SB380,3,32 40.51 (12) Every managed care plan, as defined in s. 609.01 (3c), that is offered
3by the state under sub. (6) shall comply with ch. 609.

SB380,3,65 40.51 (13) Every managed care plan, as defined in s. 609.01 (3c), that is offered
6by the group insurance board under sub. (7) shall comply with ch. 609.

SB380,3,148 51.20 (7) (am) A subject individual may not be examined, evaluated or treated
9for a nervous or mental disorder pursuant to a court order under this subsection
10unless the court first attempts to determine whether the person is an enrolled
11participant enrollee of a health maintenance organization, limited service health
12organization or preferred provider plan, as defined in s. 609.01 (4), and, if so, notifies
13the organization or plan that the subject individual is in need of examination,
14evaluation or treatment for a nervous or mental disorder.

SB380,4,416 601.42 (1g) (d) Statements, reports, answers to questionnaires or other
17information, or reports, audits or certification from a certified public accountant or

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1an actuary approved by the commissioner, relating to the extent liabilities of a health
2maintenance organization insurer are or will be covered liabilities, as defined in s.
3609.01 (1) liabilities for health care costs for which an enrollee or policyholder of the
4health maintenance organization insurer is not liable to any person under s. 609.91.

SB380,4,117 609.01 (1c) "Emergency medical condition" means a medical condition of a
8person that has a sudden onset and that manifests itself by symptoms of sufficient
9severity, including severe pain, to lead a prudent layperson who possesses an average
10knowledge of health and medicine to reasonably conclude that a lack of immediate
11medical attention might result in any of the following:

SB380,4,1212 (a) Serious jeopardy to the person's health.

SB380,4,1313 (b) Serious impairment to the person's bodily functions.

SB380,4,1414 (c) Serious dysfunction of any of the person's bodily organs or parts.

SB380,4,1716 609.01 (1d) "Enrollee" means, with respect to a managed care plan, a person
17who is entitled to receive health care services under the plan.

SB380,4,2219 609.01 (1p) "Health care professional" means any individual licensed,
20registered, permitted or certified by the department of health and family services or
21the department of regulation and licensing to provide health care services, items or
22supplies in this state.

SB380,5,424 609.01 (2) "Health maintenance organization" means a health care plan
25offered by an organization established under ch. 185, 611, 613 or 614 or issued a

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1certificate of authority under ch. 618 that makes available to its enrolled
2participants enrollees, in consideration for predetermined periodic fixed payments,
3comprehensive health care services performed by providers selected by the
4organization participating in the plan.

SB380,5,116 609.01 (3) "Limited service health organization" means a health care plan
7offered by an organization established under ch. 185, 611, 613 or 614 or issued a
8certificate of authority under ch. 618 that makes available to its enrolled
9participants enrollees, in consideration for predetermined periodic fixed payments,
10a limited range of health care services performed by providers selected by the
11organization participating in the plan.

SB380,5,1413 609.01 (3c) "Managed care plan" means a health maintenance organization,
14limited service health organization or preferred provider plan.

SB380,5,1816 609.01 (3m) "Participating" means, with respect to a physician or other
17provider, under contract with a managed care plan to provide health care services,
18items or supplies to enrollees of the plan.

SB380,5,2020 609.01 (3r) "Physician" has the meaning given in s. 448.01 (5).

SB380,6,222 609.01 (4) "Preferred provider plan" means a health care plan offered by an
23organization established under ch. 185, 611, 613 or 614 or issued a certificate of
24authority under ch. 618 that makes available to its enrolled participants enrollees,
25for consideration other than predetermined periodic fixed payments, either

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1comprehensive health care services or a limited range of health care services
2performed by providers selected by the organization participating in the plan.

SB380,6,54 609.01 (4m) "Primary care physician" means a physician specializing in family
5medical practice, general internal medicine, obstetrics and gynecology or pediatrics.

