20 * $150 = $3,000
20 * $50 = $1,000
Total revenue increase = $34,000
• Operating without a license: A fee equal to the annual licensing fee has been added to the rule for facilities found to be purposefully operating without a license. This fee will not apply to someone who is merely late in renewing, or who inadvertently misplaces the fee notice.
Benefits of the code revisions:
Pool operators understand the need to keep the public safe, and the goal of keeping their operations open. These administrative rule revisions address both of those issues.
• Serious but flexible lifeguard plans will help pool operators keep their operations safe.
• A Certified Pool Operator is an expert at maintaining water quality and pool safety, establishing policies and procedures to provide a constant safe environment, and training staff. Certified Pool Operators are also trained in monitoring and testing pool water, in order to maintain proper pool chemical balances.
• The test kit reagent required in these rule revisions is less expensive than kits currently used. Since pools are tested up to 4 or more times per day, over time, this will mean a considerable savings to the industry.
• The new fees require services to be paid for by the operators who require the services rather than by dividing them among all operators.
Operations that are built or redesigned so that pools will be direct sources of income will face additional training and labor costs as outlined above. Most pools in Wisconsin are simple swimming pools or spas designed and operated as an amenity to lodging. These operations will feel little or no impact from the proposed revisions.
Fiscal estimate
The DHFS proposes to repeal and re-establish HFS 172 regulating the operation and maintenance of public pools and water attractions. Presently, the DHFS or agent local health departments are required by statute to perform a pre-inspection - a detailed examination of a new public pool or water attraction to ensure administrative code compliance - prior to issuing a license. The proposed changes in this rule would establish a pre-inspection fee to recover the program costs associated with the pre-inspection. The DHFS also proposes to establish fees for re-inspection of facilities to recover costs associated with facilities that are found to have significant violations of administrative code which would require a follow-up inspection. The proposed rule changes also incorporate the transfer of responsibility for the routine safety inspection of waterslides from the Department of Commerce to the Department of Health and Family Services or agent local public health departments and include fees to recover the costs associated with these inspections. The proposed fees are scaled to the complexity of the facility to reflect the amount of time and cost associated with the inspection. It is estimated that the fee changes described above will result in approximately $100,000 additional program revenue to the DHFS annually.
The proposed rule changes would require additional responsibilities of the local agent public health departments. Staff would be required to verify lifeguard staffing plans for public pools and water attractions, and inspect waterslides within their jurisdiction. Local agent public health departments are able to set annual license fees to recover the costs of these additional responsibilities.
It is estimated that total annual costs to the industry for the new pre-inspection fees for approximately 200 to 400 newly constructed facilities and facilities changing ownership would be $50,000 to $60,000. It is estimated that 100 to 200 facilities will require re-inspections annually due to significant compliance problems resulting in annual costs to the industry of $7,500 to $15,000. The proposed pre-inspection and reinspection fees will not impact existing and compliant public pools and water attractions. An estimated 200 new facilities with water or pool slides will apply for permits and be charged fees of between $50 to $150, for a total estimated cost to the industry of $20,000 annually. Total charges to the industry from permit fees, pre-inspection fees, and re-inspection fees are estimated to be approximately $100,000 annually.
There will be fiscal impacts to existing public pools and water attractions associated with proposed new health and safety operational requirements. Facilities may require an additional lifeguard or attendant. It is difficult to estimate the number of facilities impacted by this proposed change; however it is estimated that only about 200 to 300 of the 4,000 licensed individual facilities in Wisconsin may be affected and most of those are likely already in full compliance. Additionally, the rule proposes that water attractions employ a certified pool operator. While most existing water attractions are already in compliance with this proposed change, it is estimated that approximately 20 new or expanded facilities will be constructed annually.
