Chapter 609

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.

609.65(1) (1) If an enrollee of a limited service health organization, preferred provider plan, or defined network plan is examined, evaluated, or treated for a nervous or mental disorder pursuant to a court order under s. 880.33 (4m) or (4r), 2003 stats., an emergency detention under s. 51.15, a commitment or a court order under s. 51.20, an order for protective placement or protective services under ch. 55, an order under s. 55.14 or 55.19 (3) (e), or an order under ch. 980, then, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) to (4) and 609.05 (3), the limited service health organization, preferred provider plan, or defined network plan shall do all of the following:

609.65(1)(a) (a) If the provider performing the examination, evaluation, or treatment has a provider agreement with the limited service health organization, preferred provider plan, or defined network plan which covers the provision of that service to the enrollee, make the service available to the enrollee in accordance with the terms of the limited service health organization, preferred provider plan, or defined network plan and the provider agreement.

609.65(1)(b) (b) If the provider performing the examination, evaluation or treatment does not have a provider agreement with the limited service health organization, preferred provider plan, or defined network plan which covers the provision of that service to the enrollee, reimburse the provider for the examination, evaluation, or treatment of the enrollee in an amount not to exceed the maximum reimbursement for the service under the medical assistance program under subch. IV of ch. 49, if any of the following applies:

609.65(1)(b)1. 1. The service is provided pursuant to a commitment or a court order, except that reimbursement is not required under this subdivision if the limited service health organization, preferred provider plan, or defined network plan could have provided the service through a provider with whom it has a provider agreement.

609.65(1)(b)2. 2. The service is provided pursuant to an emergency detention under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20 and the provider notifies the limited service health organization, preferred provider plan, or defined network plan within 72 hours after the initial provision of the service.

609.65(2) (2) If after receiving notice under sub. (1) (b) 2. the limited service health organization, preferred provider plan, or defined network plan arranges for services to be provided by a provider with whom it has a provider agreement, the limited service health organization, preferred provider plan, or plan is not required to reimburse a provider under sub. (1) (b) 2. for any services provided after arrangements are made under this subsection.

609.65(3) (3) A limited service health organization, preferred provider plan, or defined network plan is only required to make available, or make reimbursement for, an examination, evaluation, or treatment under sub. (1) to the extent that the limited service health organization, preferred provider plan, or defined network plan would have made the medically necessary service available to the enrollee or reimbursed the provider for the service if any referrals required under s. 609.05 (3) had been made and the service had been performed by a participating provider.

609.65 History History: 1987 a. 366; 1993 a. 316, 479; 1995 a. 27; 1997 a. 237; 2001 a. 16; 2005 a. 264, 387; 2007 a. 45.

609.655 609.655 Coverage of certain services provided to dependent students.

609.655(1) (1) In this section:

609.655(1)(a) (a) “Dependent student” means an individual who satisfies all of the following:

609.655(1)(a)1. 1. Is covered as a dependent child under the terms of a policy or certificate issued by a defined network plan insurer.

609.655(1)(a)2. 2. Is enrolled in a school located in this state but outside the geographical service area of the defined network plan.

609.655(1)(b) (b) “Outpatient services” has the meaning given in s. 632.89 (1) (e).

609.655(1)(c) (c) “School” means a technical college; an institution within the University of Wisconsin System; and any institution of higher education that grants a bachelor’s or higher degree.

609.655(2) (2) If a policy or certificate issued by a defined network plan insurer provides coverage of outpatient services provided to a dependent student, the policy or certificate shall provide coverage of outpatient services, to the extent and in the manner required under sub. (3), that are provided to the dependent student while he or she is attending a school located in this state but outside the geographical service area of the defined network plan, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) and 609.05 (3).

609.655(3) (3) Except as provided in sub. (5), a defined network plan shall provide coverage for all of the following services:

609.655(3)(a) (a) A clinical assessment of the dependent student’s nervous or mental disorders or alcoholism or other drug abuse problems, conducted by a provider described in s. 632.89 (1) (e) 2., 3., or 4. who is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and who may be designated by the defined network plan.

609.655(3)(b) (b) If outpatient services are recommended in the clinical assessment conducted under par. (a), the recommended outpatient services consisting of not more than 5 visits to an outpatient treatment facility or other provider that is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and that may be designated by the defined network plan, except as follows:

609.655(3)(b)1. 1. Coverage is not required under this paragraph if the medical director of the defined network plan determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.

609.655(3)(b)2. 2. Coverage is not required under this paragraph for outpatient services provided after the dependent student has terminated his or her enrollment in the school.

609.655(4) (4) 

609.655(4)(a) (a) Upon completion of the 5 visits for outpatient services covered under sub. (3) (b), the medical director of the defined network plan and the clinician treating the dependent student shall review the dependent student’s condition and determine whether it is appropriate to continue treatment of the dependent student’s nervous or mental disorders or alcoholism or other drug abuse problems in reasonably close proximity to the school in which the student is enrolled. The review is not required if the dependent student is no longer enrolled in the school or if the coverage limits under the policy or certificate for treatment of nervous or mental disorders or alcoholism or other drug abuse problems have been exhausted.

609.655(4)(b) (b) Upon completion of the review under par. (a), the medical director of the defined network plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student’s nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director’s determination, the dependent student may submit a written grievance under the defined network plan’s internal grievance procedure established under s. 632.83.

609.655(5) (5) 

609.655(5)(a) (a) A policy or certificate issued by a defined network plan insurer is required to provide coverage for the services specified in sub. (3) only to the extent that the policy or certificate would have covered the service if it had been provided to the dependent student by a participating provider within the geographical service area of the defined network plan.

609.655(5)(b) (b) Paragraph (a) does not permit a defined network plan to reimburse a provider for less than the full cost of the services provided or an amount negotiated with the provider, solely because the reimbursement rate for the service would have been less if provided by a participating provider within the geographical service area of the defined network plan.

609.655 History History: 1989 a. 121; 1993 a. 399; 1997 a. 237; 1999 a. 155; 2001 a. 16; 2009 a. 28.

609.70 609.70 Chiropractic coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (3).