601.42 (1g) (d) Statements, reports, answers to questionnaires or other information, or reports, audits or certification from a certified public accountant or an actuary approved by the commissioner, relating to the extent liabilities of a health maintenance organization insurer are or will be covered liabilities, as defined in s. 609.01 (1) liabilities for health care costs for which an enrollee or policyholder of the health maintenance organization is not liable to any person under s. 609.91.

609.01 (1c) “Emergency medical condition" has the meaning given in s. 632.85 (1) (a).

609.01 (1d) “Enrollee" means, with respect to a managed care 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) Except as provided in par. (b), “health benefit plan" means any hospital or medical policy or certificate.

(b) “Health benefit plan" does not include any of the following:

1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.

2. Coverage issued as a supplement to liability insurance.

3. Liability insurance, including general liability insurance and automobile liability insurance.

4. Worker's compensation or similar insurance.

5. Automobile medical payment insurance.

6. Credit-only insurance.

7. Coverage for on-site medical clinics.

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.

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.

10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply:

a. The benefits are provided under a separate policy, certificate or contract of insurance.

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.

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.

11. Other insurance exempted by rule of the commissioner.

609.01 (2) “Health maintenance 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 enrolled participants enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers selected by the organization participating in the plan.

609.01 (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 enrolled participants enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers selected by the organization participating in the plan.

609.01 (3c) “Managed care 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 (3m) “Participating" means, with respect to a physician or other provider, under contract with a managed care plan, preferred provider plan or limited service health organization to provide health care services, items or supplies to enrollees of the managed care plan, preferred provider plan or limited service health organization.

609.01 (3r) “Physician" has the meaning given in s. 448.01 (5).

609.01 (4) “Preferred provider plan" 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 enrolled participants enrollees, for consideration other than predetermined periodic fixed payments, either comprehensive health care services or a limited range of health care services performed by providers selected by the organization participating in the plan.

609.01 (4m) “Primary care physician" means a physician specializing in family medical practice, general internal medicine or pediatrics.

609.01 (5) “Primary provider" means a participating primary care physician, or other participating provider authorized by the managed care 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 (6) “Specialist physician" means a physician who is not a primary care physician.

609.05 (1) Except as provided in subs. (2) and (3), a health maintenance organization, limited service health organization or, preferred provider plan or managed care plan shall permit its enrolled participants enrollees to choose freely among selected participating providers.

609.05 (2) A health care plan under sub. (1) Subject to s. 609.22 (4), a limited service health organization, preferred provider plan or managed care plan may require an enrolled participant enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.

609.05 (3) Except as provided in ss. 609.65 and 609.655, a health care plan under sub. (1) limited service health organization, preferred provider plan or managed care plan may require an enrolled participant enrollee to obtain a referral from the primary provider designated under sub. (2) to another selected participating provider prior to obtaining health care services from the other selected that participating provider.

609.10 (1) (a) Except as provided in subs. (2) to (4), an employer that offers any of its employes a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employes a standard plan, as provided in pars. (b) and (c), that provides at least substantially equivalent coverage of health care expenses and that is not a health maintenance organization or a preferred provider plan.

609.15 (1) (intro.) Each health maintenance organization, limited service health organization and , preferred provider plan and managed care plan shall do all of the following:

609.15 (1) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (2) for the resolution of enrolled participants' enrollees' grievances with the health care limited service health organization, preferred provider plan or managed care plan.

609.15 (1) (b) Provide enrolled participants enrollees with complete and understandable information describing the internal grievance procedure under par. (a).

609.15 (2) (a) The opportunity for an enrolled participant enrollee to submit a written grievance in any form.

609.15 (2) (b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one enrolled participant enrollee other than the grievant, if an enrolled participant enrollee is available to serve on the grievance panel.

609.17 Reports of disciplinary action. Every health maintenance organization, limited service health organization and, preferred provider plan and managed care plan shall notify the medical examining board or appropriate affiliated credentialing board attached to the medical examining board of any disciplinary action taken against a selected participating provider who holds a license or certificate granted by the board or affiliated credentialing board.