SB380,6,87 609.01 (5) "Primary provider" means a participating health care professional
8who coordinates, supervises and may provide ongoing care to an enrollee.

SB380,6,1110 609.01 (6) "Specialist physician" means a physician who is not a primary care
11physician.

SB380,6,1413 609.01 (7) "Standard plan" means a health care plan other than a health
14maintenance organization or a preferred provider that is not a managed care plan.

SB380,6,1916 609.05 (1) Except as provided in subs. (2) and (3), a health maintenance
17organization, limited service health organization or preferred provider managed
18care plan shall permit its enrolled participants enrollees to choose freely among
19selected participating providers.

SB380,6,2421 609.05 (2) A health care plan under sub. (1) Subject to s. 609.24 (2) and (3), a
22managed care plan may require an enrolled participant enrollee to designate a
23primary provider and to obtain health care services from the primary provider when
24reasonably possible.

SB380,7,5

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1609.05 (3) Except as provided in ss. 609.65 and 609.655, a health managed care
2plan under sub. (1) may require an enrolled participant enrollee to obtain a referral
3from the primary provider designated under sub. (2) to another selected
4participating provider prior to obtaining health care services from the other selected
5that participating provider.

SB380,7,127 609.10 (1) (a) Except as provided in subs. (2) to (4), an employer that offers any
8of its employes a health maintenance organization or a preferred provider plan that
9provides comprehensive health care services shall also offer the employes a standard
10plan, as provided in pars. (b) and (c), that provides at least substantially equivalent
11coverage of health care expenses and that is not a health maintenance organization
12or a preferred provider plan.

SB380,7,1614 609.15 (1) (intro.)  Each health maintenance organization, limited service
15health organization and preferred provider managed care plan shall do all of the
16following:

SB380,7,2018 609.15 (1) (a) Establish and use an internal grievance procedure that is
19approved by the commissioner and that complies with sub. (2) for the resolution of
20enrolled participants' enrollees' grievances with the health managed care plan.

SB380,7,2422 609.15 (1) (b) Provide enrolled participants enrollees with complete and
23understandable information describing the internal grievance procedure under par.
24(a).

SB380,8,2

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1609.15 (2) (a) The opportunity for an enrolled participant enrollee to submit
2a written grievance in any form.

SB380,8,84 609.15 (2) (b) Establishment of a grievance panel for the investigation of each
5grievance submitted under par. (a), consisting of at least one individual authorized
6to take corrective action on the grievance and at least one enrolled participant
7enrollee other than the grievant, if an enrolled participant enrollee is available to
8serve on the grievance panel.

SB380,8,15 10609.17 Reports of disciplinary action. Every health maintenance
11organization, limited service health organization and preferred provider managed
12care plan shall notify the medical examining board or appropriate affiliated
13credentialing board attached to the medical examining board of any disciplinary
14action taken against a selected participating provider who holds a license or
15certificate granted by the board or affiliated credentialing board.

SB380,8,19 17609.20 Rules for preferred provider managed care plans. (intro.) The
18commissioner shall promulgate rules applicable to preferred provider plans relating
19to managed care plans for all of the following purposes:

SB380,8,2221 609.20 (1) To ensure that enrolled participants enrollees are not forced to travel
22excessive distances to receive health care services.

SB380,8,2524 609.20 (2) To ensure that the continuity of patient care for enrolled participants
25enrollees is not disrupted.

SB380,9,92 609.20 (4) To ensure that employes offered a health maintenance organization
3or a preferred provider plan that provides comprehensive services under s. 609.10
4(1) (a) are given adequate notice of the opportunity to enroll and complete and
5understandable information under s. 609.10 (1) (c) concerning the differences
6between the health maintenance organization or preferred provider plan and the
7standard plan, including differences between providers available and differences
8resulting from special limitations or requirements imposed by an institutional
9provider because of its affiliation with a religious organization.

