Chapter Ins 9

subch. III of ch. Ins 9 Subchapter III — Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations

Ins 9.20 Ins 9.20 Scope. This subchapter applies to all insurers offering a defined network plan, preferred provider plan or limited service health organization in this state. The insurer shall ensure that the requirements of this subchapter are met by all defined network plans, preferred provider plans or limited service health organizations issued by the insurer. The commissioner may approve an exemption to this subchapter for an insurer to market a defined network plan, preferred provider plan or limited service health organization if the insurer files the plan with the commissioner and the commissioner determines that all of the following conditions are met:

Ins 9.20(1) (1) The coverage involves ancillary coverage with minimal cost controls, such as minimal cost controls involving vision, prescription cards or transplant centers.

Ins 9.20(2) (2) The cost controls are unlikely to significantly affect the pattern of practice.

Ins 9.20(3) (3) The exemption is consistent with the purpose of this subchapter.

Ins 9.20 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: renum. from Ins 9.31 and am. (intro.) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (intro.) Register December 2006 No. 612, eff. 1-1-07.

Ins 9.21 Ins 9.21 Limited exemptions.

Ins 9.21(1) (1) Silent discount. An insurer, with respect to a defined network plan:

Ins 9.21(1)(a) (a) Is exempt from meeting the requirements under ss. 609.22, 609.24, 609.32, 609.34, 609.36 and 632.83, Stats., and ss. Ins 9.31, 9.32 (1), 9.35, 9.37, 9.38, 9.39, 9.40 (1) to (7), 9.42 (1) to (7), if the only owned, employed, or participating provider providing services covered under the plan is a silent provider network.

Ins 9.21(1)(b) (b) Is exempt from meeting the requirements under ss. 609.22, 609.24, 609.32, 609.34, and 609.36, Stats., and ss. Ins 9.32 (1), 9.35, 9.37, 9.38, 9.39, 9.40 (1) to (7), and 9.42 (1) to (7), solely with respect to services provided by the silent provider network, if the plan also covers services by providers that the insurer owns or employs, or another participating provider. An insurer is not exempt from those provisions with respect to a provider that is not a silent provider network.

Ins 9.21(2) (2) De minimus limited exception. Insurers offering a defined network plan are exempt from meeting the requirements under ss. 609.22 (1) to (4) and (8), 609.32 and 609.34, Stats., ss. Ins 9.32 (1), 9.40 (1) to (7), and 9.42 (6) and (7), with respect to a defined network plan, if the insurer meets all of the following requirements.

Ins 9.21(2)(a) (a) The insurer offering a defined network plan provides comprehensive benefits to insureds of at least 80% coverage for in-plan providers.

Ins 9.21(2)(b) (b) The insurer’s only financial incentive to the insureds to utilize participating providers is a co-insurance differential of not more than 10% between in-plan versus off-plan providers. Except for the co-insurance differential of no greater than 10%, all benefits, deductibles and co-payments must be the same regardless of whether the insured obtains benefits, services or supplies from in-plan or off-plan providers.

Ins 9.21(2)(c) (c) The insurer makes no representation regarding quality of care.

Ins 9.21(2)(d) (d) The insurer makes no representation that the defined network plan is a preferred provider plan or that the defined network plan directs or is responsible for the quality of health care services. Nothing in this paragraph prevents an insurer from describing the availability or limits on availability of participating providers or the extent or limits of coverage under the defined network plan if participating or non-participating providers are utilized by an insured.

Ins 9.21(2)(e) (e) The insurer, at the time an application is solicited, does all of the following.

Ins 9.21(2)(e)1. 1. Discloses to a potential applicant, and allows the applicant a reasonable opportunity to review, a directory which reasonably and clearly discloses the availability and location of providers:

Ins 9.21(2)(e)1.a. a. Within reasonable travel distance from the principle location of the place of employment of employees likely to enroll under the plan, if the applicant is an employer; or

Ins 9.21(2)(e)1.b. b. Within reasonable travel distance from the residence of the proposed insured, for any other application.

