Chapter Ins 9

Register November 2001 No. 551

Chapter Ins 9

DEFINED NETWORK PLANS

Subchapter I — Definitions

Ins 9.01   Definitions.

Ins 9.015   Scope.

Subchapter II — Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations

Ins 9.02   Purpose.

Ins 9.03   Scope.

Ins 9.04   Financial requirements.

Ins 9.05   Business plan.

Ins 9.06   Changes in the business plan.

Ins 9.07   Copies of provider agreements.

Ins 9.08   Other reporting requirements.

Ins 9.09   Notice of election and termination of hold harmless.

Ins 9.10   Receivables from affiliates.

Ins 9.11   Receivables from Individual Practice Association (“IPA”).

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

Ins 9.13   Summary.

Ins 9.14   Nondomestic HMO.

Ins 9.15   Time period.

Subchapter III — Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations

Ins 9.20   Scope.

Ins 9.21   Limited exemptions.

Ins 9.25   Preferred provider plan same service provisions.

Ins 9.26   Preferred provider plan subject to defined network plan regulations.

Ins 9.27   Preferred provider plan requirements.

Ins 9.30   Group and blanket health insurers compliance.

Ins 9.31   Annual certification of access standards.

Ins 9.32   Defined network plan requirements.

Ins 9.33   Enrollee election of nonparticipating provider reimbursement.

Ins 9.35   Continuity of care.

Ins 9.36   Gag clauses.

Ins 9.37   Notice requirements.

Ins 9.38   Policy and certificate language requirements.

Ins 9.39   Disenrollment.

Ins 9.40   Required quality assurance and remedial action plans.

Ins 9.41   Right of the commissioner to request OCI complaints be handled as grievances.

Ins 9.42   Compliance program requirements.

Ch. Ins 9 Note Note: The revisions to ch. Ins 9 that are effective March 1, 2006, apply to newly issued policies or certificates of insurance on or after January 1, 2007, and to policies renewed on or after January 1, 2008.

subch. I of ch. Ins 9 Subchapter I — Definitions

Ins 9.01 Ins 9.01 Definitions. In this chapter, and for the purposes of applying ch. 609, Stats.:

Ins 9.01(1) (1) “Acceptable letter of credit” means a clean, unconditional, irrevocable letter of credit issued by a Wisconsin bank or any other financial institution acceptable to the commissioner which renews on an annual basis for a 3–year term unless written notice of nonrenewal is given to the commissioner and the limited service health organization at least 60 days prior to the renewal date.

Ins 9.01(2) (2) “Commissioner” means the “commissioner of insurance” of this state or the commissioner’s designee.

Ins 9.01(3) (3) “Complaint” means any expression of dissatisfaction expressed to an insurer by an enrollee, or an enrollee’s authorized representative, about the insurer or its participating providers.

Ins 9.01(3m) (3m) “Defined network plan” has the meaning provided under s. 609.01 (1b), Stats., and includes Medicare select policies and certificates, as defined in s. Ins 3.39 (3) (vm) and (ve), respectively, and health benefit plans that contract for use of participating providers.

Ins 9.01(4) (4) “Expedited grievance” means a grievance where the standard resolution process may include any of the following:

Ins 9.01(4)(a) (a) Serious jeopardy to the life or health of the enrollee or the ability of the enrollee to regain maximum function.

Ins 9.01(4)(b) (b) In the opinion of a physician with knowledge of the enrollee’s medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.

Ins 9.01(4)(c) (c) It is determined to be an expedited grievance by a physician with knowledge of the enrollee’s medical condition.

Ins 9.01(5) (5) “Grievance” means any dissatisfaction with the provision of services or claims practices of an insurer offering a defined network plan, preferred provider plan or limited service health organization, or administration of a defined network, preferred provider plan or limited service health organization, that is expressed to the insurer by, or on behalf of, an enrollee.

Ins 9.01(6) (6) “Health benefit plan” has the meaning provided under s. 632.745 (11), Stats.

Ins 9.01(7) (7) “HMO” or “health maintenance organization” means a health care plan as defined in s. 609.01 (2), Stats.

Ins 9.01(8) (8) “Health maintenance organization insurer” has the meaning provided under s. 600.03 (23c), Stats.

