CHAPTER 609

1 DEFINED NETWORK PLANS 17 18 Wis. 2017 18 Wis. Stats. Published and certified under s. April 1, 18 Wisconsin Statutes updated by 2017 Wis. Acts 368 to 370 and through all Supreme Court and Controlled SubstancesBoard Orders filed before and in effect on April 1, 2019. Published and certified under s. Changes effective after April1, 2019, are designated by NOTES. (Published 4 1 19) CHAPTER 609 DEFINED NETWORK ventures; legislative of provider and plan and point of service option plan of disciplinary for preferred provider and defined network of decision making; medical of requirements to preferred provider systems and for court ordered services for the mentally of certain services provided to dependent of of alcoholism and other health services provided by a recovery charter children of of student on medical of breast of treatment for the correction of temporomandibular of hospital and ambulatory surgery center charges and anesthet-ics for dental of of related to HIV without prior authorization for emergency medical of drugs and equality for oral and injected of lead of hearing aids, cochlear implants.

2 And related treatment forinfants and of treatment for autism spectrum of colorectal cancer of reason for coverage related to domestic on recovering health care , individual practice associations and providers of physician to be subject to of election by an individual practice association or of election and of covered capital and surplus and security reference: See definitions in ss. and reference: See also ch. Ins 9, Wis. adm. Joint ventures; legislative findings. (1)Thelegislature finds that increased development of health mainte-nance organizations, preferred provider plans and limited servicehealth organizations may have the effect of putting small, inde-pendent health care providers at a competitive disadvantage withlarger health care providers.

3 In order to avoid monopolistic situa-tions and to provide competitive alternatives, it may be necessaryfor those small, independent health care providers to form jointventures. The legislature finds that these joint ventures are a desir-able means of health care cost containment to the extent that theyincrease the number of entities with which a health maintenanceorganization, preferred provider plan or limited service healthorganization may choose to contract and to the extent that the jointventures do not violate state or federal antitrust laws.(2)The legislature finds that competition in the health caremarket will be enhanced by allowing employers and organizationswhich otherwise act independently to join together in a mannerconsistent with the state and federal antitrust laws for the purposeof purchasing health care coverage for employees and joint ventures will allow purchasers of health care coverageto obtain volume discounts when they negotiate with insurers andhealth care providers.

4 These joint ventures should result in animproved business climate in this state because of reduced costsfor health care : 1985 a. Definitions. In this CHAPTER :(1b) Defined network plan means a health benefit plan thatrequires an enrollee of the health benefit plan, or creates incen-tives, including financial incentives, for an enrollee of the healthbenefit plan, to use providers that are managed, owned, under con-tract with, or employed by the insurer offering the health benefitplan.(1c) Emergency medical condition has the meaning givenin s. (1) (a).(1d) Enrollee means, with respect to a defined networkplan, preferred provider plan, or limited service health organiza-tion, a person who is entitled to receive health care services underthe plan.

5 (1g)(a) Except as provided in par. (b), health benefit plan means any hospital or medical policy or certificate.(b) Health benefit plan does not include any of the follow-ing:1. Coverage that is only accident or disability income insur-ance, or any combination of the 2 Coverage issued as a supplement to liability Liability insurance, including general liability insuranceand automobile liability Worker s compensation or similar Automobile medical payment Credit only Coverage for on site medical Other similar insurance coverage, as specified in regula-tions issued by the federal department of health and human ser-vices, under which benefits for medical care are secondary or inci-dental to other insurance If provided under a separate policy, certificate or contractof insurance, or if otherwise not an integral part of the policy, cer-tificate or contract of insurance.

6 Limited scope dental or visionbenefits; benefits for long term care, nursing home care, homehealth care, community based care, or any combination of thosebenefits; and such other similar, limited benefits as are specifiedin regulations issued by the federal department of health andhuman services under section 2791 of 104 Hospital indemnity or other fixed indemnity insurance orcoverage only for a specified disease or illness, if all of the follow-ing apply:a. The benefits are provided under a separate policy, certifi-cate or contract of 17 18 Wis. NETWORK PLANSU pdated 2017 18 Wis. Stats. Published and certified under s. April 1, 18 Wisconsin Statutes updated by 2017 Wis. Acts 368 to 370 and through all Supreme Court and Controlled SubstancesBoard Orders filed before and in effect on April 1, 2019.

7 Published and certified under s. Changes effective after April1, 2019, are designated by NOTES. (Published 4 1 19)b. There is no coordination between the provision of suchbenefits and any exclusion of benefits under any group health planmaintained by the same plan Such benefits are paid with respect to an event withoutregard to whether benefits are provided with respect to such anevent under any group health plan maintained by the same Other insurance exempted by rule of the commissioner.(1j) Health care costs means consideration for the provisionof health care, including consideration for services, equipment,supplies and drugs.(1m) Health care plan has the meaning given under (2) (a) 1.

8 (2) Health maintenance organization means a health careplan offered by an organization established under ch. 185 or 193,611, 613 or 614 or issued a certificate of authority under ch. 618that makes available to its enrollees, in consideration for predeter-mined periodic fixed payments, comprehensive health care ser-vices performed by providers participating in the plan.(3) Limited service health organization means a health careplan offered by an organization established under ch. 185, 611,613 or 614 or issued a certificate of authority under ch. 618 thatmakes available to its enrollees, in consideration for predeter-mined periodic fixed payments, a limited range of health care ser-vices performed by providers participating in the plan.

9 (3m) Participating means, with respect to a physician orother provider, under contract with a defined network plan, pre-ferred provider plan, or limited service health organization to pro-vide health care services, items or supplies to enrollees of thedefined network plan, preferred provider plan, or limited servicehealth organization.(3r) Physician has the meaning given in s. (5).(4) Preferred provider plan means a health care plan offeredby an organization established under ch. 185, 193, 611, 613, or614 or issued a certificate of authority under ch. 618 that makesavailable to its enrollees, without referral and for considerationother than predetermined periodic fixed payments, coverage ofeither comprehensive health care services or a limited range ofhealth care services, regardless of whether the health care servicesare performed by participating or nonparticipating providers.

10 (4m) Primary care physician means a physician specializ-ing in family medical practice, general internal medicine or pedi-atrics.(5) Primary provider means a participating primary carephysician, or other participating provider authorized by thedefined network plan, preferred provider plan, or limited servicehealth organization to serve as a primary provider, who coordi-nates and may provide ongoing care to an enrollee.(5m) Provider means a health care professional, a healthcare facility or a health care service or organization.(7) Standard plan means a health care plan other than ahealth maintenance organization or a preferred provider : 1985 a. 29; 1989 a. 23; 1997 a. 237; 2001 a. 16; 2005 a.