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. Ins 9.40(3)(f)6.6. The established time frame for re-evaluation of the issue to ensure resolution and compliance with the remedial action plan. Ins 9.40(4)(4) All insurers offering a defined network plan, other than a preferred provider plan, shall establish and maintain a quality assurance committee and a written policy governing the activities of the quality assurance committee that assigns to the committee responsibility and authority for the quality assurance program. All complaints, OCI complaints, appeals and grievances relating to quality of care shall be reviewed by the quality assurance committee. Ins 9.40(7)(7) No later than April 1, 2001, with respect to an insurer offering a defined network plan that is a health maintenance organization plan, and by April 1, 2008, for insurers offering a defined network plan that is not also a preferred provider plan or health maintenance organization plan, shall do all of the following: Ins 9.40(7)(a)(a) Include a summary of its quality assurance plan in its marketing materials. Ins 9.40(7)(b)(b) Include a brief summary of its quality assurance plan and a statement of patient rights and responsibilities with respect to the plan in its certificate of coverage or enrollment materials. Ins 9.40(8)(8) Beginning April 1, 2000, an insurer offering any defined network plan shall submit an annual certification for each plan with the commissioner no later than April 1 of each year. The certification shall assert the type of plan and be signed by an officer of the company. OCI shall maintain for public review a current list of health benefit plans, categorized by type. Ins 9.40 HistoryHistory: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (2), (3), (4), (6), (7) and (8), r. (1) (c) Register February 2006 No. 602, eff. 3-1-06; reprinted to restore dropped copy in (3), Register September 2006 No. 609; CR 17-015: consol. (1) (intro.), (b) and renum. and am., r. (1) (a), (5), (6) Register December 2017 No. 744, eff. 1-1-18. Ins 9.41Ins 9.41 Right of the commissioner to request OCI complaints be handled as grievances. An insurer offering a defined network plan, preferred provider plan or limited service health organization shall treat and process an OCI complaint as a grievance at the request of the commissioner. The commissioner will provide a written description of the OCI complaint to the insurer. Ins 9.42Ins 9.42 Compliance program requirements. Ins 9.42(1)(1) All insurers offering a defined network plan, preferred provider plan or limited service health organization except to the extent otherwise exempted under this chapter or by statute, are responsible for compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., applicable sections of this subchapter and other applicable sections including but not limited to s. Ins 9.07. Insurers offering a defined network plan, preferred provider plan or limited service health organization, to the extent they are required to comply with those provisions, shall establish a compliance program and procedures to verify compliance. Nothing in this section shall affect the availability of the privilege established under s. 146.38, Stats. Ins 9.42(2)(2) The insurers shall establish and operate a compliance program that provides reasonable assurance that: Ins 9.42(3)(3) The insurer’s compliance program shall include regular internal audits, including regular audits of any contractors or subcontractors who perform functions relating to compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter or any applicable sections including but not limited to s. Ins 9.07.