Ins 9.21(2)(e)2. 2. Obtains on the application, or on an addendum to the application, the applicant’s signed acknowledgement that the applicant:

Ins 9.21(2)(e)2.a. a. Has reviewed the disclosure under subd. 1.;

Ins 9.21(2)(e)2.b. b. Understands that participating providers may or may not be available to provide services and that the insurer is not required to make participating providers available; and

Ins 9.21(2)(e)2.c. c. Understands that the plan will provide reduced benefits if the insured uses a non-participating provider.

Ins 9.21(2)(e)3. 3. Provides to each applicant a copy of the provider directory at the time the policy is issued.

Ins 9.21(2)(e)4. 4. The insurer provides access to translation services for the purpose of providing information concerning benefits, to the greatest extent possible, if a significant number of enrollees of the plan customarily use languages other than English.

Ins 9.21 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; correction in (1) (a) made under s. 13.93 (2m) (b) 7., Stats., Register November 2001 No. 551; CR 05-059: renum. from Ins 9.32 and am. (1) (a) and (b), (2) (a) and (d) Register February 2006 No. 602, eff. 3-1-06.

Ins 9.25 Ins 9.25 Preferred provider plan same service provisions. For purposes of s. 609.35, Stats., an insurer offering a preferred provider plan covers the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider only if the insurer complies with all of the following:

Ins 9.25(1) (1) The insurer offering a preferred provider plan provides coverage that complies with either of the following:

Ins 9.25(1)(a) (a) Provides coverage for services performed by nonparticipating providers with the insurer paying at a coinsurance rate of not less than 60% and the enrollee paying at a coinsurance rate of not more than 40%.

Ins 9.25(1)(b) (b) Provides coverage for services performed by nonparticipating providers with the insurer paying at a coinsurance rate not less than 50% and the enrollee paying at a coinsurance rate of not more than 50% and the insurer provides the enrollee with the disclosure notice that is compliant with sub. (5).

Ins 9.25(2) (2) The insurer offering a preferred provider plan equally applies material exclusions regardless if the services are performed by either participating or nonparticipating providers. The insurer may exceed the coinsurance differential in s. Ins 9.27 (1), or the deductible differential in s. Ins 9.27 (2), or the co-payment differential in s. Ins 9.27 (3) to the extent the insurer reasonably determines the cost sharing is necessary to encourage enrollees to use participating providers or centers of excellence for transplant or other unique disease treatment services or preventive health care services limited to immunizations pursuant to s. 632.895 (14), Stats., and the services as covered benefits greater than the minimum required for specific mandated benefits under ss. 632.895 and 632.89, Stats., when the insurer at the time of solicitation and within the policy, does either or both, as applicable, of the following:

Ins 9.25(2)(a) (a) Provides a disclosure to enrollees that identify the centers of excellence and the specific covered benefits that are covered at a different rate if provided by a health care provider that is recognized and identified as a center of excellence.

Ins 9.25(2)(b) (b) Clearly and prominently discloses that either immunizations or expanded benefits above mandated minimum coverage, or both, are covered when performed by participating providers or with greater disparity than permitted in s. Ins 9.27 (1) through (3).

Ins 9.25(3) (3) The insurer offering a preferred provider plan provides coverage of services without use of any financial incentives other than maximum limits, out-of-pocket limits and those incentives described in this section and s. Ins 9.27 to encourage the use of participating providers.

Ins 9.25(4) (4) The insurer offering a preferred provider plan may use utilization management, including preauthorization or similar methods, for denying access to or coverage of services of nonparticipating providers with just cause and without such frequency as to indicate a general business practice.

Ins 9.25(5) (5) An insurer required to provide a disclosure notice under sub. (1) shall provide the disclosure notice to the applicant at the time of solicitation, and shall include in a prominent location within the certificate of coverage issued under a group policy and in a prominent location in an individual policy, the following form and in not less than 11-point bold font:

“NOTICE: LIMITED BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a nonparticipating provider for a covered service, benefit payments to such non-participating provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy’s fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the policy. YOU RISK PAYING MORE THAN THE COINSURANCE, DEDUCTIBLE AND CO-PAYMENT AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Nonparticipating providers may bill enrollees for any amount up to the billed charge after the plan has paid its portion of the bill. Participating providers have agreed to accept discounted payment for covered services with no additional billing to the enrollee other than co-payment, coinsurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling [the toll free telephone] number on your identification card [or visiting [the company’s] website].

