609.001 Joint ventures; legislative findings. (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, […]
609.01 Definitions. In this chapter: (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 […]
609.03 Indication of operations. (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). (2) Statement of operations. If an insurer is a cooperative association organized under ss. 185.981 […]
609.05 Primary provider and referrals. (1) Except as provided in subs. (2) and (3), a limited service health organization, preferred provider plan, or defined network plan shall permit its enrollees to choose freely among participating providers. (2) Subject to s. 609.22 (4) and (4m), a limited service health organization, preferred provider plan, or defined network […]
609.10 Standard plan and point-of-service option plan required. (1) (ac) In this section, “point-of-service option plan” means a health maintenance organization or preferred provider plan that permits an enrollee to obtain covered health care services from a provider that is not a participating provider of the health maintenance organization or preferred provider plan under all […]
609.17 Reports of disciplinary action. Every limited service health organization, preferred provider plan, and defined network 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 participating provider who holds a license or certificate granted by the board or affiliated […]
609.20 Rules for preferred provider and defined network plans. (1m) The commissioner may promulgate rules relating to preferred provider plans and defined network plans for any of the following purposes, as appropriate: (a) To ensure that enrollees are not forced to travel excessive distances to receive health care services. (b) To ensure that the continuity […]
609.205 Public health emergency for COVID-19. (1) In this section, “COVID-19” means an infection caused by the SARS-CoV-2 coronavirus. (2) All of the following apply to a defined network plan or preferred provider plan during the state of emergency related to public health declared under s. 323.10 on March 12, 2020, by executive order 72, […]
609.22 Access standards. (1) Providers. A defined network plan shall include a sufficient number, and sufficient types, of qualified providers to meet the anticipated needs of its enrollees, with respect to covered benefits, as appropriate to the type of plan and consistent with normal practices and standards in the geographic area. (2) Adequate choice. A […]
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 defined network 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 […]
609.30 Provider disclosures. (1) Plan may not contract. A defined network plan may not contract with a participating provider to limit the provider’s disclosure of information, to or on behalf of an enrollee, about the enrollee’s medical condition or treatment options. (2) Plan may not penalize or terminate. A participating provider may discuss, with or […]
609.32 Quality assurance. (1) Standards; other than preferred provider plans. A defined network plan that is not a preferred provider plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate, and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the […]
609.34 Clinical decision-making; medical director. (1) A defined network plan that is not a preferred provider plan shall appoint a physician as medical director. The medical director shall be responsible for clinical protocols, quality assurance activities, and utilization management policies of the plan. (2) A preferred provider plan may contract for services related to clinical […]
609.35 Applicability of requirements to preferred provider plans. Notwithstanding ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1), a preferred provider plan that does not cover the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider is subject to the requirements […]
609.36 Data systems and confidentiality. (1) Information and data reporting. (a) A defined network plan shall provide to the commissioner information related to all of the following: 1. The structure of the plan. 2. Health care benefits and exclusions. 3. Cost-sharing requirements. 4. Participating providers. (b) Subject to sub. (2), the information and data reported […]
609.38 Oversight. The office shall perform examinations of insurers that issue defined network plans consistent with ss. 601.43 and 601.44. The commissioner shall by rule develop standards for defined network plans for compliance with the requirements under this chapter. History: 1997 a. 237; 2001 a. 16.
609.60 Optometric coverage. Health maintenance organizations and preferred provider plans are subject to s. 632.87 (2m). History: 1985 a. 29.
609.65 Coverage for court-ordered services for the mentally ill. (1) If an enrollee of a limited service health organization, preferred provider plan, or defined network plan is examined, evaluated, or treated for a nervous or mental disorder pursuant to a court order under s. 880.33 (4m) or (4r), 2003 stats., an emergency detention under s. […]
609.655 Coverage of certain services provided to dependent students. (1) In this section: (a) “Dependent student” means an individual who satisfies all of the following: 1. Is covered as a dependent child under the terms of a policy or certificate issued by a defined network plan insurer. 2. Is enrolled in a school located in […]
609.70 Chiropractic coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (3). History: 1987 a. 27; 1997 a. 237; 2001 a. 16.
