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.