Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.27 - Preferred provider plan requirements
Insurers offering a preferred provider plan shall comply with all the following:
(1) Except as
provided in s.
Ins 9.25(2), insurers offering a
preferred provider plan that apply a coinsurance percentage when the services
are performed by nonparticipating providers at a different percentage than the
coinsurance percentage that is applied when the services are performed by
participating providers shall offer plans that have either of the following:
(a) The coinsurance differential between
participating and nonparticipating providers performing the same services is
30% or less.
(b) The coinsurance
differential between participating and nonparticipating provider performing the
same services is greater than 30% and the insurer provides the enrollee with a
disclosure notice that is compliant with s.
Ins 9.25(5).
(2) Except as provided in s.
Ins 9.25(2), insurers offering a
preferred provider plan that apply a deductible when the services are performed
by nonparticipating providers in a different amount than the deductible that is
applied when the services are performed by participating providers shall offer
plans that have either of the following:
(a)
The deductible applied to nonparticipating providers is no more than 2 times
greater than the deductible applied to participating providers or no more than
$2000 higher than the participating provider deductible.
(b) The deductible applied to
nonparticipating providers is more than 2 times greater than the deductible
applied to participating providers or is more than $2000 higher than the
participating provider deductible and the insurer provides the enrollee with a
disclosure notice that is compliant with s.
Ins 9.25(5).
(3) Except as provided in s.
Ins 9.25(2), insurers offering a
preferred provider plan that apply a co-payment when the services are performed
by nonparticipating providers in a different amount than the co-payment that is
applied when the services are performed by participating providers shall offer
plans that have either of the following:
(a)
The co-payment applied to nonparticipating providers is no more than 3 times
greater than the co-payment applied to participating providers or no more than
$100 for services of a health care provider or no more than $300 for services
of a health care facility.
(b) The
co-payment applied to nonparticipating providers is more than 3 times greater
than the co-payment applied to participating providers or is more than $100 for
services of a health care provider or is more than $300 for services of a
health care facility and the insurer provides the enrollee with a disclosure
notice that is compliant with s.
Ins 9.25(5).
(4) 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.
Notes
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