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.
609.75 Adopted children coverage.
609.80 Coverage of mammograms.
609.81 Coverage related to HIV infection.
609.85 Coverage of lead screening.
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.
609.98 Special deposit.
Ch. 609 Cross-reference Cross-reference: See definitions in ss. 600.03 and 628.02.
609.001 609.001 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 employes 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 History History: 1985 a. 29.
609.01 609.01 Definitions. In this chapter:
609.01(1) (1) "Covered liability" means liability of a health maintenance organization insurer for health care costs for which an enrolled participant or policyholder of the health maintenance organization insurer is not liable to any person under s. 609.91.
609.01(1d) (1d) "Enrolled participant" means a person entitled to health care services under an individual or group policy issued by a health maintenance organization, limited service health organization or preferred provider plan.
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(1m) (1m) "Health care plan" has the meaning given under s. 628.36 (2) (a) 1.
609.01(2) (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, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers selected by the organization.
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 enrolled participants, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers selected by the organization.
609.01(4) (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, 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.
609.01(5) (5) "Primary provider" means a selected provider who is an individual and who is designated by an enrolled participant.
609.01(5m) (5m) "Provider" means a health care professional, a health care facility or a health care service or organization.
609.01(6) (6) "Selected provider" means a provider selected by a health maintenance organization, limited service health organization or preferred provider plan to perform health care services for enrolled participants.
609.01(7) (7) "Standard plan" means a health care plan other than a health maintenance organization or a preferred provider plan.
609.01 History History: 1985 a. 29; 1989 a. 23.
609.03 609.03 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) (3)Restrictions on operations.
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:
609.03(3)(a)1. 1. As a health maintenance organization.
609.03(3)(a)2. 2. As a limited service health organization.
609.03(3)(a)3. 3. In other insurance business that is immaterial in relation to, or incidental to, the insurer's business under subd. 1. or 2.
609.03(3)(b) (b) The commissioner may, by rule, define "immaterial" or "incidental", or both, for purposes of par. (a) 3. as a percentage of premiums, except the percentage may not exceed 10% of the total premiums written by the insurer.
609.03(4) (4)Removing restrictions. An amendment to a certificate of authority or statement of operations that removes the limitation imposed under this section is not effective unless the insurer, on the effective date of the amendment, complies with the capital, surplus and other requirements applicable to the insurer under chs. 600 to 645.
609.03 History History: 1989 a. 23.
609.05 609.05 Primary provider and referrals.
609.05(1) (1) Except as provided in subs. (2) and (3), a health maintenance organization, limited service health organization or preferred provider plan shall permit its enrolled participants to choose freely among selected providers.
609.05(2) (2) A health care plan under sub. (1) may require an enrolled participant to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.
609.05(3) (3) Except as provided in ss. 609.65 and 609.655, a health care plan under sub. (1) may require an enrolled participant to obtain a referral from the primary provider designated under sub. (2) to another selected provider prior to obtaining health care services from the other selected provider.
609.05 History History: 1985 a. 29; 1987 a. 366; 1989 a. 121.
609.10 609.10 Standard plan required.
609.10(1) (1)
609.10(1)(a)(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.
609.10(1)(b) (b) At least once annually, the employer shall provide the employes the opportunity to enroll in the health care plans under par. (a).
609.10(1)(c) (c) The employer shall provide the employes adequate notice of the opportunity to enroll in the health care plans under par. (a) and shall provide the employes complete and understandable information concerning the differences between the health maintenance organization or preferred provider plan and the standard plan.
609.10(2) (2) If, after providing an opportunity to enroll under sub. (1) (b) and the notice and information under sub. (1) (c), fewer than 25 employes indicate that they wish to enroll in the standard plan under sub. (1) (a), the employer need not offer the standard plan on that occasion.
609.10(3) (3)Subsection (1) does not apply to an employer that employs fewer than 25 full-time employes.
