For purposes of s.
609.35,
Stats., an insurer offering a preferred provider plan covers the same services
when performed by a nonparticipating provider that it covers when those
services are performed by a participating provider only if the insurer complies
with all of the following:
(1) The
insurer offering a preferred provider plan provides coverage that complies with
either of the following:
(a) Provides coverage
for services performed by nonparticipating providers with the insurer paying at
a coinsurance rate of not less than 60% and the enrollee paying at a
coinsurance rate of not more than 40%.
(b) Provides coverage for services performed
by nonparticipating providers with the insurer paying at a coinsurance rate not
less than 50% and the enrollee paying at a coinsurance rate of not more than
50% and the insurer provides the enrollee with the disclosure notice that is
compliant with sub. (5).
(2) The insurer offering a preferred provider
plan equally applies material exclusions regardless if the services are
performed by either participating or nonparticipating providers. The insurer
may exceed the coinsurance differential in s.
Ins 9.27(1), or the deductible
differential in s.
Ins 9.27(2), or the co-payment
differential in s.
Ins 9.27(3) to the extent the insurer
reasonably determines the cost sharing is necessary to encourage enrollees to
use participating providers or centers of excellence for transplant or other
unique disease treatment services or preventive health care services limited to
immunizations pursuant to s.
632.895(14),
Stats., and the services as covered benefits greater than the minimum required
for specific mandated benefits under ss.
632.895 and
632.89,
Stats., when the insurer at the time of solicitation and within the policy,
does either or both, as applicable, of the following:
(a) Provides a disclosure to enrollees that
identify the centers of excellence and the specific covered benefits that are
covered at a different rate if provided by a health care provider that is
recognized and identified as a center of excellence.
(b) Clearly and prominently discloses that
either immunizations or expanded benefits above mandated minimum coverage, or
both, are covered when performed by participating providers or with greater
disparity than permitted in s.
Ins 9.27(1)
through (3).
(3) The insurer offering a preferred provider
plan provides coverage of services without use of any financial incentives
other than maximum limits, out-of-pocket limits and those incentives described
in this section and s.
Ins 9.27 to encourage the use of participating
providers.
(4) The insurer offering
a preferred provider plan may use utilization management, including
preauthorization or similar methods, for denying access to or coverage of
services of nonparticipating providers with just cause and without such
frequency as to indicate a general business practice.
(5) An insurer required to provide a
disclosure notice under sub. (1) shall provide the disclosure notice to the
applicant at the time of solicitation, and shall include in a prominent
location within the certificate of coverage issued under a group policy and in
a prominent location in an individual policy, the following form and in not
less than 11-point bold font:
"NOTICE: LIMITED BENEFITS WILL BE PAID WHEN
NONPARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to
utilize the services of a nonparticipating provider for a covered service,
benefit payments to such non-participating provider are not based upon the
amount billed. The basis of your benefit payment will be determined according
to your policy's fee schedule, usual and customary charge (which is determined
by comparing charges for similar services adjusted to the geographical area
where the services are performed), or other method as defined by the policy.
YOU RISK PAYING MORE THAN THE COINSURANCE, DEDUCTIBLE AND CO-PAYMENT AMOUNT
DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION.
Nonparticipating providers may bill enrollees for any amount up to the billed
charge after the plan has paid its portion of the bill. Participating providers
have agreed to accept discounted payment for covered services with no
additional billing to the enrollee other than co-payment, coinsurance and
deductible amounts. You may obtain further information about the participating
status of professional providers and information on out-of-pocket expenses by
calling [the toll free telephone] number on your identification card [or
visiting [the company's] website].
(6) The insurer files a report with the
commissioner certifying compliance with this section on a form prescribed by
the commissioner and signed by an officer of the company.
(7) The insurer does not require a referral
to obtain coverage for care from either a participating or nonparticipating
provider and complies with ss.
Ins 9.27 and
9.32(2).
(8) This section first applies to an insurer
offering a preferred provider plan beginning on January 1, 2007. This section
does not apply to an insurer with respect to a preferred provider plan issued
prior to January 1, 2007 and periodically renewed after December 31,
2006.
