Date:March 3, 2000
To:All Insurers Licensed to Write Health Insurance in Wisconsin
From:Randy Blumer, Deputy Commissioner
Subject:Ch. Ins 9, Wis. Adm. Code - Managed Care Plans - HMOs, PPOs, LSHOs
Section Ins 3.67, Wis. Adm. Code - Benefit Appeals Under Certain Policies

Ch. Ins 9, Wis. Adm. Code, replaces ss. Ins 3.48, 3.50, and 3.52, Wis. Adm. Code, and establishes standards for managed care plans for compliance with the requirements of ch. 609, Wis. Stat. Section Ins 3.67, Wis. Adm. Code, applies to all health care plans, including fixed indemnity and special disease insurance. The rule establishes requirements and standards that must be included in the process for appealing a plan decision to deny coverage of experimental treatment, and for permitting a physician to request an exception for coverage of a drug or device not covered under the plan's formulary or list of preapproved drugs and devices. A description of the appeal process must be included in every policy, certificate, and outline of coverage.

These rules are effective for all policies issued or renewed on or after March 1, 2000.

In lieu of mailing bulletins to insurers regarding the implementation of ch. Ins 9, and s. Ins 3.67, Wis. Adm. Code, OCI is publishing the bulletins on its Internet site at:

http://oci.wi.gov/bulletin.htm

INSURERS SHOULD CAREFULLY REVIEW THE BULLETINS AND THE RULES AS BOTH INSURERS OFFERING INDEMNITY INSURANCE AND INSURERS OFFERING MANAGED CARE PLANS ARE AFFECTED.

Special attention should be paid by insurers that offer HMO plans or that offer PPO plans, market PPO riders, or contract with PPO networks, as ch. Ins 9, Wis. Adm. Code, includes specific reporting requirements.

Insurers should review the provisions under the rule requiring managed care plans to provide written certification demonstrating compliance with certain access standards, and certification identifying the type of managed care plan offered by the insurer. The Certification of Managed Care Plan Type is due April 1, 2000. The Certification of Access Standards is first due June 1, 2000. Copies of the certification documents are included as Attachments 2 and 3 to the bulletin. Information regarding the persons to contact for additional information is also included in the bulletins.

IF YOUR COMPANY DOES NOT HAVE INTERNET ACCESS AND YOU NEED A PAPER COPY OF THE BULLETINS, send a written request along with a stamped, self addressed envelope to Florence DeLuca, Office of the Commissioner of Insurance, P.O. Box 7873, Madison, WI 53707-7873.