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)(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 9.40Ins 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)(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. Ins 9.40(3)(f)(f) Documentation of timely correction of access to and continuity of care issues identified in the plan. Documentation shall include all of the following: Ins 9.40(3)(f)1.1. The date of awareness that an issue exists for which a remedial action plan shall be initiated. Ins 9.40(3)(f)2.2. The type of issue that is the focus of the remedial action plan. Ins 9.40(3)(f)3.3. The person or persons responsible for developing and managing the remedial action plan.