Ins 9.25(6) (6) The insurer files a report with the commissioner certifying compliance with this section on a form prescribed by the commissioner and signed by an officer of the company.

Ins 9.25(7) (7) The insurer does not require a referral to obtain coverage for care from either a participating or nonparticipating provider and complies with ss. Ins 9.27 and 9.32 (2).

Ins 9.25(8) (8) This section first applies to an insurer offering a preferred provider plan beginning on January 1, 2007. This section does not apply to an insurer with respect to a preferred provider plan issued prior to January 1, 2007 and periodically renewed after December 31, 2006.

Ins 9.25 History History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; emerg. cr. (8), eff. 9-1-06; CR 06-083: am. (4) Register December 2006 No. 612, eff. 1-1-07; CR 06-118: cr. (8) Register April 2007 No. 616, eff. 5-1-07.

Ins 9.26 Ins 9.26 Preferred provider plan subject to defined network plan regulations. An insurer offering 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 of a defined network plan that is not a preferred provider plan including ss. Ins 9.31, 9.32 (1), 9.35 (1), 9.37 (4), 9.40 (2) and (4), and 18.03 (2) (c) 1., and ss. 609.22 (2), (3), (4) and (7), 609.32 (1) and 609.34 (1), Stats.

Ins 9.26 History History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; correction under s. 13.92 (4) (b) 7. Register December 2017 No. 745.

Ins 9.27 Ins 9.27 Preferred provider plan requirements. Insurers offering a preferred provider plan shall comply with all the following:

Ins 9.27(1) (1) Except as provided in s. Ins 9.25 (2), insurers offering a preferred provider plan that apply a coinsurance percentage when the services are performed by nonparticipating providers at a different percentage than the coinsurance percentage that is applied when the services are performed by participating providers shall offer plans that have either of the following:

Ins 9.27(1)(a) (a) The coinsurance differential between participating and nonparticipating providers performing the same services is 30% or less.

Ins 9.27(1)(b) (b) The coinsurance differential between participating and nonparticipating provider performing the same services is greater than 30% and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25 (5).

Ins 9.27(2) (2) Except as provided in s. Ins 9.25 (2), insurers offering a preferred provider plan that apply a deductible when the services are performed by nonparticipating providers in a different amount than the deductible that is applied when the services are performed by participating providers shall offer plans that have either of the following:

Ins 9.27(2)(a) (a) The deductible applied to nonparticipating providers is no more than 2 times greater than the deductible applied to participating providers or no more than $2000 higher than the participating provider deductible.

Ins 9.27(2)(b) (b) The deductible applied to nonparticipating providers is more than 2 times greater than the deductible applied to participating providers or is more than $2000 higher than the participating provider deductible and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25 (5).

Ins 9.27(3) (3) Except as provided in s. Ins 9.25 (2), insurers offering a preferred provider plan that apply a co-payment when the services are performed by nonparticipating providers in a different amount than the co-payment that is applied when the services are performed by participating providers shall offer plans that have either of the following:

Ins 9.27(3)(a) (a) The co-payment applied to nonparticipating providers is no more than 3 times greater than the co-payment applied to participating providers or no more than $100 for services of a health care provider or no more than $300 for services of a health care facility.

Ins 9.27(3)(b) (b) The co-payment applied to nonparticipating providers is more than 3 times greater than the co-payment applied to participating providers or is more than $100 for services of a health care provider or is more than $300 for services of a health care facility and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25 (5).

Ins 9.27(4) (4) This section first applies to an insurer offering a preferred provider plan beginning on January 1, 2007. This section does not apply to an insurer with respect to a preferred provider plan issued prior to January 1, 2007 and periodically renewed after December 31, 2006.

Ins 9.27 History History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; emerg. cr. (4), eff. 9-1-06; CR 06-118: cr. (4) Register April 2007 No. 616, eff. 5-1-07.

Ins 9.30 Ins 9.30 Group and blanket health insurers compliance. The commissioner finds that the circumstances of offering a group or blanket health insurance policy require that the insurer offering the policy otherwise exempt from chs. 600 to 646, Stats., under s. 600.01 (1) (b) 3., Stats., comply with s. Ins 9.32 (2) and s. 609.22 (2), Stats., in order to provide adequate protection to Wisconsin enrollees and the public. An insurer that covers 100 or more residents of this state under a policy otherwise exempt under s. 600.01 (1) (b) 3., Stats., shall comply with s. Ins 9.32 (2) and s. 609.22 (2), Stats.

