Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.39 - Disenrollment

(1) DISCLOSURE. The health maintenance organization or limited service health organization shall clearly disclose in the policy and certificate any circumstances under which the health maintenance organization or limited service health organization may disenroll an enrollee.

(2) ENROLLEE DISENROLLMENT CRITERIA. Except as provided in s. 632.897, Stats., the health maintenance organization or limited service health organization may only disenroll an enrollee if one of the following occurs:

(a) The enrollee has failed to pay required premiums by the end of the grace period.

(b) The enrollee has committed acts of physical or verbal abuse that pose a threat to providers or other members of the organization.

(c) The enrollee has allowed a nonmember to use the health maintenance or limited service health organization's certification card to obtain services or has knowingly provided fraudulent information in applying for coverage.

(d) The enrollee has moved outside of the geographical service area of the organization.

(e) The enrollee is unable to establish or maintain a satisfactory physician-patient relationship with the physician responsible for the enrollee's care. Disenrollment of an enrollee under this paragraph shall be permitted only if the health maintenance organization or limited service health organization can demonstrate that it did all of the following:

1. Provided the enrollee with the opportunity to select an alternate primary care physician.

2. Made a reasonable effort to assist the enrollee in establishing a satisfactory patient-physician relationship.

3. Informed the enrollee that he or she may file a grievance on this matter.

(3) PROHIBITED DISENROLLMENT CRITERIA. Notwithstanding sub. (2), the health maintenance organization or limited service health organization plan may not disenroll an enrollee for reasons related to any of the following:

(a) The physical or mental condition of the enrollee.

(b) The failure of the enrollee to follow a prescribed course of treatment.

(c) The failure of an enrollee to keep appointments or to follow other administrative procedures or requirements.

(4) ALTERNATIVE COVERAGE FOR DISENROLLED ENROLLEES. An insurer offering a health maintenance organization plan or limited service health organization plan that has disenrolled an enrollee for any reason except failure to pay required premiums shall make arrangements to provide similar alternate insurance coverage to the enrollee. In the case of group certificate holders, the insurance coverage shall be continued until the affected enrollee finds his or her own coverage or until the next opportunity to change insurers, whichever comes first. In the case of an enrollee covered on an individual basis, coverage shall be continued until the anniversary date of the policy or for one year, whichever is earlier.

Notes

Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.39

Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (4) Register February 2006 No. 602, eff. 3-1-06.