Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.21 - Limited exemptions
(1) SILENT DISCOUNT. An insurer, with respect
to a defined network plan:
(a) Is exempt from
meeting the requirements under ss.
609.22,
609.24,
609.32,
609.34,
609.36
and
632.83,
Stats., and ss.
Ins 9.31, 9.32(1), 9.35, 9.37, 9.38, 9.39, to 9.40(1) (7), to 9.42(1) (7), if the
only owned, employed, or participating provider providing services covered
under the plan is a silent provider network.
(b) Is exempt from meeting the requirements
under ss.
609.22,
609.24,
609.32,
609.34,
and
609.36,
Stats., and ss.
Ins 9.32(1), 9.35, 9.37, 9.38, 9.39, to 9.40(1) (7), and to
9.42(1) (7), solely with respect to services provided by the silent provider
network, if the plan also covers services by providers that the insurer owns or
employs, or another participating provider. An insurer is not exempt from those
provisions with respect to a provider that is not a silent provider
network.
(2) DE MINIMUS
LIMITED EXCEPTION. Insurers offering a defined network plan are exempt from
meeting the requirements under ss.
609.22(1) to (4) and
(8),
609.32 and
609.34,
Stats., ss.
Ins 9.32(1), to 9.40(1) (7), and and
9.42(6) (7), with respect to a defined network plan, if the insurer meets all
of the following requirements.
(a) The
insurer offering a defined network plan provides comprehensive benefits to
insureds of at least 80% coverage for in-plan providers.
(b) The insurer's only financial incentive to
the insureds to utilize participating providers is a co-insurance differential
of not more than 10% between in-plan versus off-plan providers. Except for the
co-insurance differential of no greater than 10%, all benefits, deductibles and
co-payments must be the same regardless of whether the insured obtains
benefits, services or supplies from in-plan or off-plan providers.
(c) The insurer makes no representation
regarding quality of care.
(d) The
insurer makes no representation that the defined network plan is a preferred
provider plan or that the defined network plan directs or is responsible for
the quality of health care services. Nothing in this paragraph prevents an
insurer from describing the availability or limits on availability of
participating providers or the extent or limits of coverage under the defined
network plan if participating or non-participating providers are utilized by an
insured.
(e) The insurer, at the
time an application is solicited, does all of the following.
1. Discloses to a potential applicant, and
allows the applicant a reasonable opportunity to review, a directory which
reasonably and clearly discloses the availability and location of providers:
a. Within reasonable travel distance from the
principle location of the place of employment of employees likely to enroll
under the plan, if the applicant is an employer; or
b. Within reasonable travel distance from the
residence of the proposed insured, for any other application.
2. Obtains on the application, or
on an addendum to the application, the applicant's signed acknowledgement that
the applicant:
a. Has reviewed the disclosure
under subd. 1.;
b. Understands that
participating providers may or may not be available to provide services and
that the insurer is not required to make participating providers available;
and
c. Understands that the plan
will provide reduced benefits if the insured uses a non-participating
provider.
3. Provides to
each applicant a copy of the provider directory at the time the policy is
issued.
4. The insurer provides
access to translation services for the purpose of providing information
concerning benefits, to the greatest extent possible, if a significant number
of enrollees of the plan customarily use languages other than
English.
Notes
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