also s. Ins 9.38, Wis. adm. code.

609.24 609.24 Continuity of care.

609.24(1) (1) Requirement to provide access.

609.24(1)(a) (a) Subject to pars. (b) and (c) and except as provided in par. (d), a defined network plan shall, with respect to covered benefits, provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the defined network plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times:

609.24(1)(a)1. 1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period.

609.24(1)(a)2. 2. If the plan under which the enrollee has coverage has no open enrollment period, the time of the enrollee’s enrollment or most recent coverage renewal, whichever is later.

609.24(1)(b) (b) Except as provided in par. (d), a defined network plan shall provide the coverage required under par. (a) with respect to the services of a provider who is a primary care physician for the following period of time:

609.24(1)(b)1. 1. For an enrollee of a plan with no open enrollment period, until the end of the current plan year.

609.24(1)(b)2. 2. For an enrollee of a plan with an open enrollment period, until the end of the plan year for which it was represented that the provider was, or would be, a participating provider.

609.24(1)(c) (c) Except as provided in par. (d), if an enrollee is undergoing a course of treatment with a participating provider who is not a primary care physician and whose participation with the plan terminates, the defined network plan shall provide the coverage under par. (a) with respect to the services of the provider for the following period of time:

609.24(1)(c)1. 1. Except as provided in subd. 2., for the remainder of the course of treatment or for 90 days after the provider’s participation with the plan terminates, whichever is shorter, except that the coverage is not required to extend beyond the period specified in par. (b) 1. or 2., whichever applies.

609.24(1)(c)2. 2. If maternity care is the course of treatment and the enrollee is a woman who is in the 2nd or 3rd trimester of pregnancy when the provider’s participation with the plan terminates, until the completion of postpartum care for the woman and infant.

609.24(1)(d) (d) The coverage required under this section need not be provided or may be discontinued if any of the following applies:

609.24(1)(d)1. 1. The provider no longer practices in the defined network plan’s geographic service area.

609.24(1)(d)2. 2. The insurer issuing the defined network plan terminates or terminated the provider’s contract for misconduct on the part of the provider.

609.24(1)(e) (e)

609.24(1)(e)1. 1. An insurer issuing a defined network plan shall include in its provider contracts provisions addressing reimbursement to providers for services rendered under this section.

609.24(1)(e)2. 2. If a contract between a defined network plan and a provider does not address reimbursement for services rendered under this section, the insurer shall reimburse the provider according to the most recent contracted rate.

609.24(2) (2) Medical necessity provisions. This section does not preclude the application of any provisions related to medical necessity that are generally applicable under the plan.

609.24(3) (3) Hold harmless requirements. A provider that receives or is due reimbursement for services provided to an enrollee under this section is subject to s. 609.91 with respect to the enrollee, regardless of whether the provider is a participating provider in the enrollee’s plan and regardless of whether the enrollee’s plan is a health maintenance organization.

609.24(4) (4) Notice of provisions. A defined network plan shall notify all plan enrollees of the provisions under this section whenever a participating provider’s participation with the plan terminates, or shall, by contract, require a participating provider to notify all plan enrollees of the provisions under this section if the participating provider’s participation with the plan terminates.

609.24 History History: 1997 a. 237; 2001 a. 16.

609.24 Cross-reference Cross-reference: See also s. Ins 9.35, Wis. adm. code.

609.30 609.30 Provider disclosures.

609.30(1) (1) Plan may not contract. A defined network plan may not contract with a participating provider to limit the provider’s disclosure of information, to or on behalf of an enrollee, about the enrollee’s medical condition or treatment options.

609.30(2) (2) Plan may not penalize or terminate. A participating provider may discuss, with or on behalf of an enrollee, all treatment options and any other information that the provider determines to be in the best interest of the enrollee. A defined network plan may not penalize or terminate the contract of a participating provider because the provider makes referrals to other participating providers or discusses medically necessary or appropriate care with or on behalf of an enrollee.

609.30 History History: 1997 a. 237; 2001 a. 16.

609.32 609.32 Quality assurance.

609.32(1) (1) Standards; other than preferred provider plans. A defined network plan that is not a preferred provider plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate, and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following:

609.32(1)(a) (a) An ongoing, written internal quality assurance program.

609.32(1)(b) (b) Specific written guidelines for quality of care studies and monitoring.

609.32(1)(c) (c) Performance and clinical outcomes-based criteria.

609.32(1)(d) (d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

609.32(1)(e) (e) A plan for gathering and assessing data.

609.32(1)(f) (f) A peer review process.

609.32(1m) (1m) Procedure for remedial action; preferred provider plans. A preferred provider plan shall develop a procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

609.32(2) (2) Selection and evaluation of providers.

609.32(2)(a) (a) A defined network plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider’s license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider.

609.32(2)(b) (b) A defined network plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider’s initial acceptance for participation. The reevaluation shall include all of the following:

609.32(2)(b)1. 1. Updating the previous review criteria.

609.32(2)(b)2. 2. Assessing the provider’s performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.

609.32(2)(c) (c) A defined network plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.

609.32 History History: 1997 a. 237; 2001 a. 16.

609.32 Cross-reference Cross-reference: See also s. Ins 9.40, Wis. adm. code.

609.34 609.34 Clinical decision-making; medical director.

609.34(1) (1) A defined network plan that is not a preferred provider plan shall appoint a physician as medical director. The medical director shall be responsible for clinical protocols, quality assurance activities, and utilization management policies of the plan.

609.34(2) (2) A preferred provider plan may contract for services related to clinical protocols and utilization management. A preferred provider plan or its designee is required to appoint a medical director only to the extent that the preferred provider plan or its designee assumes direct responsibility for clinical protocols and utilization management policies of the plan. The medical director, who shall be a physician, shall be responsible for such protocols and policies of the plan.

609.34 History History: 1997 a. 237; 2001 a. 16.

609.35 609.35 Applicability of requirements to preferred provider plans. Notwithstanding ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1), a preferred provider plan that does not cover the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider is subject to the requirements under ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1).

609.35 History History: 2001 a. 16.

609.36 609.36 Data systems and confidentiality.

609.36(1) (1) Information and data reporting.

609.36(1)(a) (a) A defined network plan shall provide to the commissioner information related to all of the following:

609.36(1)(a)1. 1. The structure of the plan.

609.36(1)(a)2. 2. Health care benefits and exclusions.

609.36(1)(a)3. 3. Cost-sharing requirements.

609.36(1)(a)4. 4. Participating providers.

609.36(1)(b) (b) Subject to sub. (2), the information and data reported under par. (a) shall be open to public inspection under ss. 19.31 to 19.39.

609.36(2) (2) Confidentiality. A defined network plan shall establish written policies and procedures, consistent with ss. 51.30, 146.82, and 252.15, for the handling of medical records and enrollee communications to ensure confidentiality.

609.36 History History: 1997 a. 237; 2001 a. 16.

609.38 609.38 Oversight. The office shall perform examinations of insurers that issue defined network plans consistent with ss. 601.43 and 601.44. The commissioner shall by rule develop standards for defined network plans for compliance with the requirements under this chapter.

609.38 History History: 1997 a. 237; 2001 a. 16.

609.60 609.60 Optometric coverage. Health maintenance organizations and preferred provider plans are subject to s. 632.87 (2m).

609.60 History History: 1985 a. 29.

609.65 609.65 Coverage for court-ordered services for the mentally ill.