Chapter 609 — DEFINED NETWORK PLANS

55 sections in this chapter.

55 sectionsFiltered byCh 609

Wis. Stat. § 609.001 Joint ventures; legislative findings
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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 c…
Wis. Stat. § 609.01 Definitions
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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,…
Wis. Stat. § 609.03 Indication of operations
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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…
Wis. Stat. § 609.05 Primary provider and referrals
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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 …
Wis. Stat. § 609.10 Standard plan and point-of-service option plan required
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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 …
Wis. Stat. § 609.17 Reports of disciplinary action
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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 a…
Wis. Stat. § 609.20 Rules for preferred provider and defined network plans
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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 excess…
Wis. Stat. § 609.205 Public health emergency for COVID-19
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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 declar…
Wis. Stat. § 609.22 Access standards
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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 May 22, 2026, are designated by N…
Wis. Stat. § 609.24 Continuity of care
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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…
Wis. Stat. § 609.30 Provider disclosures
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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 M…
Wis. Stat. § 609.32 Quality assurance
Wis. Stat. § 609.34 Clinical decision-making; medical director
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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 manag…
Wis. Stat. § 609.35 Applicability of requirements to preferred provider plans
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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…
Wis. Stat. § 609.36 Data systems and confidentiality
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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 requirement…
Wis. Stat. § 609.38 Oversight
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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:…
Wis. Stat. § 609.60 Optometric coverage
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609.60 Optometric coverage. Health maintenance organizations and preferred provider plans are subject to s. 632.87 (2m). History: 1985 a. 29.
Wis. Stat. § 609.65 Coverage for court-ordered services for the mentally ill
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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. 88…
Wis. Stat. § 609.655 Coverage of certain services provided to dependent students
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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…
Wis. Stat. § 609.70 Chiropractic coverage
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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.
Wis. Stat. § 609.71 Disclosure of payments
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609.71 Disclosure of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.798. History: 2009 a. 146.
Wis. Stat. § 609.715 Coverage of alcoholism and other diseases
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609.715 Coverage of alcoholism and other diseases. Defined network plans are subject to s. 632.89. History: 2009 a. 218 s. 14; 2011 a. 260 s. 80.
Wis. Stat. § 609.717 Mental health services provided by a recovery charter school
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609.717 Mental health services provided by a recovery charter school. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (4m). History: 2017 a. 30.
Wis. Stat. § 609.75 Adopted children coverage
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609.75 Adopted children coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.896. Coverage of health care services obtained by adopted children and children placed for adoption may be subject to any requirements…
Wis. Stat. § 609.755 Coverage of dependents
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609.755 Coverage of dependents. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.885. History: 2009 a. 28.
Wis. Stat. § 609.76 Coverage of student on medical leave
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609.76 Coverage of student on medical leave. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (15). History: 2007 a. 36. 609.77 Coverage of breast reconstruction. Limited ser- DEFINED NETWORK PLANS 609.85 vice hea…
Wis. Stat. § 609.77 Coverage of breast reconstruction
Wis. Stat. § 609.78 Coverage of treatment for the correction of temporomandibular disorders
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609.78 Coverage of treatment for the correction of temporomandibular disorders. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (11). History: 1997 a. 27, 237; 2001 a. 16.
Wis. Stat. § 609.79 Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care
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609.79 Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (12). History: 1997 a. 27, 237; 2001 a. 16.
Wis. Stat. § 609.80 Coverage of mammograms
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609.80 Coverage of mammograms. Defined network plans and preferred provider plans are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be subject to any requirements that the defined network plan or preferred provider plan imposes under s. 609.05 (2) and…
Wis. Stat. § 609.805 Coverage of contraceptives