Document Copies
A copy of the full text of the rules and the full text of the fiscal estimate, and other documents associated with this rulemaking may be obtained, at no charge, from the Wisconsin Administrative Rules website at
http://adminrules.wisconsin.gov or by contacting:
Tracynda Davis
1 W. Wilson Street, Room 150
Madison, WI 53702
Phone: 608-266-8924
Fax: 608-267-3241
Small Business Regulatory Review Coordinator
For matters or comments concerning a rule's impact on small businesses, contact:
Notice of Hearing
Insurance
NOTICE IS HEREBY GIVEN that pursuant to the authority granted under s.
601.41(3), Stats., and the procedures set forth in under s.
227.18, Stats., OCI will hold a public hearing to consider the adoption of the attached proposed rulemaking order affecting Section
Ins , Wis. Adm. Code, relating to defined network plans, preferred provider plans, limited service health organizations and limited scope plans and affecting small businesses.
Hearing Information
Date: August 2, 2006
Time: 1:30 p.m., or as soon thereafter as the
matter may be reached
Place: OCI, Room 227
125 South Webster Street
2nd Floor
Madison, WI
Written comments
Written comments can be mailed to:
Julie Walsh
Legal Unit - OCI Rule Comment for Rule Ins
Office of the Commissioner of Insurance
PO Box 7873
Madison WI 53707-7873
Written comments can be hand delivered to:
Julie Walsh
Legal Unit - OCI Rule Comment for Rule Ins
Office of the Commissioner of Insurance
125 South Webster St – 2nd Floor
Madison WI 53702
Comments can be emailed to:
Julie Walsh
Comments submitted through the Wisconsin Administrative Rule website at: http://adminrules. wisconsin.gov on the proposed rule will be considered.
The deadline for submitting comments is 4:00 p.m. on the 8th day after the date for the hearing stated in this Notice of Hearing.
Copy of rule and contact person
A copy of the full text of the proposed rule changes, analysis and fiscal estimate may be obtained from the OCI internet WEB site at
http://oci.wi.gov/ocirules.htm or by contacting Inger Williams, Services Section, OCI, at:
Analysis prepared by the Office of the Commissioner of Insurance (OCI)
The Commissioner of Insurance is authorized to promulgate rules under ss.
601.41 and
609.20, Stats. Section
609.20, Stats., permits the Commissioner to promulgate rules relating to preferred provider plans and defined network plans in order to ensure enrollee access to health care services and ensure continuity of health care while recognizing the differences between preferred provider plans and defined network plans.
4. Related Statutes or rules: There are no related statutes or rules.
Plain language analysis and summary
The proposed rule:
1) Eliminates the term “limited scope plan" from provisions governing defined network and preferred provider plans. The commissioner's intent is to eliminate the application to limited scope plans of certain rules promulgated in
Clearinghouse Rule 05-059.
2) Changes the provision governing improper utilization practices so as prohibit improper practices but not deem the insurer a defined network plan.
3) Eliminates specific requirements relating to network location, hours, waiting times and availability of after hours care but retains the requirement that access must be reasonably prompt consistent with normal practices and standards in the area.
4) Makes it clear that coverage of emergency medical services at in-network cost sharing is not required after the point that the provider has met its obligation to treat the enrollee under federal law.
Comparison with federal regulation
There is no federal regulation that addresses the activities regulated by the proposed rule.
Comparison of adjacent states
Iowa: Iowa statute §514C.16, requires a carrier which provides coverage for emergency services to be responsible for charges for emergency services furnished outside any contractual provider network or preferred provider network for covered individuals. Iowa Administrative Code s. 191-27.4 (1)(a), requires a health benefit plan which provides for incentives for covered persons to use the health care services of a preferred provider to contain a provision that if a covered person receives emergency services specified in the preferred provider arrangement and cannot reasonably reach a preferred provider, emergency services rendered during the course of the emergency will be reimbursed as though the covered person had been treated by a preferred provider, subject to any restrictions which may govern payment by a preferred provider for emergency services. Iowa statute §514B and Administrative Code 191-40.21, require HMOs to reimburse a provider of emergency services after a review of the care and may not deny reimbursement solely on the grounds that the services were provided by non-contracted providers.