609.10(4) (4) Nothing in sub. (1) requires an employer to offer a particular health care plan to an employe if the health care plan determines that the employe does not meet reasonable medical underwriting standards of the health care plan.
609.10(5) (5) The commissioner may establish by rule standards in addition to those established under s. 609.20 for what constitutes adequate notice and complete and understandable information under sub. (1) (c).
609.10 History History: 1985 a. 29.
609.15 609.15 Grievance procedure.
609.15(1)(1) Each health maintenance organization, limited service health organization and preferred provider plan shall do all of the following:
609.15(1)(a) (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' grievances with the health care plan.
609.15(1)(b) (b) Provide enrolled participants with complete and understandable information describing the internal grievance procedure under par. (a).
609.15(1)(c) (c) Submit an annual report to the commissioner describing the internal grievance procedure under par. (a) and summarizing the experience under the procedure for the year.
609.15(2) (2) The internal grievance procedure established under sub. (1) (a) shall include all of the following elements:
609.15(2)(a) (a) The opportunity for an enrolled participant to submit a written grievance in any form.
609.15(2)(b) (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 other than the grievant, if an enrolled participant is available to serve on the grievance panel.
609.15(2)(c) (c) Prompt investigation of each grievance submitted under par. (a).
609.15(2)(d) (d) Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.
609.15(2)(e) (e) Retention of records pertaining to each grievance for at least 3 years after the date of notification under par. (d).
609.15 History History: 1985 a. 29.
609.17 609.17 Reports of disciplinary action. Every health maintenance organization, limited service health organization and preferred provider 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 provider who holds a license or certificate granted by the board or affiliated credentialing board.
609.17 History History: 1985 a. 340; 1993 a. 107.
609.20 609.20 Rules for preferred provider plans. The commissioner shall promulgate rules applicable to preferred provider plans for all of the following purposes:
609.20(1) (1) To ensure that enrolled participants are not forced to travel excessive distances to receive health care services.
609.20(2) (2) To ensure that the continuity of patient care for enrolled participants is not disrupted.
609.20(3) (3) To define substantially equivalent coverage of health care expenses for purposes of s. 609.10 (1) (a).
609.20(4) (4) To ensure that employes offered a preferred provider plan that provides comprehensive services under s. 609.10 (1) (a) are given adequate notice of the opportunity to enroll and complete and understandable information under s. 609.10 (1) (c) concerning the differences between the 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.
609.20 History History: 1985 a. 29.
609.60 609.60 Optometric coverage. Health maintenance organizations and preferred provider plans are subject to s. 632.87 (2m).
609.60 History History: 1985 a. 29.
609.65 609.65 Coverage for court-ordered services for the mentally ill.
609.65(1)(1) If an enrolled participant of a health maintenance organization, limited service health organization or preferred provider plan is examined, evaluated or treated for a nervous or mental disorder pursuant to an emergency detention under s. 51.15, a commitment or a court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the limitations regarding selected providers, primary providers and referrals under ss. 609.01 (2) to (4) and 609.05 (3), the health maintenance organization, limited service health organization or preferred provider plan shall do all of the following:
609.65(1)(a) (a) If the provider performing the examination, evaluation or treatment has a provider agreement with the health maintenance organization, limited service health organization or preferred provider plan which covers the provision of that service to the enrolled participant, make the service available to the enrolled participant in accordance with the terms of the health care plan and the provider agreement.
609.65(1)(b) (b) If the provider performing the examination, evaluation or treatment does not have a provider agreement with the health maintenance organization, limited service health organization or preferred provider plan which covers the provision of that service to the enrolled participant, reimburse the provider for the examination, evaluation or treatment of the enrolled participant in an amount not to exceed the maximum reimbursement for the service under the medical assistance program under subch. IV of ch. 49, if any of the following applies:
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This is an archival version of the Wis. Stats. database for 1995. See Are the Statutes on this Website Official?