What the statutes mean

A company operating a voluntary health care plan may pay chiropractors on a salary, per patient or fee-for-service basis. This gives managed care companies virtually unlimited authority to establish any type of reimbursement plan as long as they can find chiropractors to agree to its terms.

Unless the insurer is a health maintenance organization (HMO) or preferred provider plan (PPO) an insurance company:

• May not prevent any of the people covered under the plan from choosing freely among all of the providers that are participating for the plan. The only exception is that an insurer is allowed to require the enrollee to select primary providers when it is reasonably possible.

• May not require a chiropractor to participate exclusively in their health care plan.

• May not exclude a chiropractor from participating in their plan unless they have good cause related to the chiropractor’s practice of chiropractic. Generally this means that a chiropractor could not be excluded from a plan unless he or she was disciplined by the chiropractic examining board or was found guilty by the insurer of some type of fraud.

The law specifically requires that all health care plans, including health maintenance organizations, limited service health organizations and preferred provider plans cover chiropractic services.

The insurance commissioner has the authority to issue rules that would exempt insurers if they provide innovative approaches to the delivery of health care or design plans to contain health care costs, and could not operate successfully if that had to follow all of the provisions that are detailed above. The law limits the insurance commissioner to issue these rules only if he or she finds that the interests of the public require such plans as an experiment, to supply health care services that are not otherwise available in adequate quantity or quality, or to contain health care costs. Even then the rule/s must be as narrow as possible to be compatible with as much of this law as possible. The insurance commissioner has never used this authority to exclude chiropractic care from an insurance plan.

Insurance commissioner’s role in facilitating cost-effective health care

The State of Wisconsin employs more people than any other business in Wisconsin. Since all of its employees are eligible for health care this makes the state’s Department of Employee Trust Funds the largest purchaser of health care in the state. The insurance commissioner is required to help the Department of Employee Trust Funds by providing information to state employees and the public for the following purposes:

• To facilitate the development and implementation of health care plans that provide innovative approaches to the delivery of health care services or that are designed to contain health care costs.

• To increase the awareness and understanding among employers and their employes, providers of health care services, and members of the public regarding the availability and nature of innovative or cost-effective health care plans.

The commissioner’s responsibilities in accomplishing these communication responsibilities include all of the following:

• Assist the Department of Employe Trust Funds in the development of health care plans through the state’s group insurance board.

• Provide employers and their employes with information regarding the availability and nature of health care coverage that may be obtained through the state’s group insurance board.

• Provide information to employers regarding how to obtain health care coverage for their employes through the state’s group insurance board.

• Provide information to employers, employes and members of the public regarding the availability and nature of various kinds of health care plans, including comparing and contrasting of different plans.

• Provide information to employers, employes, providers of health care services, and members of the public regarding the relative effectiveness of various kinds of health care plans in containing health care costs.

Practical advice

Beginning about 1997 the insurance commissioner began to collect specific information from chiropractors as part of the license renewal process. Chiropractors are required to submit the information requested by the state. The insurance commissioner may use the information collected by the state to publish consumer guides for chiropractic services.

Statute excerpts

628.36(1) Payment methods. Any corporation operating a voluntary health care plan may pay health care professionals on a salary, per patient or fee-for-service basis to provide health care to policyholders or beneficiaries of the corporation.

628.36(2) Discrimination against professionals.

628.36(2)(a)In this section:

628.36(2)(a)1. “Health care plan” means an insurance contract providing coverage of health care expenses.

628.36(2)(a)2. “Provider” means a health care professional, a health care facility or a health care service or organization.

628.36(2)(b)1. Except for health maintenance organizations, preferred provider plans and limited service health organizations, no health care plan may prevent any person covered under the plan from choosing freely among providers who have agreed to participate in the plan and abide by its terms, except by requiring the person covered to select primary providers to be used when reasonably possible.

628.36(2)(b)2. No provider may be required to participate exclusively in a health care plan as a condition of participation in it.

628.36(2)(b)3. Except as provided in subd. 4., no provider may be denied the opportunity to participate in a health care plan, other than a health maintenance organization, a limited service health organization or a preferred provider plan, under the terms of the plan.

628.36(2)(b)4. Any health care plan may exclude a provider from participation in the health care plan for cause related to the practice of his or her profession.

628.36(2)(b)5. All health care plans, including health maintenance organizations, limited service health organizations and preferred provider plans are subject to s. 632.87 (3).

628.36(3) Exemption by rule. By rule the commissioner may exempt from the application of any part of subs. (1) to (2m) plans which provide innovative approaches to the delivery of health care or which are designed to contain health care costs, and which cannot operate successfully consistent with all of the provisions in subs. (1) to (2m). The commissioner may promulgate such a rule only if on a finding that the interests of the public require such plans as an experiment, to supply health care services that are not otherwise available in adequate quantity or quality, or to contain health care costs. The promulgated rule shall be as narrow as is compatible with the success of the plans.

628.36(4) Facilitating cost-effective provision of health care services.

628.36(4)(a) The commissioner shall provide information and assistance to the department of employe trust funds, employers and their employes, providers of health care services and members of the public, as provided in par. (b), for the following purposes:

628.36(4)(a)1. To facilitate the development and implementation of health care plans that provide innovative approaches to the delivery of health care services or that are designed to contain health care costs.

628.36(4)(a)2. To increase the awareness and understanding among employers and their employes, providers of health care services and members of the public regarding the availability and nature of innovative or cost-effective health care plans.

628.36(4)(b) The commissioner’s responsibilities in accomplishing the purposes set forth in par. (a) shall include all of the following:

628.36(4)(b)1. Assisting the department of employe trust funds in the development of health care plans under s. 40.51 (7).

628.36(4)(b)2. Providing employers and their employes with information regarding the availability and nature of health care coverage that may be obtained under s. 40.51 (7).

628.36(4)(b)3. Providing information to employers regarding how to proceed under s. 40.51 (7) to obtain health care coverage for their employes.

628.36(4)(b)4. Providing information to employers and their employes and members of the public regarding the availability and nature of various kinds of health care plans, including their distinct and contrasting characteristics.

628.36(4)(b)5. Providing information to employers and their employes, providers of health care services and members of the public regarding the relative effectiveness of various kinds of health care plans in containing health care costs.