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)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(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 9.36(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 9.37(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(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.