What the statutes mean

Free choice

Managed care organizations must permit its enrollees to choose freely among its participating providers except:

• They may require an enrollee to designate a primary care provider and to obtain health care services from that doctor. Every patient, however, may choose to see a chiropractor without going through the primary care provider.

• They may require the enrollee to obtain a referral from the primary provider to another participating medical provider prior to obtaining health care services from that medical provider. Referrals are not necessary for a patient to see a chiropractor.

Even if a chiropractor were willing to sign these rights away, they may not do so. Wi stats. 632.87 (3) protect a patient’s right to direct access to a chiropractor.

Rules for preferred provider and managed care plans.

The insurance commissioner has the responsibility for issuing rules covering all of the following areas (see the index for to locate information on a specific topic):

• To ensure that enrollees are not forced to travel excessive distances to receive health care services.
• To ensure the continuity of patient care if a managed care plan goes out of business or a provider leaves the plan.
• To ensure that employees that are offered health care through a managed care plan are given adequate notice of the opportunity to enroll. Employees must also be given complete and understandable information concerning the differences among the HMO plan, the PPO plan, the standard plan, and the point-of-service plan.

Access standards

• A managed care plan must have a sufficient number of chiropractors to meet the anticipated needs of its enrollees.
• A managed care plan must ensure that, with respect to covered benefits, each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.
• A managed care plan must permit each enrollee to select his or her own primary provider from a list of participating primary care physicians and any other participating providers that are authorized by the managed care plan to serve as primary providers.

Marketing errors

A managed care plan must allow a patient to see a chiropractor, even if the chiropractor is not a participating provider of the plan, if the managed care plan listed the chiropractic in the provider handbook or any other marketing materials that were provided or available to the enrollee at any of the following times:

• During the most recent open enrollment period.
• The time of the enrollee’s enrollment or most recent coverage renewal, whichever is later.

If the mistake is made, the managed care plan must provide coverage:

• Until the end of the current plan year for enrollee with no open enrollment period.
• Until the end of the plan year for which it was represented that the chiropractor was, or would be, a participating provider for enrollees with open enrollment periods.

If a patient is under care at the time the chiropractor’s coverage should end, the managed care plan must provide coverage for the remainder of the course of treatment or for 90 days after the provider’s participation with the plan terminates, whichever is shorter. However, coverage is not required to extend beyond the normal termination of the patient’s policy.

The coverage required does not need to be provided or may be discontinued if any of the following applies:

• The chiropractor no longer practices in the managed care plan’s geographic service area.
• The insurer issuing the managed care plan terminates or terminated the chiropractor’s contract for misconduct on the part of the chiropractor.

Reimbursement & medical necessity

• A managed care plan must include reimbursement provisions in its contract to chiropractors.
• If a contract between a managed care plan and a chiropractor does not address reimbursement, the insurer must reimburse the chiropractor according to the most recent contracted rate.
• A managed care company is allowed to determine what standards it will use to determine if care is medically necessary.

Secrecy agreements

• A managed care plan’s contract may not limit the chiropractor’s right to discuss any aspect of the patient’s condition or any treatment options available to the patient.
• A chiropractor may discuss, with his or her patients, all treatment options and any other information that the chiropractor determines to be in the best interest of the patient.
• A managed care plan may not penalize or terminate the contract of a chiropractor because the chiropractor makes referrals to other participating providers or discusses medically necessary or appropriate care with the patient.

Quality assurance

A managed care plan must develop comprehensive quality assurance standards that are adequate to identify, evaluate and remedy problems related to access, continuity and quality of care. The standards must include all of the following:

• An ongoing, written internal quality assurance program.
• Specific written guidelines for quality of care studies and monitoring.
• Performance and clinical outcomes-based criteria.
• A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

• A plan for gathering and assessing data.
• A peer review process.

Selection and evaluation of providers

A managed care plan must develop a process for selecting chiropractors, including written policies and procedures that the plan uses for review and approval of chiropractors. After consulting with appropriately qualified chiropractors, the plan must establish minimum professional requirements for its chiropractors. The process for selection must include verification of a chiropractor’s license, including the history of any suspensions or revocations, and the history of any liability claims made against the doctor. These selection criteria are used by most managed plans to screen out chiropractors with malpractice or discipline problems. There is little, if any work done to select chiropractors based on their quality of care they offer.

A managed care plan must establish a written plan for the ongoing reevaluation of each chiropractor within a specified number of years after the chiropractor’s initial acceptance for participation. The reevaluation must include all of the following:

• Updating the previous review criteria.
• Assessing the provider’s performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.

A managed care plan may not require a chiropractor to provide services that are outside the scope of his or her license.