Ins 9.30 History History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06.

Ins 9.31 Ins 9.31 Annual certification of access standards.

Ins 9.31(1) (1) An insurer offering a defined network plan that is not a preferred provider plan shall file an annual certification with the commissioner no later than August 1 of each year certifying compliance with the access standards of s. 609.22, Stats., and s. Ins 9.32 (1) for the preceding year. The certification shall be submitted on a form prescribed by the commissioner and signed by an officer of the company.

Ins 9.31(2) (2) An insurer offering a preferred provider plan shall file an annual certification with the commissioner no later than August 1 of each year certifying compliance with the access standards contained in ss. 609.22 (1), (4m), (5), (6) and (8), Stats., and s. Ins 9.32 (2) for the preceding year, on a form prescribed by the commissioner and signed by an officer of the company. The certification is to be filed within 3 months after March 1, 2006, and thereafter, no later than August 1 of each year.

Ins 9.31 Note Note: A copy of the certification of access standards form required under sub. (1), OCI26-110, and sub. (2), OCI26-111, may be obtained at no cost from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison, WI, 53707-7873 or from the OCI website address: http://oci.wi.gov.

Ins 9.31 History History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06.

Ins 9.32 Ins 9.32 Defined network plan requirements.

Ins 9.32(1) (1) An insurer offering a defined network plan that is not a preferred provider plan shall do all of the following:

Ins 9.32(1)(a) (a) Provide covered benefits by plan providers with reasonable promptness with respect to geographic location, hours of operation, waiting times for appointments in provider offices and after hours care. The hours of operation, waiting times, and availability of after hours care shall reflect the usual practice in the local area. Geographic availability shall reflect the usual medical travel times within the community.

Ins 9.32(1)(b) (b) Have sufficient number and type of plan providers to adequately deliver all covered services based on the demographics and health status of current and expected enrollees served by the plan.

Ins 9.32(1)(c) (c) Provide 24-hour nationwide toll-free telephone access for its enrollees to the plan or to a Wisconsin participating provider for authorization for care which is covered by the plan.

Ins 9.32(1)(d) (d) Provide as a covered benefit the emergency services rendered during the treatment of an emergency medical condition, as defined by s. 632.85, Stats., by a nonparticipating provider as though the services was provided by a participating provider, if the insurer provides coverage for emergency medical services and the enrollee cannot reasonably reach a participating provider or, as a result of the emergency, is admitted for inpatient care subject to any restriction which may govern payment to a participating provider for emergency services. The insurer shall pay the nonparticipating provider at the rate the insurer pays a nonparticipating provider after applying any co-payments, coinsurance, deductibles or other cost-sharing provisions that apply to participating providers.

Ins 9.32(2) (2) An insurer offering a preferred provider plan shall do all of the following:

Ins 9.32(2)(a) (a) Provide covered benefits by participating providers with reasonable promptness consistent with normal practices and standards in the geographic area. Geographic availability shall reflect the usual medical travel times within the community. This does not require an insurer offering a preferred provider plan to offer geographic availability of a choice of participating providers.

Ins 9.32(2)(b) (b) Provide sufficient number and type of participating providers to adequately deliver all covered services based on the demographics and to meet the anticipated needs of its enrollees served by the plan including at least one primary care provider and a participating provider with expertise in obstetrics and gynecology accepting new enrollees.

Ins 9.32(2)(d) (d) Include in its provider directory a prominent notice that complies with Appendix D and is printed in 11-point bold font.

Ins 9.32(2)(fm) (fm) Provide emergency medical services as a covered benefit when the enrollee receives treatment for an emergency medical condition, as defined by s. 632.85, Stats., from a nonparticipating provider. The insurer shall cover the treatment of the emergency medical condition rendered by a nonparticipating provider as though the services were rendered by a participating provider if the insurer provides coverage for emergency medical services and the enrollee cannot reasonably reach a participating provider or, as a result of the emergency, is admitted for inpatient care. The insurer shall compensate the nonparticipating providers at the rate the insurer pays nonparticipating providers and after applying any co-payments, coinsurance, deductibles or other cost-sharing provisions that apply to participating providers until the nonparticipating provider has met its obligations under 42 U.S.C. §1395dd.