609.20 (title) Rules for preferred provider and managed care plans. (intro.) The commissioner shall promulgate rules applicable relating to preferred provider plans and managed care plans for all of the following purposes:

609.20 (1) To ensure that enrolled participants enrollees are not forced to travel excessive distances to receive health care services.

609.20 (2) To ensure that the continuity of patient care for enrolled participants is not disrupted enrollees meets the requirements under s. 609.24.

609.20 (4) To ensure that employes offered a health maintenance organization or a preferred provider plan that provides comprehensive services under s. 609.10 (1) (a) are given adequate notice of the opportunity to enroll and, as well as complete and understandable information under s. 609.10 (1) (c) concerning the differences between the health maintenance organization or preferred provider plan and the standard plan, including differences between providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization.

609.22 Access standards. (1) Providers. A managed care plan shall include a sufficient number, and sufficient types, of providers to meet the anticipated needs of its enrollees, with respect to covered benefits.

(2) Adequate choice. A managed care plan shall ensure that, with respect to covered benefits, each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.

(3) Primary provider selection. A managed care plan shall permit each enrollee to select his or her own primary provider from a list of participating primary care physicians and any other participating providers that are authorized by the managed care plan to serve as primary providers. The list shall be updated on an ongoing basis and shall include a sufficient number of primary care physicians and any other participating providers authorized by the plan to serve as primary providers who are accepting new enrollees.

(4) Specialist providers. (a) A managed care plan shall allow all enrollees under the plan to have access to specialist physicians on a timely basis when specialty medical care is warranted, with respect to covered benefits. An enrollee shall be allowed to choose among participating specialist physicians, within the limitations of the managed care plan, when a referral is made for specialty care, with respect to covered benefits. A managed care plan shall clearly disclose to enrollees any limitations.

(b) If the treatment of a specific condition for which coverage is provided under the plan requires the services of a particular type of specialist physician and a managed care plan has no participating specialist physicians of that type, the managed care plan shall provide enrollees with the specific condition with coverage for the services of nonparticipating specialist physicians of that type.

(c) 1. If a managed care plan requires a referral to a specialist physician for coverage of the specialist physician's services, the managed care plan shall establish a procedure by which an enrollee may apply for a standing referral to a specialist physician. The procedure must specify the criteria and conditions that must be met in order for an enrollee to obtain a standing referral.

2. A managed care plan may require the enrollee's primary provider to remain responsible for coordinating the care of an enrollee who receives a standing referral to a specialist physician. A managed care plan may restrict the specialist physician from making any secondary referrals without prior approval by the enrollee's primary provider. If an enrollee requests primary care services from a specialist physician to whom the enrollee has a standing referral, the specialist physician, in agreement with the enrollee and the enrollee's primary provider, may provide primary care services to the enrollee in accordance with procedures established by the managed care plan.

3. A managed care plan must include information regarding referral procedures in policies or certificates provided to enrollees and must provide such information to an enrollee or prospective enrollee upon request.

(5) Second opinions. A managed care plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.

(6) Emergency care. Notwithstanding s. 632.85, if a managed care plan provides coverage of emergency services, with respect to covered benefits, the managed care plan shall do all of the following:

(a) Cover emergency medical services for which coverage is provided under the plan and that are obtained without prior authorization for the treatment of an emergency medical condition.

(b) Cover emergency medical services or urgent care for which coverage is provided under the plan and that is provided to an individual who has coverage under the plan as a dependent child and who is a full-time student attending school outside of the geographic service area of the plan.

(7) Telephone access. A managed care plan shall provide telephone access for sufficient time during business and evening hours to ensure that enrollees have adequate access to routine health care services for which coverage is provided under the plan. A managed care plan shall provide 24-hour telephone access to the plan or to a participating provider for emergency care, or authorization for care, for which coverage is provided under the plan.

(8) Access plan for certain enrollees. A managed care plan shall develop an access plan to meet the needs, with respect to covered benefits, of its enrollees who are members of underserved populations. If a significant number of enrollees of the plan customarily use languages other than English, the managed care plan shall provide access to translation services fluent in those languages to the greatest extent possible.

609.24 Continuity of care. (1) Requirement to provide access. (a) Subject to pars. (b) and (c) and except as provided in par. (d), a managed care plan shall, with respect to covered benefits, provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the managed care plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times:

1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period.