Ins 9.01(9) (9) “Hospital emergency facility” means any hospital facility that offers services for emergency medical conditions as described in s. 632.85 (1) (a), Stats., within its capability to do so and in accordance with s. DHS 124.24, or the licensure requirements of the jurisdiction in which the hospital resides.

Ins 9.01(9m) (9m) “Intermediate entity” means a provider network, a provider association, a provider leasing arrangement or other similar entity that contracts with providers for the rendering of health care services, items or supplies to enrollees of a defined network plan, preferred provider plan or limited service health organization and also contracts with the insurer offering a defined network plan, preferred provider plan or limited service health organization.

Ins 9.01(10) (10) “IPA” or “individual practice association” has the meaning provided under s. 600.03 (23g), Stats.

Ins 9.01(11) (11) “Limited service health organization” means a health care plan as defined in s. 609.01 (3), Stats.

Ins 9.01(13) (13) “OCI complaint” means any written complaint received by the office of the commissioner of insurance by, or on behalf of, an enrollee of an insurer offering a defined network plan, preferred provider plan or limited service health organization.

Ins 9.01(14) (14) “Office” means the “office of the commissioner of insurance.”

Ins 9.01(14m) (14m) “Participating” has the meaning provided under s. 609.01 (3m), Stats., and includes a provider as being under contract with the insurer when the provider is under contract with an intermediate entity.

Ins 9.01(15) (15) “Preferred provider plan” has the meaning provided under s. 609.01 (4), Stats.

Ins 9.01(16) (16) “Primary provider” has the meaning provided under s. 609.01 (5), Stats.

Ins 9.01(17) (17) “Silent provider network” means one or more participating providers that provide services covered under a defined network plan where all of the following apply:

Ins 9.01(17)(a) (a) The insurer does not include any incentives or penalties in the defined network plan related to utilization or failure to utilize the provider.

Ins 9.01(17)(b) (b) The only direct or indirect compensation arrangement the insurer has with the provider provides for compensation that is:

Ins 9.01(17)(b)1. 1. On a fee for service basis and not on a risk sharing basis, including, but not limited to, capitation, withholds, global budgets, or target expected expenses or claims;

Ins 9.01(17)(b)2. 2. The compensation arrangement provides for compensation that is not less than 80% of the provider’s usual fee or charge.

Ins 9.01(17)(c) (c) The insurer, in any arrangement described under par. (b), requires that the reduction in fees will be applied with respect to cost sharing portions of expenses incurred under the defined network plan to the extent the provider submits the claim directly to the insurer.

Ins 9.01(17)(d) (d) The provider is not directly or indirectly managed, owned, or employed by the insurer.

Ins 9.01(17)(e) (e) The insurer does not disclose, market, advertise, provide a telephone service or number relating to, or include in policyholder or enrollee material information relating to, the availability of the compensation arrangement described under par. (b), or the names or addresses of the provider or an entity that maintains a compensation arrangement described under par. (b), except to the extent required by law in processing of explanation of benefits. The insurer may not indirectly cause or permit a prohibited disclosure and may not make any such disclosure in the course of utilization review or pre-authorization functions.

Ins 9.01 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; correction in (12) made under s. 13.93 (2m) (b) 7., Stats., Register February 2006 No. 602; CR 05-059: renum. (12) to be (3m), am. (3), (3m), (5), (13), (17) (a) and (c), cr. (9m), (10m) and (14m) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (5), (9m) and (13), r. (10m) Register December 2006 No. 612, eff. 1-1-07; correction in (9) made under s. 13.92 (4) (b) 7., Stats., Register February 2013 No. 686; CR 19-036: am. (3m) Register December 2019 No. 768, eff. 1-1-20; correction in (3m) made under s. 35.17, Stats., Register December 2019 No. 768.

Ins 9.015 Ins 9.015 Scope. This chapter applies to all insurers offering a defined network plan, a preferred provider plan or a limited service health organization plan except to an insurer offering a preferred provider plan that also meets the subject matter of s. 632.745 (11) (b) 9., Stats.

Ins 9.015 History History: CR 06-083: cr. Register December 2006 No. 612, eff. 1-1-07.

subch. II of ch. Ins 9 Subchapter II — Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations

Ins 9.02 Ins 9.02 Purpose. This subchapter establishes financial standards for health maintenance organizations and limited service health organizations doing business in Wisconsin. These requirements are in addition to any other statutory or administrative rule requirements that apply to health maintenance organizations and limited service health organizations.

Ins 9.02 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.