Date:January 12, 1999
To:All Insurers Licensed to Write Health Insurance in Wisconsin
From:Connie L. O'Connell, Commissioner of Insurance
Subject:Implementation of 1997 Wisconsin Acts 155 and 237

The health insurance provisions of 1997 Wisconsin Act 155 are in effect as of November 1, 1998 and the provisions of 1997 Wisconsin Act 237 are in effect as of January 1, 1999. OCI issued draft administrative rules relating to these provisions and conducted a public hearing on December 17, 1998. OCI intends to modify the draft rule prior to submission to the Legislature and is anticipating the rules will not go into effect for several months. In the interim, insurers must comply with the statutes. OCI will be monitoring policy forms and certificates issued or renewed on or after the effective dates and company activities for compliance with the new laws.

The following descriptions highlight certain provisions of both acts. This is not an exhaustive list or a complete description of the new laws. To obtain the complete text of the statutes, you may contact the Revisor of Statutes Bureau or it may be reviewed on the web at http://www.legis.state.wi.us/.

The following changes are applicable only to managed care plans:

Section 609.01(3c), Wis. Stat., defines a managed care plan as a health benefit plan that requires the enrollee, or creates incentives, including financial, for an enrollee to use providers that are managed, owned, under contract with, or employed by the insurer offering the health benefit plan. The new definition broadens the applicability of the statute beyond the previous regulatory scope. Under this definition, all health maintenance organizations, preferred provider plans and point-of-service plans, as well as other plans utilizing a network, unless specifically exempted, are treated as managed care plans and are subject to the statutory provisions.

Section 609.22, Wis. Stat., creates new access standards for managed care plans. The section requires plans to maintain adequate numbers and types of providers to meet the needs of their enrollees. Plans must permit a choice among available participating providers and ensure there are adequate numbers of primary providers available to enrollees.

If plans require referrals to specialist providers, the plan must establish a procedure by which an enrollee may request and obtain a standing referral. The procedure must state the criteria and conditions that must be met in order for the enrollee to receive the standing referral. Information on the process for obtaining a referral must be included in the policy or certificates provided to an enrollee, and must be provided upon the request of an enrollee or prospective enrollee.

Managed care plans must provide enrollees with coverage to obtain a second opinion from another participating provider. This benefit must be stated in the policy or certificate provided to an enrollee.

Managed care plans that cover emergency services must permit the use of an emergency room without prior authorization when a reasonably prudent layperson would consider the symptoms to indicate an emergency. Additionally, plans must cover emergency medical services or urgent care that is provided to a covered dependent child who is a full-time student attending school outside of the geographic service area of the plan.

If it is determined that a significant number of a plans' enrollees are members of an underserved population, a managed care plan must have an access plan to meet the specific needs of those enrollees with respect to covered benefits.

Section 609.24, Wis. Stat., requires managed care plans to permit enrollees to continue to use providers who have left the plan for a certain period of time. If a managed care plan represents at the time of a member's enrollment or renewal, that specific providers are available to plan enrollees, the plan must ensure access to primary care physicians for up to one year and to other providers for up to 90 days, under certain circumstances. Managed care plans are required to have terms and conditions in their provider contracts to address reimbursement for services provided under this section.

Section 609.30, Wis. Stat., strengthens the existing ban on "gag clauses" in provider contracts.

Section 609.32, Wis. Stat., requires managed care plans to develop comprehensive quality assurance plans. The plans must include a process for selecting and evaluating providers.

Section 609.34, Wis. Stat., requires that a managed care plan appoint a physician as medical director and that the medical director be responsible for clinical protocols, utilization review and quality assurance activities of the plan.

In addition, several provisions in the law apply to all health plans, not just managed care plans. These provisions can be summarized as follows.

Section 632.85, Wis. Stat., establishes a standard of coverage for emergency room care. A health plan may not deny coverage for emergency services that a reasonably prudent person would consider an emergency, nor require prior authorization for emergency services. This requirement applies to services that are needed to stabilize the patient.

Section 632.853, Wis. Stat., requires health plans that use a formulary or other list of pre-approved drugs and devices establish a process to permit an enrollee's physician to submit medical evidence for an individual patient exemption. The process must include timelines for both urgent and non-urgent review of the case.

Section 632.855, Wis. Stat., requires health plans that limit coverage of experimental treatment to disclose the limitations. Information concerning such limitation must be included in the policy or certificate provided to an insured, specifically delineating the criteria used to determine whether a treatment, procedure, drug or device is experimental, who is authorized to make such a determination (title of individual or department), and the appeal procedure if coverage is denied. In addition, a health plan must issue a coverage decision on a request for experimental treatment that includes all the necessary information upon which to make a decision, within 5 working days of receiving the request. If a health plan denies a request for experimental treatment for an individual who has a terminal condition or illness, the health plan must provide the insured with a denial letter that includes a statement indicating the specific medical and scientific reason for denying coverage, and a notice of the insured's right to appeal the decision, including a description of the appeal procedure.

Insurers who have questions regarding the new law may contact OCI by writing to Barbara Belling or e-mailing Ms. Belling at barbara.belling@wisconsin.gov.

Thank you for your attention.