Ins 9.25 HistoryHistory: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; emerg. cr. (8), eff. 9-1-06; CR 06-083: am. (4) Register December 2006 No. 612, eff. 1-1-07; CR 06-118: cr. (8) Register April 2007 No. 616, eff. 5-1-07.

Ins 9.26Ins 9.26 Preferred provider plan subject to defined network plan regulations. An insurer offering a preferred provider plan that does not cover the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider is subject to the requirements of a defined network plan that is not a preferred provider plan including ss. Ins 9.31, 9.32 (1), 9.35 (1), 9.37 (4), 9.40 (2) and (4), and 18.03 (2) (c) 1., and ss. 609.22 (2), (3), (4) and (7), 609.32 (1) and 609.34 (1), Stats.

Ins 9.27(1)(1) Except as provided in s. Ins 9.25 (2), insurers offering a preferred provider plan that apply a coinsurance percentage when the services are performed by nonparticipating providers at a different percentage than the coinsurance percentage that is applied when the services are performed by participating providers shall offer plans that have either of the following:

Ins 9.27(1)(a)(a) The coinsurance differential between participating and nonparticipating providers performing the same services is 30% or less.

Ins 9.27(1)(b)(b) The coinsurance differential between participating and nonparticipating provider performing the same services is greater than 30% and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25 (5).

Ins 9.27(2)(2) Except as provided in s. Ins 9.25 (2), insurers offering a preferred provider plan that apply a deductible when the services are performed by nonparticipating providers in a different amount than the deductible that is applied when the services are performed by participating providers shall offer plans that have either of the following:

Ins 9.27(2)(a)(a) The deductible applied to nonparticipating providers is no more than 2 times greater than the deductible applied to participating providers or no more than $2000 higher than the participating provider deductible.

Ins 9.27(2)(b)(b) The deductible applied to nonparticipating providers is more than 2 times greater than the deductible applied to participating providers or is more than $2000 higher than the participating provider deductible and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25 (5).

Ins 9.27(3)(3) Except as provided in s. Ins 9.25 (2), insurers offering a preferred provider plan that apply a co-payment when the services are performed by nonparticipating providers in a different amount than the co-payment that is applied when the services are performed by participating providers shall offer plans that have either of the following:

Ins 9.27(3)(a)(a) The co-payment applied to nonparticipating providers is no more than 3 times greater than the co-payment applied to participating providers or no more than $100 for services of a health care provider or no more than $300 for services of a health care facility.

Ins 9.27(3)(b)(b) The co-payment applied to nonparticipating providers is more than 3 times greater than the co-payment applied to participating providers or is more than $100 for services of a health care provider or is more than $300 for services of a health care facility and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25 (5).

Ins 9.27(4)(4) This section first applies to an insurer offering a preferred provider plan beginning on January 1, 2007. This section does not apply to an insurer with respect to a preferred provider plan issued prior to January 1, 2007 and periodically renewed after December 31, 2006.

Ins 9.27 HistoryHistory: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; emerg. cr. (4), eff. 9-1-06; CR 06-118: cr. (4) Register April 2007 No. 616, eff. 5-1-07.

Ins 9.30Ins 9.30 Group and blanket health insurers compliance. The commissioner finds that the circumstances of offering a group or blanket health insurance policy require that the insurer offering the policy otherwise exempt from chs. 600 to 646, Stats., under s. 600.01 (1) (b) 3., Stats., comply with s. Ins 9.32 (2) and s. 609.22 (2), Stats., in order to provide adequate protection to Wisconsin enrollees and the public. An insurer that covers 100 or more residents of this state under a policy otherwise exempt under s. 600.01 (1) (b) 3., Stats., shall comply with s. Ins 9.32 (2) and s. 609.22 (2), Stats.

Ins 9.31(1)(1) An insurer offering a defined network plan that is not a preferred provider plan shall file an annual certification with the commissioner no later than August 1 of each year certifying compliance with the access standards of s. 609.22, Stats., and s. Ins 9.32 (1) for the preceding year. The certification shall be submitted on a form prescribed by the commissioner and signed by an officer of the company.

Ins 9.31(2)(2) An insurer offering a preferred provider plan shall file an annual certification with the commissioner no later than August 1 of each year certifying compliance with the access standards contained in ss. 609.22 (1), (4m), (5), (6) and (8), Stats., and s. Ins 9.32 (2) for the preceding year, on a form prescribed by the commissioner and signed by an officer of the company. The certification is to be filed within 3 months after March 1, 2006, and thereafter, no later than August 1 of each year.

Ins 9.31 NoteNote: A copy of the certification of access standards form required under sub. (1), OCI26-110, and sub. (2), OCI26-111, may be obtained at no cost from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison, WI, 53707-7873 or from the OCI website address: http://oci.wi.gov.

Ins 9.32(1)(a)(a) Provide covered benefits by plan providers with reasonable promptness with respect to geographic location, hours of operation, waiting times for appointments in provider offices and after hours care. The hours of operation, waiting times, and availability of after hours care shall reflect the usual practice in the local area. Geographic availability shall reflect the usual medical travel times within the community.

Ins 9.32(1)(b)(b) Have sufficient number and type of plan providers to adequately deliver all covered services based on the demographics and health status of current and expected enrollees served by the plan.

Ins 9.32(1)(c)(c) Provide 24-hour nationwide toll-free telephone access for its enrollees to the plan or to a Wisconsin participating provider for authorization for care which is covered by the plan.

Ins 9.32(1)(d)(d) Provide as a covered benefit the emergency services rendered during the treatment of an emergency medical condition, as defined by s. 632.85, Stats., by a nonparticipating provider as though the services was provided 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 subject to any restriction which may govern payment to a participating provider for emergency services. The insurer shall pay the nonparticipating provider at the rate the insurer pays a nonparticipating provider after applying any co-payments, coinsurance, deductibles or other cost-sharing provisions that apply to participating providers.