Wisconsin Administrative Code

Ins 8.78 Participation; enrollment. (1) PARTICIPATION. (a) A small employer insurer shall offer a plan to any small employer meeting the definition of eligible employer in s. 635.20 (2), Stats., regardless of the number required for participation in other small group health benef…

Ins 8.79 Managed care options. A small employer insurer that offers health benefit plans with one or more managed care options in the small employer market shall offer purchasers of a basic health benefit plan at least one managed care option. If the option offered is a preferred…

Ins 8.80 Rating. (1) In establishing the new business premium rate for the plan, a small employer insurer shall take into account the experience of all of its small employer health benefit plans. The differences between the plan[s new business premium rate and the insurer[s new b…

Ins 8.81 Form approval and marketing. (1) Except as provided in s. 635.26 (2m) to (4), Stats., each small employer insurer shall file its basic health benefit plan policy form with the commissioner of insurance under s. 631.20, Stats., before October 1, 1993. Note: 1997 Wis. Act …

Ins 9.01 Definitions. In this chapter, and for the purposes of applying ch. 609, Stats.: (1) XAcceptable letter of creditY means a clean, unconditional, irrevocable letter of credit issued by a Wisconsin bank or any other financial institution acceptable to the commissioner which…

Ins 9.015 Scope. Subchapter II — Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations Ins 9.02 Purpose. Ins 9.03 Scope. Ins 9.04 Financial requirements. Ins 9.05 Business plan. Ins 9.06 Changes in the business plan. Ins 9.07 Copies of p…

Ins 9.02 Purpose. This subchapter establishes financial standards for health maintenance organizations and limited service health organizations doing business in Wisconsin. These requirements are in addition to any other statutory or administrative rule requirements that apply to…

Ins 9.03 Scope. This subchapter applies to all insurers writing health maintenance organization or limited service health organization business in this state. History: Cr. Register, February, 2000, No. 530, eff. 3-1-00. Ins 9.04 Financial requirements. The following are 2 the min…

Ins 9.05 Business plan. All applications for certificates of incorporation and certificates of authority of a health maintenance organization insurer or an insurer licensed to write only limited service health organization business shall include a proposed business plan. In addit…

Ins 9.06 Changes in the business plan. (1) A health maintenance organization insurer or an insurer licensed to write only limited service health organization business shall file a written report of any proposed substantial change in its business plan. The insurer shall file the r…

Ins 9.07 Copies of provider agreements. (1) Notwithstanding any claim of trade secret or proprietary information, all insurers offering a defined network plan, preferred provider plan or limited service health organization shall, upon request, from the commissioner, make availabl…

Ins 9.08 Other reporting requirements. (1) ANNUAL 4 STATEMENT. All insurers authorized to write health maintenance organization business and insurers licensed to write only limited service health organization business shall file with the commissioner by March 1 of each year an an…

Ins 9.09 Notice of election and termination of hold harmless. (1) A notice of election to be exempt from s. 609.91 (1) (b), Stats., or a notice of termination of election to be subject to s. 609.91 (1) (c), Stats., in accord with s. 609.925 (1), Stats., is effective only if filed…

Ins 9.10 Receivables from affiliates. A receivable, note or other obligation of an affiliate to a health maintenance organization insurer and limited service health organization insurer shall be valued at zero by the insurer for all purposes including, but not limited to, the pur…

Ins 9.11 Receivables from Individual Practice Association (XIPAY). After December 31, 1990, a health maintenance organization insurer shall value receivables, notes or obligations of individual practice associations as defined under s. 600.03 (23g), Stats., at zero for all purpos…

Ins 9.12 Incidental or immaterial indemnity business in health maintenance organizations. (1) Except as provided by sub. (2), insurance business is not incidental or immaterial under s. 609.03 (3) (a) 3., Stats., if a health maintenance organization insurer issues coverage which …

Ins 9.13 Summary. A health maintenance organization insurer shall use the form prescribed in appendix C to comply with s. 609.94, Stats. History: Cr. Register, February, 2000, No. 530, eff. 3-1-00.

Ins 9.14 Nondomestic HMO. No certificate of authority may be issued under ch. 618, Stats., to a person to do health maintenance organization or limited service health organization business in this state unless the person is organized and regulated as an insurer and domiciled in t…

Ins 9.15 Time period. In accordance with s. 227.116, Stats., the commissioner shall review and make a determination on an application for a certificate of authority within 60 business days after it has been received. History: Cr. Register, February, 2000, No. 530, eff. 3-1-00. Su…

Ins 9.20 Scope. This subchapter applies to all insurers offering a defined network plan, preferred provider plan or limited service health organization in this state. The insurer shall ensure that the requirements of this subchapter are met by all defined network plans, preferred…

Ins 9.21 Limited exemptions. (1) SILENT DISCOUNT. An insurer, with respect to a defined network plan: (a) Is exempt from meeting the requirements under ss. 609.22, 609.24, 609.32, 609.34, 609.36 and 632.83, Stats., and ss. Ins 9.31, 9.32 (1), 9.35, 9.37, 9.38, 9.39, 9.40 (1) to (…

Ins 9.25 Preferred provider plan same service provisions. For purposes of s. 609.35, Stats., an insurer offering a preferred provider plan covers the same services when performed by a nonparticipating provider that it covers when those services 6 are performed by a participating …

Ins 9.26 Preferred provider plan subject to defined network plan regulations. An insurer offering 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 prov…

Ins 9.27 Preferred provider plan requirements. Insurers offering a preferred provider plan shall comply with all the following: (1) Except as provided in s. Ins 9.25 (2), insurers offering a preferred provider plan that apply a coinsurance percentage when the services are perform…

Ins 9.30 Group and blanket health insurers compliance. The commissioner finds that the circumstances of offering a group or blanket health insurance policy require that the insurer offering the policy otherwise exempt from chs. 600 to 646, Stats., under s. 600.01 (1) (b) 3., Stat…

Ins 9.31 Annual certification of access standards. (1) An insurer offering a defined network plan that is not a preferred provider plan shall file an annual certification with the commissioner no later than August 1 of each year certifying compliance with the access standards of …

Ins 9.32 Defined network plan requirements. (1) An insurer offering a defined network plan that is not a preferred provider plan shall do all of the following: (a) Provide covered benefits by plan providers with reasonable promptness with respect to geographic location, hours of …

Ins 9.33 Enrollee election of nonparticipating provider reimbursement. Nothing in s. Ins 9.32 changes the reimbursement payable or the amounts due, including co-payments, coinsurance, deductibles and other cost-sharing provisions from an enrollee when the enrollee of a preferred …

Ins 9.35 Continuity of care. (1) In addition to the requirements of s. 609.24, Stats., an insurer offering a defined network plan shall do one of the following: (a) Upon termination of a provider from a defined network plan, the insurer offering a defined network plan shall appro…

Ins 9.36 Gag clauses. (1) No contract between an insurer offering a defined network plan and a participating provider may limit the provider[s ability to disclose information, to or on behalf of an enrollee, about the enrollee[s medical condition. (2) A participating provider may…

Ins 9.37 Notice requirements. (1) PROVIDED INFORMATION. Prior to enrolling members, insurers offering a defined network plan shall provide to prospective group or individual policyholders information on the plan including all of the following: (a) Covered services. (b) A definiti…

Ins 9.38 Policy and certificate language requirements. Each policy form marketed or each certificate issued to an enrollee by an insurer offering a defined network plan or limited service health organization plan shall contain all of the following: (1) DEFINITIONS. A definition o…

Ins 9.39 Disenrollment. (1) DISCLOSURE. The health maintenance organization or limited service health organization shall clearly disclose in the policy and certificate any circumstances under which the health maintenance organization or limited service health organization may dis…

Ins 9.40 Required quality assurance and remedial action plans. (1) In this section Xquality assuranceY means 10 the measurement and evaluation of the quality and outcomes of medical care provided. (2) (a) By April 1, 2000, an insurer, with respect to a defined network plan that i…

Ins 9.41 Right of the commissioner to request OCI complaints be handled as grievances. An insurer offering a defined network plan, preferred provider plan or limited service health organization shall treat and process an OCI complaint as a grievance at the request of the commissi…

Ins 9.42 Compliance program requirements. (1) All insurers offering a defined network plan, preferred provider plan or limited service health organization except to the extent otherwise exempted under this chapter or by statute, are responsible for compliance with ss. 609.22, 609…

JC 1.01 Authorization. The rules in chs. JC 1 to 6 are adopted by the commission pursuant to s. 757.83 (3), Stats., and relate to ss. 757.81 to 757.99, Stats. History: Cr. Register, May, 1979, No. 281, eff. 6-1-79.

JC 1.02 Definitions. The definitions in s. 757.81, Stats., apply in chs. JC 1 to 6. In addition, in chs. JC 1 to 6: (1) XAllegationY means a charge of misconduct or disability directed to the commission. (2) XComplaintY means a written document filed by the commission with the su…

JC 2.01 Officers. The officers of the commission are a chairperson and vice chairperson. If the chairperson is absent, unavailable, or otherwise unable to act, or refuses to act, the vice chairperson shall perform the duties of the chairperson. If the chairperson resigns or dies,…

JC 2.02 Meetings. (1) Regular meetings shall be held at least 6 times a year upon the call of and at a time and place fixed by the chairperson. Sufficient notice shall be given to enable the commissioners so notified to attend the meetings. Public notice of all meetings shall com…

JC 2.03 Screening committee. The chairperson shall appoint a screening committee consisting of at least 3 commissioners to review annually a sample of decisions to close initial inquiries made by staff without commission action, for appropriateness and consistency of those decisi…

JC 2.04 Other committees. The chairperson shall appoint a personnel and a nominations committee and any additional committee that the commission establishes for a specified purpose, to serve at the pleasure of the chairperson or the commission. History: Cr. Register, August, 1991…

JC 3.01 Confidentiality. The proceedings of the judicial commission prior to the filing of a formal complaint concerning misconduct or a petition concerning permanent disability are confidential, unless a written waiver of confidentiality has been made by the judge or court commi…

JC 3.02 Independent investigators. The commission may authorize the executive director to appoint independent persons to investigate allegations of misconduct or permanent disability, with authority and duties specified by the executive director or commission. History: Cr. Regist…

JC 3.03 Revised allegation. The commission may decide after an investigation has started that a particular allegation of misconduct is properly an allegation of disability or that a particular allegation of disability is properly an allegation of misconduct. If an allegation is r…

JC 3.04 Disqualification. (1) A member shall not participate in any matter if a judge similarly situated would be disqualified in a court proceeding. In cases other than mandatory disqualification if the propriety of participation is challenged, the question shall be decided by a…

JC 3.05 Internal proceedings. The commission shall prescribe procedures for its internal proceedings as the commission deems appropriate.