Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.40 - Required quality assurance and remedial action plans
(1) In this section
"quality assurance" means the measurement and evaluation of the quality and
outcomes of medical care provided.
(2)
(a) By
April 1, 2000, an insurer, with respect to a defined network plan that is not a
preferred provider plan shall submit a quality assurance plan consistent with
the requirements of s.
609.32, Stats.,
to the commissioner, except as provided in par. (b). The insurers shall submit
a quality assurance plan that is consistent with the requirements of s.
609.32, Stats.,
by April 1 of each subsequent year. The quality assurance plan shall be
designed to reasonably assure that health care services provided to enrollees
of the defined network plan meet the quality of care standards consistent with
prevailing standards of medical practice in the community. The quality
assurance plan shall document the procedures used to train employees of the
defined network plan in the content of the quality assurance plan.
(b) Insurers offering a defined network plan
that is not also a preferred provider plan or health maintenance organization
plan shall submit a quality assurance plan consistent with the requirements of
par. (a) and s.
609.32, Stats.,
to the commissioner by April 1, 2007, and April 1 of each subsequent
year.
(3) Insurers
offering a preferred provider plan shall develop procedures for taking
effective and timely remedial action to address issues arising from quality
problems including access to, and continuity of care from, participating
primary care providers. The remedial action plan shall at least contain all of
the following:
(a) Designation of a
senior-level staff person responsible for the oversight of the insurer's
remedial action plan.
(b) A written
plan for the oversight of any functions delegated to other contracted
entities.
(c) A procedure for the
periodic review of services related to clinical protocols and utilization
management performed by the insurer offering a preferred provider plan or by
another contracted entity.
(d)
Periodic and regular review of grievances, complaints and OCI
complaints.
(e) A written plan for
maintaining the confidentiality of protected information.
(f) Documentation of timely correction of
access to and continuity of care issues identified in the plan. Documentation
shall include all of the following:
1. The
date of awareness that an issue exists for which a remedial action plan shall
be initiated.
2. The type of issue
that is the focus of the remedial action plan.
3. The person or persons responsible for
developing and managing the remedial action plan.
4. The remedial action plan utilized in each
situation.
5. The outcome of the
remedial action plan.
6. The
established time frame for re-evaluation of the issue to ensure resolution and
compliance with the remedial action plan.
(4) All insurers offering a defined network
plan, other than a preferred provider plan, shall establish and maintain a
quality assurance committee and a written policy governing the activities of
the quality assurance committee that assigns to the committee responsibility
and authority for the quality assurance program. All complaints, OCI
complaints, appeals and grievances relating to quality of care shall be
reviewed by the quality assurance committee.
(7) No later than April 1, 2001, with respect
to an insurer offering a defined network plan that is a health maintenance
organization plan, and by April 1, 2008, for insurers offering a defined
network plan that is not also a preferred provider plan or health maintenance
organization plan, shall do all of the following:
(a) Include a summary of its quality
assurance plan in its marketing materials.
(b) Include a brief summary of its quality
assurance plan and a statement of patient rights and responsibilities with
respect to the plan in its certificate of coverage or enrollment
materials.
(8) Beginning
April 1, 2000, an insurer offering any defined network plan shall submit an
annual certification for each plan with the commissioner no later than April 1
of each year. The certification shall assert the type of plan and be signed by
an officer of the company. OCI shall maintain for public review a current list
of health benefit plans, categorized by type.
Notes
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