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609.805 Coverage of contraceptives. Defined network plans are subject to s. 632.895 (17). History: 2009 a. 28.
Wis. Stat. § 609.81 Coverage related to HIV infection
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609.81 Coverage related to HIV infection. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 631.93. Defined network plans are subject to s. 632.895 (9). History: 1989 a. 201; 1989 a. 359 s. 389; 1997 a. 237; 2001 a. 16.
Wis. Stat. § 609.82 Coverage without prior authorization for emergency medical condition treatment
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609.82 Coverage without prior authorization for emergency medical condition treatment. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.85. History: 1997 a. 237; 2001 a. 16.
Wis. Stat. § 609.83 Coverage of drugs and devices
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609.83 Coverage of drugs and devices. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, and 632.895 (16t) and (16v). History: 1997 a. 237; 2001 a. 16; 2017 a. 305; 2019 a. 185; 2021 a. 9.
Wis. Stat. § 609.837 Copayment equality for oral and injected chemotherapy
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609.837 Copayment equality for oral and injected chemotherapy. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.867. History: 2013 a. 186.
Wis. Stat. § 609.84 Experimental treatment
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609.84 Experimental treatment. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.855. History: 1997 a. 237; 2001 a. 16.
Wis. Stat. § 609.846 Discrimination based on COVID-19 prohibited
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609.846 Discrimination based on COVID-19 prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.729. History: 2019 a. 185.
Wis. Stat. § 609.85 Coverage of lead screening
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609.85 Coverage of lead screening. Health maintenance organizations and preferred provider plans are subject to s. 632.895 (10). History: 1993 a. 450. May 22, 2026, are designated by NOTES. (Published 5-22-26) 609.86 DEFINED NETWORK PLANS
Wis. Stat. § 609.86 Coverage of hearing aids, cochlear implants, and related treatment for infants and children
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609.86 Coverage of hearing aids, cochlear implants, and related treatment for infants and children. Defined network plans are subject to s. 632.895 (16). History: 2009 a. 14.
Wis. Stat. § 609.87 Coverage of treatment for autism spectrum disorders
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609.87 Coverage of treatment for autism spectrum disorders. Defined network plans are subject to s. 632.895 (12m). History: 2009 a. 28.
Wis. Stat. § 609.875 Coverage of colorectal cancer screening
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609.875 Coverage of colorectal cancer screening. Defined network plans are subject to s. 632.895 (16m). History: 2009 a. 346 s. 8; 2011 a. 260 s. 80.
Wis. Stat. § 609.88 Coverage of immunizations
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609.88 Coverage of immunizations. plans are subject to s. 632.895 (14). Defined network History: 1999 a. 115; 2001 a. 16.
Wis. Stat. § 609.885 Coverage of COVID-19 testing
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609.885 Coverage of COVID-19 testing. Defined network plans, preferred provider plans, and limited service health organizations are subject to s. 632.895 (14g). History: 2019 a. 185.
Wis. Stat. § 609.89 Written reason for coverage denial
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609.89 Written reason for coverage denial. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 631.17. History: 1999 a. 95; 2001 a. 16.
Wis. Stat. § 609.90 Restrictions related to domestic abuse
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609.90 Restrictions related to domestic abuse. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 631.95. History: 1999 a. 95; 2001 a. 16.
Wis. Stat. § 609.91 Restrictions on recovering health care costs
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609.91 Restrictions on recovering health care costs. (1) IMMUNITY OF ENROLLEES AND POLICYHOLDERS. Except as provided in sub. (1m) or (1p), an enrollee or policyholder of a health maintenance organization insurer is not liable for health care costs that are incurred on or after Ja…
Wis. Stat. § 609.92 Hospitals, individual practice associations and providers of physician services
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609.92 to 609.935, is not affected by any of the following: (a) An agreement, other than a notice of election or termination of election in accordance with s. 609.92 or 609.925, entered into by the provider, the health maintenance organization insurer, the insurer described in su…
Wis. Stat. § 609.925 Election to be subject to restrictions
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609.925 Election to be subject to restrictions. (1) NOTICE OF ELECTION. Except as provided in s. 609.93, a provider described in s. 609.91 (1) (c) is subject to s. 609.91 (1) (c) for purposes of recovering health care costs arising from health care provided by the provider, if th…
Wis. Stat. § 609.93 Scope of election by an individual practice association or clinic
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609.93 Scope of election by an individual practice association or clinic. (1) INDIVIDUAL PRACTICE ASSOCIATION. The election by an individual practice association under s. 609.92 to be exempt from s. 609.91 (1) (b) or the failure of the individual practice association to so elect …
Wis. Stat. § 609.935 Notices of election and termination
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609.935 Notices of election and termination. (1) IN ACCORDANCE WITH RULES. If the commissioner promulgates rules governing the form or manner of filing a notice of election or termination notice under s. 609.92 or 609.925, a notice of election or termination notice filed after th…