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:

Ins 9.39(2)(a)(a) The enrollee has failed to pay required premiums by the end of the grace period.

Ins 9.39(2)(b)(b) The enrollee has committed acts of physical or verbal abuse that pose a threat to providers or other members of the organization.

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(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)(a)(a) The physical or mental condition of the enrollee.

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 9.40(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: