Sec. Ins 9.32 - Defined network plan requirements

§ 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 operation, waiting times for appointments in provider offices and after hours care. The hours of operation, waiting times, and availability of after hours care shall reflect the usual practice in the local area. Geographic availability shall reflect the usual medical travel times within the community.

(b) Have sufficient number and type of plan providers to adequately deliver all covered services based on the demographics and health status of current and expected enrollees served by the plan.

(c) Provide 24-hour nationwide toll-free telephone access for its enrollees to the plan or to a Wisconsin participating provider for authorization for care which is covered by the plan.

(d) Provide as a covered benefit the emergency services rendered during the treatment of an emergency medical condition, as defined by s. 632.85, Stats., by a nonparticipating provider as though the services was provided by a participating provider, if the insurer provides coverage for emergency medical services and the enrollee cannot reasonably reach a participating provider or, as a result of the emergency, is admitted for inpatient care subject to any restriction which may govern payment to a participating provider for emergency services. The insurer shall pay the nonparticipating provider at the rate the insurer pays a nonparticipating provider after applying any co-payments, coinsurance, deductibles or other cost-sharing provisions that apply to participating providers.

(2) An insurer offering a preferred provider plan shall do all of the following:

(a) Provide covered benefits by participating providers with reasonable promptness consistent with normal practices and standards in the geographic area. Geographic availability shall reflect the usual medical travel times within the community. This does not require an insurer offering a preferred provider plan to offer geographic availability of a choice of participating providers.

(b) Provide sufficient number and type of participating providers to adequately deliver all covered services based on the demographics and to meet the anticipated needs of its enrollees served by the plan including at least one primary care provider and a participating provider with expertise in obstetrics and gynecology accepting new enrollees.

(d) Include in its provider directory a prominent notice that complies with Appendix D and is printed in 11-point bold font.

(fm) Provide emergency medical services as a covered benefit when the enrollee receives treatment for an emergency medical condition, as defined by s. 632.85, Stats., from a nonparticipating provider. The insurer shall cover the treatment of the emergency medical condition rendered by a nonparticipating provider as though the services were rendered by a participating provider if the insurer provides coverage for emergency medical services and the enrollee cannot reasonably reach a participating provider or, as a result of the emergency, is admitted for inpatient care. The insurer shall compensate the nonparticipating providers at the rate the insurer pays nonparticipating providers and after applying any co-payments, coinsurance, deductibles or other cost-sharing provisions that apply to participating providers until the nonparticipating provider has met its obligations under 42 U.S.C. § 1395 dd.

(CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (2) (a), r. (2) (c), (e) and (f), cr. (fm), Register December 2006 No. 612. eff. 1-1-07.)

The following state regulations pages link to this page.