Statute excerpts

609.01 Definitions
609.05 Primary provider and referrals
609.20 Rules for preferred provider and managed care plans
609.22 Access standards
609.22(4) Specialist providers
609.24 Community care
609.30 Provider disclosures
609.32 Quality assurance
609.32(2) Selection and evaluation of providers

609.01 Definitions. In this chapter:

609.01(1c) “Emergency medical condition” has the meaning given in s. 632.85 (1) (a).

609.01(1d) “Enrollee” means, with respect to a managed care plan, preferred provider plan or limited service health organization, a person who is entitled to receive health care services under the plan.

609.01(1g)(a) Except as provided in par. (b), “health benefit plan” means any hospital or medical policy or certificate.

609.01(1g)(b) “Health benefit plan” does not include any of the following:

609.01(1g)(b)1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.

609.01(1g)(b)2. Coverage issued as a supplement to liability insurance.

609.01(1g)(b)3. Liability insurance, including general liability insurance and automobile liability insurance.

609.01(1g)(b)4. Worker’s compensation or similar insurance.

609.01(1g)(b)5. Automobile medical payment insurance.

609.01(1j) “Health care costs” means consideration for the provision of health care, including consideration for services, equipment, supplies and drugs.

609.01(1m) “Health care plan” has the meaning given under s. 628.36 (2) (a) 1.

609.01(2) “Health maintenance organization” means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers participating in the plan.

609.01(3) “Limited service health organization” means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers participating in the plan.

609.01(3c) “Managed care plan” means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with or employed by the insurer offering the health benefit plan.

609.01(3m) “Participating” means, with respect to a physician or other provider, under contract with a managed care plan, preferred provider plan or limited service health organization to provide health care services, items or supplies to enrollees of the managed care plan, preferred provider plan or limited service health organization.

609.01(3r) “Physician” has the meaning given in s. 448.01 (5).

609.01(4) “Preferred provider plan” means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, for consideration other than predetermined periodic fixed payments, either comprehensive health care services or a limited range of health care services performed by providers participating in the plan.

609.01(4m) “Primary care physician” means a physician specializing in family medical practice, general internal medicine or pediatrics.

609.01(5) “Primary provider” means a participating primary care physician, or other participating provider authorized by the managed care plan, preferred provider plan or limited service health organization to serve as a primary provider, who coordinates and may provide ongoing care to an enrollee.

609.01(5m) “Provider” means a health care professional, a health care facility or a health care service or organization.

609.01(7) “Standard plan” means a health care plan other than a health maintenance organization or a preferred provider plan.

Primary provider and referrals

609.05(1) Except as provided in subs. (2) and (3), a limited service health organization, preferred provider plan or managed care plan shall permit its enrollees to choose freely among participating providers.

609.05(2) Subject to s. 609.22 (4) and (4m), a limited service health organization, preferred provider plan or managed care plan may require an enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.

609.05(3) Except as provided in ss. 609.22 (4m), 609.65 and 609.655, a limited service health organization, preferred provider plan or managed care plan may require an enrollee to obtain a referral from the primary provider designated under sub. (2) to another participating provider prior to obtaining health care services from that participating provider.

Rules for preferred provider and managed care plans

The commissioner shall promulgate rules relating to preferred provider plans and managed care plans for all of the following purposes:

609.20(1) To ensure that enrollees are not forced to travel excessive distances to receive health care services.

609.20(2) To ensure that the continuity of patient care for enrollees meets the requirements under s. 609.24.

609.20(3) To define substantially equivalent coverage of health care expenses for purposes of s. 609.10 (1) (am).

609.20(4) To ensure that employees offered a health maintenance organization or a preferred provider plan that provides comprehensive services under s. 609.10 (1) (am) are given adequate notice of the opportunity to enroll, as well as complete and understandable information under s. 609.10 (1) (c) concerning the differences among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan, as defined in s. 609.10 (1) (ac), including differences among providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization.

Access standards

609.22(1) Providers. A managed care plan shall include a sufficient number, and sufficient types, of providers to meet the anticipated needs of its enrollees, with respect to covered benefits.

609.22(2) Adequate choice. A managed care plan shall ensure that, with respect to covered benefits, each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.

609.22(3) Primary provider selection. A managed care plan shall permit each enrollee to select his or her own primary provider from a list of participating primary care physicians and any other participating providers that are authorized by the managed care plan to serve as primary providers. The list shall be updated on an ongoing basis and shall include a sufficient number of primary care physicians and any other participating providers authorized by the plan to serve as primary providers who are accepting new enrollees.

609.22(4)
(4) Specialist providers.
609.22(4)(a)

(a)
609.22(4)(a)1.
1. If a managed care plan requires a referral to a specialist for coverage of specialist services, the managed care plan shall establish a procedure by which an enrollee may apply for a standing referral to a specialist. The procedure must specify the criteria and conditions that must be met in order for an enrollee to obtain a standing referral.

