Ins 9.05(6)(f)(f) A peer review process.
Ins 9.05(6)(g)(g) A process to inform enrollees on the results of the insurer’s quality assurance program.
Ins 9.05(6)(h)(h) Any additional information requested by the commissioner.
Ins 9.05(7)(7)Plan administration. A summary of how administrative services will be provided, including the size and qualifications of the administrative staff and the projected cost of administration in relation to premium income. If management authority for a major corporate function is delegated to a person outside the organization, the business plan shall include a copy of the contract. Contracts for delegated management authority shall be filed for approval with the commissioner under ss. 611.67 and 618.22, Stats. The contract shall include all of the following:
Ins 9.05(7)(a)(a) The services to be provided.
Ins 9.05(7)(b)(b) The standards of performance for the manager.
Ins 9.05(7)(c)(c) The method of payment including, any provisions for the administrator to participate in the profit or losses of the plan.
Ins 9.05(7)(d)(d) The duration of the contract.
Ins 9.05(7)(e)(e) Any provisions for modifying, terminating or renewing the contract.
Ins 9.05(8)(8)Financial projections. A summary of: current and projected enrollment; income from premiums by type of payor; other income; administrative and other costs; the projected break even point, including the method of funding the accumulated losses until the break even point is reached; and a summary of the assumptions made in developing projected operating results.
Ins 9.05(9)(9)Financial guarantees. A summary of all financial guarantees by providers, sponsors, affiliates or parents within a holding company system, or any other guarantees which are intended to ensure the financial success of the health maintenance organization insurer. These include hold harmless agreements by providers, insolvency insurance, reinsurance or other guarantees.
Ins 9.05(10)(10)Contracts with enrollees. A summary of benefits to be offered enrollees including any limitations and exclusions and the renewability of all contracts to be written.
Ins 9.05 HistoryHistory: Cr. Register, February, 2000, No. 530, eff. 3-1-00.
Ins 9.06Ins 9.06Changes in the business plan.
Ins 9.06(1)(1)A health maintenance organization insurer or an insurer licensed to write only limited service health organization business shall file a written report of any proposed substantial change in its business plan. The insurer shall file the report at least 30 days prior to the effective date of the change. The office may disapprove the change. The insurer may not enter into any transaction, contract, amendment to a transaction or contract or take action or make any omission that is a substantial change in the insurer’s business plan prior to the effective date of the change or if the change is disapproved. Substantial changes include changes in articles and bylaws, organization type, geographical service areas, provider agreements, provider availability, plan administration, financial projections and guarantees and any other change that might affect the financial solvency of the plan. Any changes in the items listed in s. Ins 9.05 (4) shall be filed under this section.
Ins 9.06(2)(2)A change in the quality assurance plan conducted in accordance with s. Ins 9.40 and s. 609.32, Stats., is not a reportable change in a business plan.
Ins 9.06 HistoryHistory: Cr. Register, February, 2000, No. 530, eff. 3-1-00.
Ins 9.07Ins 9.07Copies of provider agreements.
Ins 9.07(1)(1)Notwithstanding any claim of trade secret or proprietary information, all insurers offering a defined network plan, preferred provider plan or limited service health organization shall, upon request, from the commissioner, make available to the commissioner all executed copies of any provider agreements between the insurer and intermediate entities or individual providers. Any party to a provider agreement may assert that a portion of the contracts contain trade secrets, and the commissioner may withhold that portion to the extent it may be withheld under s. Ins 6.13.
Ins 9.07(2)(2)All health maintenance organization insurers or insurers licensed to write only limited service health organization business shall file with the commissioner, prior to doing business, copies of all executed provider agreements and other contracts covering liabilities of the health maintenance organization. For contracts with providers, a list of providers executing a standard contract and a copy of the form of the contract may be filed instead of copies of the executed contracts.
Ins 9.07 HistoryHistory: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (1) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (1) Register December 2006 No. 612, eff. 1-1-07.
Ins 9.08Ins 9.08Other reporting requirements.
Ins 9.08(1)(1)Annual statement. All insurers authorized to write health maintenance organization business and insurers licensed to write only limited service health organization business shall file with the commissioner by March 1 of each year an annual statement for the preceding year. A health maintenance organization insurer and limited service health organization insurer shall use the current health annual statement blank prepared by the national association of insurance commissioners.
Ins 9.08(1)(a)(a) A health maintenance organization insurer shall include with its annual statement a statement of covered expenses, and a special procedures opinion from a certified public accountant, in the form prescribed by the commissioner as appendix A.
Ins 9.08(1)(b)(b) A health maintenance organization insurer shall file a quarterly report, including a report concerning covered expenses, in a form prescribed by the commissioner within 45 days after the close of each of the first 3 calendar quarters of the year unless the commissioner has notified the insurer that another reporting schedule is appropriate.
Ins 9.08(1)(c)(c) A health maintenance organization insurer shall include with its annual audit financial reports filed under s. Ins 50.05 a statement of covered expenses and an audit opinion concerning the statement. Both the statement and opinion shall be in the form prescribed by the commissioner as appendix B and are due no later than May 1 of each year.
Ins 9.08(1m)(1m)Medicare and Medicaid Health Maintenance Organizations. A health maintenance organization insurer that writes 100 % of its business to Medicare or Medicaid recipients, or a combination of the 2, is not required to include a special procedures opinion from a certified public accountant as required by sub. (1) (a) or an audit opinion concerning the statement of covered expenses as required by sub. (1) (c).
Ins 9.08(2)(2)Quarterly report. An insurer writing health maintenance organization business, other than a health maintenance organization insurer, shall file a quarterly report in a form prescribed by the commissioner within 45 days after the close of each of the first 3 calendar quarters of the year unless the commissioner notifies the insurer that another reporting schedule is appropriate.
Ins 9.08(3)(3)Presumptions.