Chapter Ins 9

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.

Ins 9.35(3) (3) The insurer offering a defined network plan shall make available to the commissioner upon request all information needed to establish cause for termination of providers.

Ins 9.35 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. Register February 2006 No. 602, eff. 3-1-06.

Ins 9.36 Ins 9.36 Gag clauses.

Ins 9.36(1) (1) No contract between an insurer offering a defined network plan and a participating provider may limit the provider’s ability to disclose information, to or on behalf of an enrollee, about the enrollee’s medical condition.

Ins 9.36(2) (2) 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 and within the scope of the provider’s professional license. An insurer offering a defined network plan may not penalize the participating provider nor 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. An insurer offering a defined network plan may not retaliate against a provider for advising an enrollee of treatment options that are not covered benefits under the plan.

Ins 9.36 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. Register February 2006 No. 602, eff. 3-1-06.

Ins 9.37 Ins 9.37 Notice requirements.

Ins 9.37(1) (1) Provided information. Prior to enrolling members, insurers offering a defined network plan shall provide to prospective group or individual policyholders information on the plan including all of the following:

Ins 9.37(1)(a) (a) Covered services.

Ins 9.37(1)(b) (b) A definition of emergency and out-of-area coverage.

Ins 9.37(1)(c) (c) Cost sharing requirements.

Ins 9.37(1)(d) (d) Enrollment procedures.

Ins 9.37(1)(e) (e) Limitations on benefits including limitations on choice of providers and the geographical area serviced by the plan.

Ins 9.37(2) (2) Provider directories. Insurers offering a defined network plan shall make current provider directories available to enrollees upon enrollment, and no less than annually, following the first year of enrollment. Preferred provider plans shall also include the language of Appendix D.

Ins 9.37(3) (3) Obstetricians and gynecologists. Insurers offering a defined network plan that permits obstetricians or gynecologists to serve as primary care providers shall clearly so state in enrollment materials. Insurers offering a defined network plan that limits access to obstetricians and gynecologists shall clearly so state in enrollment materials the process for obtaining referrals.

Ins 9.37(4) (4) Standing referral criteria. Insurers offering a defined network plan other than a preferred provider plan shall make information available to their enrollees describing the criteria for obtaining a standing referral to a specialist, including under what circumstances and for what services a standing referral is available, how to request a standing referral, and how to appeal a standing referral determination. For purposes of s. 609.22 (4), Stats., and this subsection, referral includes prior authorization for services if the insurer uses this or similar methods for denying standing referrals to specialists without just cause and with such frequency to indicate a general business practice, as determined by the commissioner.

Ins 9.37 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (1) to (4) Register February 2006 No. 602, eff. 3-1-06.

Ins 9.38 Ins 9.38 Policy and certificate language requirements. Each policy form marketed or each certificate issued to an enrollee by an insurer offering a defined network plan or limited service health organization plan shall contain all of the following:

Ins 9.38(1) (1) Definitions. A definition of geographical service area, emergency care, urgent care, out–of–area service, dependent and primary provider, if these terms or terms of similar meaning are used in the policy or certificate and have an effect on the benefits covered by the plan. The definition of geographical service area need not be stated in the text of the policy or certificate if such definition is adequately described in an attachment that is given to all enrollees along with the policy or certificate.

Ins 9.38(2) (2) Disclosure of exclusions, limitations and exceptions. Clear disclosure of any provision that limits benefits or access to services in the exclusions, limitations, and exceptions sections of the policy or certificate. Among the exclusions, limitations and exceptions that shall be disclosed are those relating to:

Ins 9.38(2)(a) (a) Emergency and urgent care.

Ins 9.38(2)(b) (b) Restrictions on the selection of primary or referral providers.

Ins 9.38(2)(c) (c) Restrictions on changing providers during the contract period.

Ins 9.38(2)(d) (d) Out–of–pocket costs including copayments and deductibles.

Ins 9.38(2)(e) (e) Any restrictions on coverage for dependents who do not reside in the service area.

Ins 9.38(3) (3) Disclosure of mandated benefits. Clear disclosure of all benefit mandates outlined in Wisconsin statutes.

Ins 9.38(4) (4) Disclosure of procedures and emergency care notification. Insurers offering a defined network plan shall do all of the following in a manner consistent with s. 609.22, Stats.:

Ins 9.38(4)(a) (a) Provide a description of the procedure for an enrollee to obtain any required referral, including the right to a standing referral, and notice that any enrollee may request the criteria for the standing referral.

Ins 9.38(4)(b) (b) Provide a description of the procedure for any enrollee to obtain a second opinion from a participating plan provider consistent with s. 609.22 (5), Stats.

Ins 9.38(4)(c) (c) Consistent with s. 609.22 (6), Stats., and s. Ins 9.32 (1) (d), an insurer offering a defined network plan may require enrollees to notify the insurer of emergency room usage, but in no case may the insurer offering a defined network plan require notification less than 48 hours after receiving services or before it is medically feasible for the enrollee to provide the notice, whichever is later. An insurer offering a defined network plan may impose no greater penalty than assessing a deductible that may not exceed the lesser of 50% of covered expenses for emergency treatment or $250.00 for failing to comply with emergency treatment notification requirements.