Iowa statute §514F.3 requires the commissioner of insurance to adopt rules for preferred provider contracts and organizations and to adopt rules related to preferred provider arrangements. Iowa statute §514K.1 requires HMOs, organized delivery systems or an insurer using a preferred provider arrangement to provide to its enrollees written information that at a minimum must include the following; a description of the plan's benefits and exclusions, enrollee cost-sharing requirements, list of participating providers, disclosure of drug formularies, explanation for accessing emergency care services, policy for addressing investigational or experimental treatments, methodologies used to compensate providers, performance measures as determined by the commissioner and information on how to access internal and external grievance procedures. In addition the Iowa department must annually publish a consumer guide providing a comparison by plan on performance measures, network composition, and other key information to enable consumers to better understand plan differences.
Iowa Administrative Code 191-27.3 (1), requires preferred provider arrangements to establish the amount and manner of payment to a preferred provider, the mechanisms designed to minimize cost of the health benefits plan and ensure reasonable access to covered services under the preferred provider arrangement. Iowa Administrative Code 191-27.4 (1) (b), requires preferred provider plans to contain a provision that clearly identifies the differentials in benefit levels for health care services of preferred providers and non-preferred providers. Iowa Administrative Code 191-27.4 (2), requires that if a health benefit plan provides difference in benefit levels payable to preferred providers compared to other providers, such difference shall not unfairly deny payment for covered services and shall be no greater than necessary to provide a reasonable incentive for covered persons to use the preferred provider.
Illinois: Illinois statutory code 215 ILCS 5/370o, requires any preferred provider contract to provide the enrollee emergency care coverage regardless of whether the emergency care is provided by a preferred or non-preferred provider and the coverage shall be at the same benefit level as if the service or treatment had been rendered by a plan provider. Section 215 ILCS 5/370i, sec. (a) prohibits policies from containing provisions that would unreasonably restrict the access and availability of health care services for the enrollee. Section 215 ILCS 134/40, sec. 40 (d) requires a health care plan to pay for services of a specialist with the enrollee only responsible for the services as though the services were provided by an in-network provider when the plan does not have the specialist that the enrollee needs for the care of an on-going specific condition. The primary care physician arranges for the enrollee to see a specialist that is within a reasonable distance and travel time and the primary provider notifies the plan of the referral.
The information required to be provided to consumers is contained in s. 215 ILCS 134/15, that requires annual reporting of participating health care providers in the plan's service area and in addition to basic terms of the plan, includes disclosure of out-of-area coverage, if any, financial responsibility of enrollees including co-payments, deductibles, premium and any other out-of-pocket expenses, continuity of care, appeal rights and mandated benefits. Illinois Administrative Code s. 5420.40, requires disclosure so that a person can compare the attributes of various health care plans based upon a description of coverage. This disclosure includes that 2 appendices are completed that detail specific co-payments, coinsurance, deductibles, and other cost-sharing provisions for services that must be included with the policy for consumer information.
In addition to the worksheets that provide consumers with detailed information, Illinois statutory code s. 215ILCS 5/356z.2, also requires an insurer that issues or renews a individual or group accident and health policy and arranges, contracts with or administers contracts with providers whereby the beneficiary are provided an incentive to use the services of such provider must include the following disclosure of limited benefits in its contracts and evidence of coverage:
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a non-participating provider for a covered service in non-emergency situations, benefit payments to such non-participating provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy's fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical are where the services are performed), or other method as defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-participating providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill. Participating providers have agreed to accept discounted payment for services with no additional billing to the member other than co-insurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll free telephone number on your identification card. (Emphasis in original.)
Illinois statute s. 215 ILCS 134/80 requires that health care plans have procedures for quality assessment program including in s. (3) and (4) that require plans have a procedure for remedial action to correct quality problems that have been verified in accordance with the written plan's methodology and criteria, including written procedures for taking appropriate corrective action and follow-up measures implemented to evaluate the effectiveness of the action plan.
