609.60 Optometric coverage. 609.65 Coverage for court-ordered services for the mentally ill. 609.655 Coverage of certain services provided to dependent students. 609.70 Chiropractic coverage. 609.71 Disclosure of payments. 609.715 Coverage of alcoholism and other diseases. 609.717 Mental health services provided by a recovery charter school. 609.75 Adopted children coverage. 609.755 Coverage of dependents. 609.76 Coverage of student on medical leave. 609.77 Coverage of breast reconstruction. 609.78 Coverage of treatment for the correction of temporomandibular disorders. 609.79 Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care. 609.80 Coverage of mammograms. 609.805 Coverage of contraceptives. 609.81 Coverage related to HIV infection. 609.82 Coverage without prior authorization for emergency medical condition treatment. 609.83 Coverage of drugs and devices. 609.837 Copayment equality for oral and injected chemotherapy. 609.84 Experimental treatment. 609.846 Discrimination based on COVID-19 prohibited. 609.85 Coverage of lead screening. 609.86 Coverage of hearing aids, cochlear implants, and related treatment for infants and children. 609.87 Coverage of treatment for autism spectrum disorders. 609.875 Coverage of colorectal cancer screening. 609.88 Coverage of immunizations. 609.885 Coverage of COVID-19 testing. 609.89 Written reason for coverage denial. 609.90 Restrictions related to domestic abuse. 609.91 Restrictions on recovering health care costs. 609.92 Hospitals, individual practice associations and providers of physician services. 609.925 Election to be subject to restrictions. 609.93 Scope of election by an individual practice association or clinic. 609.935 Notices of election and termination. 609.94 Summary of restrictions. 609.95 Minimum covered liabilities. 609.96 Initial capital and surplus requirements. 609.97 Compulsory and security surplus. Ch. 609 Cross-referenceCross-reference: See definitions in ss. 600.03 and 628.02. Ch. 609 Cross-referenceCross-reference: See also ch. Ins 9, Wis. adm. code. 609.001609.001 Joint ventures; legislative findings. 609.001(1)(1) The legislature finds that increased development of health maintenance organizations, preferred provider plans and limited service health organizations may have the effect of putting small, independent health care providers at a competitive disadvantage with larger health care providers. In order to avoid monopolistic situations and to provide competitive alternatives, it may be necessary for those small, independent health care providers to form joint ventures. The legislature finds that these joint ventures are a desirable means of health care cost containment to the extent that they increase the number of entities with which a health maintenance organization, preferred provider plan or limited service health organization may choose to contract and to the extent that the joint ventures do not violate state or federal antitrust laws. 609.001(2)(2) The legislature finds that competition in the health care market will be enhanced by allowing employers and organizations which otherwise act independently to join together in a manner consistent with the state and federal antitrust laws for the purpose of purchasing health care coverage for employees and members. These joint ventures will allow purchasers of health care coverage to obtain volume discounts when they negotiate with insurers and health care providers. These joint ventures should result in an improved business climate in this state because of reduced costs for health care coverage. 609.001 HistoryHistory: 1985 a. 29. 609.01609.01 Definitions. In this chapter: 609.01(1b)(1b) “Defined network plan” means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with, or employed by the insurer offering the health benefit plan. 609.01(1d)(1d) “Enrollee” means, with respect to a defined network plan, preferred provider plan, or limited service health organization, a person who is entitled to receive health care services under the plan. 609.01(1g)(a)(a) Except as provided in par. (b), “health benefit plan” means any hospital or medical policy or certificate. 609.01(1g)(b)(b) “Health benefit plan” does not include any of the following: 609.01(1g)(b)1.1. Coverage that is only accident or disability income insurance, or any combination of the 2 types. 609.01(1g)(b)3.3. Liability insurance, including general liability insurance and automobile liability insurance. 609.01(1g)(b)8.8. Other similar insurance coverage, as specified in regulations issued by the federal department of health and human services, under which benefits for medical care are secondary or incidental to other insurance benefits. 609.01(1g)(b)9.9. If provided under a separate policy, certificate or contract of insurance, or if otherwise not an integral part of the policy, certificate or contract of insurance: limited-scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those benefits; and such other similar, limited benefits as are specified in regulations issued by the federal department of health and human services under section 2791 of P.L. 104-191. 609.01(1g)(b)10.10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply: 609.01(1g)(b)10.a.a. The benefits are provided under a separate policy, certificate or contract of insurance. 609.01(1g)(b)10.b.b. There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor. 609.01(1g)(b)10.c.c. Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. 609.01(1j)(1j) “Health care costs” means consideration for the provision of health care, including consideration for services, equipment, supplies and drugs. 609.01(2)(2) “Health maintenance organization” means a health care plan offered by an organization established under ch. 185 or 193, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers participating in the plan. 609.01(3)(3) “Limited service health organization” means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers participating in the plan. 609.01(3m)(3m) “Participating” means, with respect to a physician or other provider, under contract with a defined network plan, preferred provider plan, or limited service health organization to provide health care services, items or supplies to enrollees of the defined network plan, preferred provider plan, or limited service health organization. 609.01(4)(4) “Preferred provider plan” means a health care plan offered by an organization established under ch. 185, 193, 611, 613, or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, without referral and for consideration other than predetermined periodic fixed payments, coverage of either comprehensive health care services or a limited range of health care services, regardless of whether the health care services are performed by participating or nonparticipating providers. 609.01(4m)(4m) “Primary care physician” means a physician specializing in family medical practice, general internal medicine or pediatrics. 609.01(5)(5) “Primary provider” means a participating primary care physician, or other participating provider authorized by the defined network plan, preferred provider plan, or limited service health organization to serve as a primary provider, who coordinates and may provide ongoing care to an enrollee. 609.01(5m)(5m) “Provider” means a health care professional, a health care facility or a health care service or organization. 609.01(7)(7) “Standard plan” means a health care plan other than a health maintenance organization or a preferred provider plan. 609.01 AnnotationUnder this section, an HMO enrollee has no personal liability for the costs of covered health care received. A hospital only has recourse against the HMO and may not assert its lien rights under this section against insurance proceeds paid by a tortfeasor’s insurer to the HMO enrollee. Dorr v. Sacred Heart Hospital, 228 Wis. 2d 425, 597 N.W.2d 462 (Ct. App. 1999), 98-1772. 609.01 AnnotationSections 609.01 and 609.91 do not prohibit HMOs from asserting contractual subrogation rights with respect to actual medical expenses incurred by an HMO for medical care covered by the HMO’s contract with an enrollee. Sub. (2) says that an HMO is an entity that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services but does not put in place a general limitation on all sources of funds available to HMOs. Torres v. Dean Health Plan, Inc. 2005 WI App 89, 282 Wis. 2d 725, 698 N.W.2d 107, 03-3274. 609.03609.03 Indication of operations. 609.03(1)(1) Certificate of authority. An insurer may apply to the commissioner for a new or amended certificate of authority that limits the insurer to engaging in only the types of insurance business described in sub. (3). 609.03(2)(2) Statement of operations. If an insurer is a cooperative association organized under ss. 185.981 to 185.985, the insurer may apply to the commissioner for a statement of operations that limits the insurer to engaging in only the types of insurance business described in sub. (3). 609.03(3)(a)(a) An insurer that has a new or amended certificate of authority under sub. (1) or a statement of operations under sub. (2) may engage in only the following types of insurance business:
/statutes/statutes/609
true
statutes
/statutes/statutes/609/_48
Chs. 600-655, Insurance
section
true
