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.

Ins 9.37(4)(4) Standing referral criteria. Insurers offering a defined network plan other than a preferred provider plan shall make information available to their enrollees describing the criteria for obtaining a standing referral to a specialist, including under what circumstances and for what services a standing referral is available, how to request a standing referral, and how to appeal a standing referral determination. For purposes of s. 609.22 (4), Stats., and this subsection, referral includes prior authorization for services if the insurer uses this or similar methods for denying standing referrals to specialists without just cause and with such frequency to indicate a general business practice, as determined by the commissioner.

Ins 9.38Ins 9.38 Policy and certificate language requirements. Each policy form marketed or each certificate issued to an enrollee by an insurer offering a defined network plan or limited service health organization plan shall contain all of the following:

Ins 9.38(1)(1) Definitions. A definition of geographical service area, emergency care, urgent care, out–of–area service, dependent and primary provider, if these terms or terms of similar meaning are used in the policy or certificate and have an effect on the benefits covered by the plan. The definition of geographical service area need not be stated in the text of the policy or certificate if such definition is adequately described in an attachment that is given to all enrollees along with the policy or certificate.

Ins 9.38(2)(2) Disclosure of exclusions, limitations and exceptions. Clear disclosure of any provision that limits benefits or access to services in the exclusions, limitations, and exceptions sections of the policy or certificate. Among the exclusions, limitations and exceptions that shall be disclosed are those relating to:

Ins 9.38(3)(3) Disclosure of mandated benefits. Clear disclosure of all benefit mandates outlined in Wisconsin statutes.

Ins 9.38(4)(4) Disclosure of procedures and emergency care notification. Insurers offering a defined network plan shall do all of the following in a manner consistent with s. 609.22, Stats.:

Ins 9.38(4)(a)(a) Provide a description of the procedure for an enrollee to obtain any required referral, including the right to a standing referral, and notice that any enrollee may request the criteria for the standing referral.

Ins 9.38(4)(b)(b) Provide a description of the procedure for any enrollee to obtain a second opinion from a participating plan provider consistent with s. 609.22 (5), Stats.

Ins 9.38(4)(c)(c) Consistent with s. 609.22 (6), Stats., and s. Ins 9.32 (1) (d), an insurer offering a defined network plan may require enrollees to notify the insurer of emergency room usage, but in no case may the insurer offering a defined network plan require notification less than 48 hours after receiving services or before it is medically feasible for the enrollee to provide the notice, whichever is later. An insurer offering a defined network plan may impose no greater penalty than assessing a deductible that may not exceed the lesser of 50% of covered expenses for emergency treatment or $250.00 for failing to comply with emergency treatment notification requirements.

Ins 9.38 HistoryHistory: Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (intro.), (4) (intro.) and (c) Register February 2006 No. 602, eff. 3-1-06.

Ins 9.39(1)(1) Disclosure. The health maintenance organization or limited service health organization shall clearly disclose in the policy and certificate any circumstances under which the health maintenance organization or limited service health organization may disenroll an enrollee.

Ins 9.39(2)(2) Enrollee disenrollment criteria. Except as provided in s. 632.897, Stats., the health maintenance organization or limited service health organization may only disenroll an enrollee if one of the following occurs: