Ins 9.12(2)(2) Insurance business is incidental or immaterial under s. 609.03 (3) (a) 3., Stats., if the business is written according to the terms of a specific business plan for issuance of coverage under s. 609.03 (3) (a) 3., Stats., and the business plan is approved in writing by the office. A request for approval to do business under this paragraph including, but not limited to, issuance of policies with point of service coverage, shall include a detailed business plan, a copy of the policy form, a detailed description of how the business will be marketed and premium volume controlled, and other information prescribed by the office. The total premium for policies containing coverages subject to this paragraph and policies issued under sub. (1) may not exceed 10% of premium earned or projected to be earned in any 12–month period.

Ins 9.12(3)(3) If the commissioner approves insurance business as incidental or immaterial the commissioner may also, by order under s. Ins 9.04 (2), require the insurer to maintain more than the minimum compulsory surplus.

Ins 9.12(4)(4) For the purpose of this section, any coverage that covers services by a provider other than a participating provider is not typically included in a health maintenance organization or limited service health organization policy, except coverage of emergency out–of–area services.

Ins 9.14Ins 9.14 Nondomestic HMO. No certificate of authority may be issued under ch. 618, Stats., to a person to do health maintenance organization or limited service health organization business in this state unless the person is organized and regulated as an insurer and domiciled in the United States.

Ins 9.15Ins 9.15 Time period. In accordance with s. 227.116, Stats., the commissioner shall review and make a determination on an application for a certificate of authority within 60 business days after it has been received.

Ins 9.20Ins 9.20 Scope. This subchapter applies to all insurers offering a defined network plan, preferred provider plan or limited service health organization in this state. The insurer shall ensure that the requirements of this subchapter are met by all defined network plans, preferred provider plans or limited service health organizations issued by the insurer. The commissioner may approve an exemption to this subchapter for an insurer to market a defined network plan, preferred provider plan or limited service health organization if the insurer files the plan with the commissioner and the commissioner determines that all of the following conditions are met:

Ins 9.20(1)(1) The coverage involves ancillary coverage with minimal cost controls, such as minimal cost controls involving vision, prescription cards or transplant centers.

Ins 9.20(2)(2) The cost controls are unlikely to significantly affect the pattern of practice.

Ins 9.20(3)(3) The exemption is consistent with the purpose of this subchapter.

Ins 9.20 HistoryHistory: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: renum. from Ins 9.31 and am. (intro.) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (intro.) Register December 2006 No. 612, eff. 1-1-07.

Ins 9.21(1)(1) Silent discount. An insurer, with respect to a defined network plan:

Ins 9.21(1)(a)(a) Is exempt from meeting the requirements under ss. 609.22, 609.24, 609.32, 609.34, 609.36 and 632.83, Stats., and ss. Ins 9.31, 9.32 (1), 9.35, 9.37, 9.38, 9.39, 9.40 (1) to (7), 9.42 (1) to (7), if the only owned, employed, or participating provider providing services covered under the plan is a silent provider network.

Ins 9.21(1)(b)(b) Is exempt from meeting the requirements under ss. 609.22, 609.24, 609.32, 609.34, and 609.36, Stats., and ss. Ins 9.32 (1), 9.35, 9.37, 9.38, 9.39, 9.40 (1) to (7), and 9.42 (1) to (7), solely with respect to services provided by the silent provider network, if the plan also covers services by providers that the insurer owns or employs, or another participating provider. An insurer is not exempt from those provisions with respect to a provider that is not a silent provider network.

Ins 9.21(2)(2) De minimus limited exception. Insurers offering a defined network plan are exempt from meeting the requirements under ss. 609.22 (1) to (4) and (8), 609.32 and 609.34, Stats., ss. Ins 9.32 (1), 9.40 (1) to (7), and 9.42 (6) and (7), with respect to a defined network plan, if the insurer meets all of the following requirements.

Ins 9.21(2)(b)(b) The insurer’s only financial incentive to the insureds to utilize participating providers is a co-insurance differential of not more than 10% between in-plan versus off-plan providers. Except for the co-insurance differential of no greater than 10%, all benefits, deductibles and co-payments must be the same regardless of whether the insured obtains benefits, services or supplies from in-plan or off-plan providers.

Ins 9.21(2)(d)(d) The insurer makes no representation that the defined network plan is a preferred provider plan or that the defined network plan directs or is responsible for the quality of health care services. Nothing in this paragraph prevents an insurer from describing the availability or limits on availability of participating providers or the extent or limits of coverage under the defined network plan if participating or non-participating providers are utilized by an insured.

Ins 9.21(2)(e)1.1. Discloses to a potential applicant, and allows the applicant a reasonable opportunity to review, a directory which reasonably and clearly discloses the availability and location of providers:

Ins 9.21(2)(e)1.a.a. Within reasonable travel distance from the principle location of the place of employment of employees likely to enroll under the plan, if the applicant is an employer; or