SB380,9,15 11609.22 Access to personnel and facilities. (1) Providers. A managed care
12plan shall include a sufficient number, and sufficient types, of primary care and
13specialist physicians throughout the service area of the plan to meet the anticipated
14needs of its enrollees and to provide its enrollees with a meaningful choice among
15physicians. A managed care plan shall offer all of the following:

SB380,9,1616 (a) Adequate accessible acute care hospital services for all of its enrollees.

SB380,9,1817 (b) An adequate number of accessible primary care physicians for all of its
18enrollees.

SB380,9,2019 (c) Subject to sub. (2), an adequate number of accessible specialist physicians
20for all of its enrollees within a reasonable distance or travel time.

SB380,9,2221 (d) The availability of specialty medical services, including physical therapy,
22occupational therapy and rehabilitation services.

SB380,9,2523 (e) The availability of nonparticipating specialist physicians for enrollees
24whose medical conditions require services that cannot be provided by participating
25specialist physicians.

SB380,10,5

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1(2) Nonparticipating specialists. If the treatment of a specific condition
2requires the services of a particular type of specialist physician and a managed care
3plan has no participating specialist physicians of that type, the managed care plan
4shall provide enrollees with the specific condition with coverage for the services of
5nonparticipating specialist physicians of that type.

SB380,10,10 6(3) Telephone access. A managed care plan shall provide telephone access to
7the plan for sufficient time during business and evening hours to ensure that
8enrollees have adequate access to routine health care services. A managed care plan
9shall provide 24-hour telephone access to the plan or to a participating provider for
10emergency care or authorization for care.

SB380,10,15 11(4) Standards for appointment scheduling. A managed care plan shall
12establish standards for reasonable waiting times for obtaining appointments for
13health care services, except for emergency care. The standards shall include
14scheduling guidelines based on the type of health care service for which an
15appointment is being made.

SB380,10,18 16(5) Emergency care. A managed care plan shall cover, and reimburse expenses
17for, emergency care obtained without prior authorization for the treatment of an
18emergency medical condition.

SB380,10,24 19(6) Access plan for certain enrollees. A managed care plan shall develop an
20access plan to meet the needs of its enrollees who are members of underserved
21populations. The managed care plan shall provide culturally appropriate services
22to the greatest extent possible. If a significant number of enrollees of the plan
23customarily use languages other than English, the managed care plan shall provide
24access to personnel who are fluent in those languages to the greatest extent possible.

SB380,11,8

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1(7) Enrollees held harmless for claims. A limited service health organization
2or a preferred provider plan shall hold an enrollee harmless against any claim from
3a participating provider for payment of any portion of the cost of covered health care
4services. This subsection does not affect the liability of an enrollee, policyholder or
5insured for any deductibles, copayments or premiums owed under the policy or
6certificate issued by the limited service health organization insurer or the preferred
7provider plan insurer. A health maintenance organization is subject to ss. 609.91 to
8609.94.

SB380,11,12 10609.24 Choice of providers. (1) Adequate choice. A managed care plan
11shall ensure that each enrollee has adequate choice among participating providers
12and that the providers are accessible and qualified.

SB380,11,16 13(2) Primary providers. Except as provided in sub. (3), a managed care plan
14shall permit each enrollee to select his or her own primary provider from a list of
15participating health care professionals. The list shall be updated on an ongoing basis
16and shall include all of the following:

SB380,11,1817 (a) A sufficient number of health care professionals who are accepting new
18enrollees.

SB380,11,2119 (b) A sufficient diversity of health care professionals to adequately meet the
20needs of an enrollee population with varied characteristics, including age, gender,
21race and health status.

SB380,11,24 22(3) Specialist providers. (a) A managed care plan shall establish a system
23under which an enrollee with a chronic disease or other special needs may select a
24participating specialist physician as his or her primary provider.

SB380,12,4

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1(b) A managed care plan shall allow all enrollees under the plan to have access
2to specialist physicians on a timely basis when specialty medical care is warranted.
3An enrollee shall be allowed to choose among participating specialist physicians
4when a referral is made for specialty care.