609.22(4)(a)2.
2. A managed care plan may require the enrollee’s primary provider to remain responsible for coordinating the care of an enrollee who receives a standing referral to a specialist. A managed care plan may restrict the specialist from making any secondary referrals without prior approval by the enrollee’s primary provider. If an enrollee requests primary care services from a specialist to whom the enrollee has a standing referral, the specialist, in agreement with the enrollee and the enrollee’s primary provider, may provide primary care services to the enrollee in accordance with procedures established by the managed care plan.

609.22(4)(a)3.
3. A managed care plan must include information regarding referral procedures in policies or certificates provided to enrollees and must provide such information to an enrollee or prospective enrollee upon request.

Continuity of care

609.24(1) Requirement to provide access.

609.24(1)(a) Subject to pars. (b) and (c) and except as provided in par. (d), a managed care plan shall, with respect to covered benefits, provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the managed care plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times:

609.24(1)(a)1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period.

609.24(1)(a)2. If the plan under which the enrollee has coverage has no open enrollment period, the time of the enrollee’s enrollment or most recent coverage renewal, whichever is later.

609.24(1)(b) Except as provided in par. (d), a managed care plan shall provide the coverage required under par. (a) with respect to the services of a provider who is a primary care physician for the following period of time:

609.24(1)(b)1. For an enrollee of a plan with no open enrollment period, until the end of the current plan year.

609.24(1)(b)2. For an enrollee of a plan with an open enrollment period, until the end of the plan year for which it was represented that the provider was, or would be, a participating provider.

609.24(1)(c) Except as provided in par. (d), if an enrollee is undergoing a course of treatment with a participating provider who is not a primary care physician and whose participation with the plan terminates, the managed care plan shall provide the coverage under par. (a) with respect to the services of the provider for the following period of time:

609.24(1)(c)1. Except as provided in subd. 2., for the remainder of the course of treatment or for 90 days after the provider’s participation with the plan terminates, whichever is shorter, except that the coverage is not required to extend beyond the period specified in par. (b) 1. or 2., whichever applies.

609.24(1)(d) The coverage required under this section need not be provided or may be discontinued if any of the following applies:

609.24(1)(d)1. The provider no longer practices in the managed care plan’s geographic service area.

609.24(1)(d)2. The insurer issuing the managed care plan terminates or terminated the provider’s contract for misconduct on the part of the provider.

609.24(1)(e)1. An insurer issuing a managed care plan shall include in its provider contracts provisions addressing reimbursement to providers for services rendered under this section.

609.24(1)(e)2. If a contract between a managed care plan and a provider does not address reimbursement for services rendered under this section, the insurer shall reimburse the provider according to the most recent contracted rate.

609.24(2) Medical necessity provisions. This section does not preclude the application of any provisions related to medical necessity that are generally applicable under the plan.

609.24(3) Hold harmless requirements. A provider that receives or is due reimbursement for services provided to an enrollee under this section is subject to s. 609.91 with respect to the enrollee, regardless of whether the provider is a participating provider in the enrollee’s plan and regardless of whether the enrollee’s plan is a health maintenance organization.

Provider disclosures

609.30(1) Plan may not contract. A managed care plan may not contract with a participating provider to limit the provider’s disclosure of information, to or on behalf of an enrollee, about the enrollee’s medical condition or treatment options.

609.30(2) Plan may not penalize or terminate. A participating provider may discuss, with or on behalf of an enrollee, all treatment options and any other information that the provider determines to be in the best interest of the enrollee. A managed care plan may not penalize or terminate the contract of a

participating provider because the provider makes referrals to other participating providers or discusses medically necessary or appropriate care with or on behalf of an enrollee.

Quality assurance.

609.32(1) Standards. A managed care plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following:

609.32(1)(a) An ongoing, written internal quality assurance program.

609.32(1)(b) Specific written guidelines for quality of care studies and monitoring.

609.32(1)(c) Performance and clinical outcomes-based criteria.

609.32(1)(d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

609.32(1)(e) A plan for gathering and assessing data.

609.32(1)(f) A peer review process.

Selection and evaluation of providers.

609.32(2)(a) A managed care plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider’s license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider.

609.32(2)(b) A managed care plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider’s initial acceptance for participation. The reevaluation shall include all of the following:

609.32(2)(b)1. Updating the previous review criteria.

609.32(2)(b)2. Assessing the provider’s performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.

609.32(2)(c) A managed care plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.

609.34 Clinical decision-making; medical director. A managed care plan shall appoint a physician as medical director. The medical director shall be responsible for clinical protocols, quality assurance activities and utilization management policies of the plan.