Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.12 - Incidental or immaterial indemnity business in health maintenance organizations

(1) Except as provided by sub. (2), insurance business is not incidental or immaterial under s. 609.03(3) (a) 3, Stats., if a health maintenance organization insurer issues coverage which is not typically included in a health maintenance organization or limited service health organization policy and the insurer does any of the following:

(a) Markets the policy containing the coverage.

(b) The total premium for policies containing the coverage exceeds or is projected to exceed 5% of total premium earned in any 12-month period.

(2) Insurance business is incidental or immaterial under s. 609.03(3) (a) 3, Stats., if the business is written according to the terms of a specific business plan for issuance of coverage under s. 609.03(3) (a) 3, Stats., and the business plan is approved in writing by the office. A request for approval to do business under this paragraph including, but not limited to, issuance of policies with point of service coverage, shall include a detailed business plan, a copy of the policy form, a detailed description of how the business will be marketed and premium volume controlled, and other information prescribed by the office. The total premium for policies containing coverages subject to this paragraph and policies issued under sub. (1) may not exceed 10% of premium earned or projected to be earned in any 12-month period.

(3) If the commissioner approves insurance business as incidental or immaterial the commissioner may also, by order under s. Ins 9.04(2), require the insurer to maintain more than the minimum compulsory surplus.

(4) For the purpose of this section, any coverage that covers services by a provider other than a participating provider is not typically included in a health maintenance organization or limited service health organization policy, except coverage of emergency out-of-area services.

Notes

Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.12

Cr. Register, February, 2000, No. 530, eff. 3-1-00.