What the statutes mean

Managed care has fundamentally changed the traditional relationship between doctors and their patients. Relationships are no longer measured in generations, they now last until the next contract negotiating session. Managed care companies do not respect the importance of a long term relationship between a patient and their doctor. In fact, because of rapid turnover in provider panels and guidelines that emphasize cost over quality, managed care is designed to virtually ensure that patients will not develop trusting relationships with their doctors. When the state legislature passed the “point of service” law that allows patients to choose health care providers that are not part of the managed care panel, they acknowledged:

• that most individuals have little control when their health care comes from a managed care company.
• that people have no choice but to accept the managed care plan offered by their employer.
• that some doctors on a managed care panel may be competent but, there are times when a doctor who is not part of the managed care plan’s panel of providers will better meet a patient’s health care needs.

Point of service plans give the patient the opportunity to restore some balance to their health care relationships. When it is in their interest, they can use the doctors on the managed care panel. But when they have great confidence in a particular chiropractor, or have special needs that are understood because of their long tern relationship with a particular chiropractor, they have the choice to retain that relationship.

If a patient purchases a point of service plan can they choose any chiropractor to treat them?

They may choose any chiropractor they wish to provide their services.

What is the managed care company required to pay for the services?

The managed care company is required to pay the chiropractor the same amount that they would pay a participating provider for those health care services.

Who is responsible for the difference between the chiropractor’s usual and customary charge and the amount reimbursed by the managed care company?

If the doctor chooses, he or she may bill the patient for any additional costs or charges.

How often must a enrollee be offered the chance to purchase a point of service plan?

The employer must provide their employees with the opportunity to enroll in a point of service plan at least once a year. As part of the annual notification, the employer must provide the employees with complete and understandable information concerning the differences among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan.

Are their any employers exempt from offering their employees point of service plans?

• Self insured employers covered under federal ERISA laws
• Employers that have less than 25 full time employees.
• Employers that have fewer than 25 employees that express interest in a POS plan.
• Group Health Cooperative and Family Health Plan

Statute excerpts

Standard plan and point-of-service option plan required.

609.10(1)(ac) In this section, “point-of-service option plan” means a health maintenance organization or preferred provider plan that permits an enrollee to obtain covered health care services from a provider that is not a participating provider of the health maintenance organization or preferred provider plan under all of the following conditions:

609.10(1)(ac) 1. The nonparticipating provider holds a license or certificate that authorizes or qualifies the provider to provide the health care services.

609.10(1)(ac) 2. The health maintenance organization or preferred provider plan is required to pay the nonparticipating provider only the amount that the health maintenance organization or preferred provider plan would pay a participating provider for those health care services.

609.10(1)(ac) 3. The enrollee is responsible for any additional costs or charges related to the coverage.

609.10(1)(am) Except as provided in subs. (2) to (4), an employer that offers any of its employees a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employees a standard plan that provides at least substantially equivalent coverage of health care expenses and a point-of-service option plan, as provided in pars. (b) and (c).

609.10(1)(b) At least once annually, the employer shall provide the employees the opportunity to enroll in the health care plans under par. (am).

609.10(1)(c) The employer shall provide the employees adequate notice of the opportunity to enroll in the health care plans under par. (am) and shall provide the employees complete and understandable information concerning the differences among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan.

609.10(2) If, after providing an opportunity to enroll under sub. (1) (b) and the notice and information under sub. (1) (c), fewer than 25 employees indicate that they wish to enroll in the standard plan under sub. (1) (am), the employer need not offer the standard plan on that occasion.

609.10(3) Subsection (1) does not apply to an employer that does any of the following:

609.10(3)(a) Employs fewer than 25 full-time employees.

609.10(3)(b) Offers its employees a health maintenance organization or a preferred provider plan only through an insurer that is a cooperative association organized under ss. 185.981 to 185.985 or only through an insurer that is restricted under s. 609.03 (3).

609.10(4) Nothing in sub. (1) requires an employer to offer a particular health care plan to an employee if the health care plan determines that the employee does not meet reasonable medical underwriting standards of the health care plan.

609.10(5) The commissioner may establish by rule standards in addition to those established under s. 609.20 for what constitutes adequate notice and complete and understandable information under sub. (1) (c).

609.10(6) The commissioner shall promulgate rules necessary for the administration of the requirement to offer point-of-service option plans under sub. (1) (am).