Ins 9.38 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (intro.), (4) (intro.) and (c) Register February 2006 No. 602, eff. 3-1-06.

Ins 9.39 Ins 9.39 Disenrollment.

Ins 9.39(1) (1) Disclosure. The health maintenance organization or limited service health organization shall clearly disclose in the policy and certificate any circumstances under which the health maintenance organization or limited service health organization may disenroll an enrollee.

Ins 9.39(2) (2) Enrollee disenrollment criteria. Except as provided in s. 632.897, Stats., the health maintenance organization or limited service health organization may only disenroll an enrollee if one of the following occurs:

Ins 9.39(2)(a) (a) The enrollee has failed to pay required premiums by the end of the grace period.

Ins 9.39(2)(b) (b) The enrollee has committed acts of physical or verbal abuse that pose a threat to providers or other members of the organization.

Ins 9.39(2)(c) (c) The enrollee has allowed a nonmember to use the health maintenance or limited service health organization’s certification card to obtain services or has knowingly provided fraudulent information in applying for coverage.

Ins 9.39(2)(d) (d) The enrollee has moved outside of the geographical service area of the organization.

Ins 9.39(2)(e) (e) The enrollee is unable to establish or maintain a satisfactory physician–patient relationship with the physician responsible for the enrollee’s care. Disenrollment of an enrollee under this paragraph shall be permitted only if the health maintenance organization or limited service health organization can demonstrate that it did all of the following:

Ins 9.39(2)(e)1. 1. Provided the enrollee with the opportunity to select an alternate primary care physician.

Ins 9.39(2)(e)2. 2. Made a reasonable effort to assist the enrollee in establishing a satisfactory patient–physician relationship.

Ins 9.39(2)(e)3. 3. Informed the enrollee that he or she may file a grievance on this matter.

Ins 9.39(3) (3) Prohibited disenrollment criteria. Notwithstanding sub. (2), the health maintenance organization or limited service health organization plan may not disenroll an enrollee for reasons related to any of the following:

Ins 9.39(3)(a) (a) The physical or mental condition of the enrollee.

Ins 9.39(3)(b) (b) The failure of the enrollee to follow a prescribed course of treatment.

Ins 9.39(3)(c) (c) The failure of an enrollee to keep appointments or to follow other administrative procedures or requirements.

Ins 9.39(4) (4) Alternative coverage for disenrolled enrollees. An insurer offering a health maintenance organization plan or limited service health organization plan that has disenrolled an enrollee for any reason except failure to pay required premiums shall make arrangements to provide similar alternate insurance coverage to the enrollee. In the case of group certificate holders, the insurance coverage shall be continued until the affected enrollee finds his or her own coverage or until the next opportunity to change insurers, whichever comes first. In the case of an enrollee covered on an individual basis, coverage shall be continued until the anniversary date of the policy or for one year, whichever is earlier.

Ins 9.39 History History: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (4) Register February 2006 No. 602, eff. 3-1-06.

Ins 9.40 Ins 9.40 Required quality assurance and remedial action plans.

Ins 9.40(1) (1) In this section “quality assurance” means the measurement and evaluation of the quality and outcomes of medical care provided.

Ins 9.40(2) (2) 

Ins 9.40(2)(a) (a) By April 1, 2000, an insurer, with respect to a defined network plan that is not a preferred provider plan shall submit a quality assurance plan consistent with the requirements of s. 609.32, Stats., to the commissioner, except as provided in par. (b). The insurers shall submit a quality assurance plan that is consistent with the requirements of s. 609.32, Stats., by April 1 of each subsequent year. The quality assurance plan shall be designed to reasonably assure that health care services provided to enrollees of the defined network plan meet the quality of care standards consistent with prevailing standards of medical practice in the community. The quality assurance plan shall document the procedures used to train employees of the defined network plan in the content of the quality assurance plan.

Ins 9.40(2)(b) (b) Insurers offering a defined network plan that is not also a preferred provider plan or health maintenance organization plan shall submit a quality assurance plan consistent with the requirements of par. (a) and s. 609.32, Stats., to the commissioner by April 1, 2007, and April 1 of each subsequent year.

Ins 9.40(3) (3) Insurers offering a preferred provider plan shall develop procedures for taking effective and timely remedial action to address issues arising from quality problems including access to, and continuity of care from, participating primary care providers. The remedial action plan shall at least contain all of the following:

Ins 9.40(3)(a) (a) Designation of a senior-level staff person responsible for the oversight of the insurer’s remedial action plan.

Ins 9.40(3)(b) (b) A written plan for the oversight of any functions delegated to other contracted entities.

Ins 9.40(3)(c) (c) A procedure for the periodic review of services related to clinical protocols and utilization management performed by the insurer offering a preferred provider plan or by another contracted entity.

Ins 9.40(3)(d) (d) Periodic and regular review of grievances, complaints and OCI complaints.

Ins 9.40(3)(e) (e) A written plan for maintaining the confidentiality of protected information.