Ins 9.32 History History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (2) (a), r. (2) (c), (e) and (f), cr. (fm), Register December 2006 No. 612. eff. 1-1-07.

Ins 9.33 Ins 9.33 Enrollee election of nonparticipating provider reimbursement. Nothing in s. Ins 9.32 changes the reimbursement payable or the amounts due, including co-payments, coinsurance, deductibles and other cost-sharing provisions from an enrollee when the enrollee of a preferred provider plan that is not a defined network plan elects to utilize the services of a nonparticipating provider when a participating provider is available in accordance with s. Ins 9.32 (2) (a) and (b) and the requirements of s. Ins 9.32 (2) (d), are provided to the enrollee.

Ins 9.33 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 9.35 Ins 9.35 Continuity of care.

Ins 9.35(1) (1) In addition to the requirements of s. 609.24, Stats., an insurer offering a defined network plan shall do one of the following:

Ins 9.35(1)(a) (a) Upon termination of a provider from a defined network plan, the insurer offering a defined network plan shall appropriately notify all enrollees of the termination, provide information on substitute providers, and at least identify the terminated providers within a separate section of the annual provider directory. In addition, the insurer shall comply with all of the following as appropriate:

Ins 9.35(1)(a)1. 1. If the terminating provider is a primary care provider and the insurer offering a defined network plan requires enrollees to designate a primary care provider, the insurer shall notify each enrollee who designated the terminating provider of the termination no later than 30 days prior to the termination or 15 days following the date the insurer received the provider’s termination notice, whichever is later, and shall describe each enrollee’s options for receiving continued care from the terminated provider.

Ins 9.35(1)(a)2. 2. If the terminating provider is a specialist and the insurer offering a defined network plan requires a referral, the insurer shall notify each enrollee authorized by referral to receive care from the specialist of the termination no later than 30 days prior to the termination or 15 days following the date the insurer received the provider’s termination notice, whichever is later, and describe each enrollee’s options for receiving continued care from the terminated provider.

Ins 9.35(1)(a)3. 3. If the terminating provider is a specialist and the insurer offering a defined network plan does not require a referral, the provider’s contract with the insurer shall comply with the requirements of s. 609.24, Stats., and require the provider to post a notification of termination with the plan in the provider’s office no later than 30 days prior to the termination or 15 days following the date the insurer received the provider’s termination notice, whichever is later.

Ins 9.35(1)(b) (b)

Ins 9.35(1)(b)1. 1. Upon termination of a provider from a defined network plan, the insurer offering a defined network plan shall notify all affected enrollees of the termination and each enrollee’s options for receiving continued care from the terminated provider not later than 30 days prior to the termination, or upon notice by the provider if the insurer receives less than 30 days notice. The insurer offering a defined network plan shall provide information on substitute providers to all affected enrollees.

Ins 9.35(1)(b)2. 2. If the provider is a primary care provider and the insurer offering a defined network plan requires enrollees to designate a primary care provider, the insurer shall notify all enrollees who designated the terminating provider.

Ins 9.35(1m) (1m) An insurer offering a preferred provider plan shall either comply with sub. (1) (a) or (b) or have a contract with participating providers requiring the provider to notify all plan enrollees of the enrollees’ rights under s. 609.24, Stats., if the provider’s participation terminates for reasons other than provided in sub. (2) (a) or (b). The participating provider contracted with the insurer shall post a notification of termination with the plan no later than 30 days prior to the termination or 15 days following the date the insurer received the provider’s termination notice, whichever is later, and describe each enrollee’s options for receiving continued care from the terminated provider. The insurer offering a preferred provider plan shall enforce the contract and ensure that enrollees are informed of a participating provider’s termination.

Ins 9.35(2) (2) An insurer offering a defined network plan is not required to provide continued coverage for the services of a provider if either of the following is met:

Ins 9.35(2)(a) (a) The provider no longer practices in the defined network plan’s geographic service area.

Ins 9.35(2)(b) (b) The insurer offering a defined network plan terminates the provider’s contract due to misconduct on the part of the provider.