Illinois Administrative Code s. 5420.50 requires that all provider agreements contain provisions providing for advance notice from providers when terminating from the plan and requirements that the plan notify affected enrollees on a timely basis. The notice provided to the enrollee must contain information on how enrollees are to select a new health care provider.
Minnesota: Minnesota statute s. 62A.049, prohibits an accident and sickness policy from requiring prior authorization in cases of emergency confinement or emergency treatment. The enrollee or authorized representative must notify the insurer as soon as reasonably possible. Section 62Q.55 requires managed care organizations including preferred provider organization, to provide enrollees with available and accessible emergency services. Services shall be covered whether provided by participating or nonparticipating providers and whether provided within or outside the health plan's service area. Section 62D.20 and s. 4685.0700, Minnesota Administrative Code, require HMOs to provide out-of-area services including for emergency care.
Minnesota statute s. 62Q.49 (subd. 2) (a), requires all health plans to clearly specify how the cost of health care used to calculate any co-payments, coinsurance or lifetime benefits will be affected by the contracting in which health care providers agree to accept discounted charges. Further any marketing or summary materials must be disclosed prominently and clearly explain the provisions relating to co-payments, coinsurance or maximum lifetime benefits.
Minnesota statute s. 62Q.58, requires that if an enrollee receives services from a nonparticipating specialist because a participating specialist is not available, the services must be provided at no additional cost to the enrollee beyond what the enrollee would otherwise pay for services received from a participating specialist.
Minnesota statute s. 62Q.746, permits the department to request and the health plan to provide the following information including how the plan determines who are eligible to participating in the network, the number of full-time equivalent physicians, by specialty, non-physician providers and allied health providers used to provide services and summary data that is broken down by type of provider reflecting actual utilization of network and non-network practitioners and allied professionals by enrollees of the plan.
Michigan: Michigan statute s.
500.3406k, requires an expense-incurred hospital, medical or surgical policy that provides coverage for emergency health services, including an HMO plan, to provide coverage for medically necessary services provided to an enrollee for the sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity, that the absence of immediate care could reasonably be expected to result in serious jeopardy to health without prior authorization.
Insurers that contract with providers are governed by the Prudent Purchaser Act of 1984 including preferred provider organization (MCL 550.50 et seq.). The organization that contracts with providers shall annually report to the commissioner basic utilization of the providers (MCL 550.56). Under MCL 550.53, organizations that contract with providers to control costs and utilization may limit the number of providers to the number necessary to assure reasonable levels of access to health care services, located within reasonable distance.
Summary of factual data and analytical methodologies
The information OCI used in support of this proposed rule includes the information described in the analysis of
Clearinghouse Rule 05-059. However more specifically it includes the information provided by representatives of the insurance industry, preferred provider organizations, and providers in a series of meetings, and in responses to OCI's requests for comments and information, concerning the topics addressed by the proposed rule.
Fiscal estimate
There will be no state or local government fiscal effect.
This rule will not have a significant fiscal effect on the private sector. Its effect will be to limit requirements otherwise applied by rules currently in effect, including
Clearinghouse rule 05-059.
Initial regulatory flexibility analysis
This rule does not impose any additional requirements on small businesses. Its effect will be to limit requirements otherwise applied by rules currently in effect, including Clearing house rule 05-059.
Notice is hereby further given that pursuant to s.
227.114, Stats., the proposed rule may have an effect on small businesses. The initial regulatory flexibility analysis is as follows:
a. Types of small businesses affected: Insurers
b. Description of reporting and bookkeeping procedures required: None beyond those currently required.
c. Description of professional skills required: None beyond those currently required.
The OCI small business coordinator is Eileen Mallow and may be reached at phone number (608) 266- 7843 or at email address
Eileen.Mallow@oci.state.wi.us
