Date: January 5, 2006
For more information contact: Eileen Mallow, Assistant Deputy Commissioner, (608) 266-7843 or eileen.mallow@wisconsin.gov

Health Insurance Consumer Protections Adopted

Insurance Commissioner Announces New PPP Regulations

Madison, WI—The Wisconsin Office of the Commissioner of Insurance (OCI) today announced the adoption of new regulations for a type of managed care known as a Preferred Provider Plan (PPP). The rules establish minimum requirements for PPPs and will help consumers better understand the requirements and limitations of their insurance and avoid surprises when they see what benefits will be paid.

"We want consumers to be able to understand and use their health insurance to get the care they need," said Insurance Commissioner Jorge Gomez. "We have seen too many complaints from consumers who do not have the information needed to make cost effective choices about where to get medical treatment."

The new regulations distinguish PPPs from other types of managed care products and outline requirements for this type of health insurance product. Among the new requirements:

• PPPs must have available in their network at least one primary provider and one provider with expertise in gynecology and obstetrics who are accepting new patients;
• PPPs must have reasonable differentials in copayments, co-insurance and deductibles between in- and out-of-network care, to be able to assure reasonable coverage for out-of-network care. Consumers must be given clear disclosure about the financial impact of using out-of-network providers;
• PPPs are required to develop and implement remedial action plans for quality problems; and
• Coverage of emergency medical care must be at in-network levels when the enrollee cannot reasonably reach an in-network provider, even if care is provided by a non-network provider.

Promulgation of these regulations followed a detailed analysis of consumer complaints that had been filed with the Commissioner and was subject to review by the Wisconsin Legislature. Commissioner Gomez said, "I am grateful for the interest taken by the Legislature in how these regulations affect Wisconsin consumers."

Many of Wisconsin's major insurers that offer PPPs endorsed the new regulations. The regulations go into effect for health insurance policies issued on or after January 1, 2007.

Consumers who have had difficulty with any insurance problem are encouraged to contact OCI for assistance. Publications such as "Consumer's Guide to Managed Care Health Plans in Wisconsin" can be ordered free from the agency by writing to OCI Publications, P.O. Box 7873, Madison, WI 53707-7873, calling 800-236-8517 or visiting the OCI Web site at oci.wi.gov.

Created by the Legislature in 1871, Wisconsin's Office of the Commissioner of Insurance (OCI) was vested with broad powers to ensure that the insurance industry responsibly and adequately met the insurance needs of Wisconsin citizens. Today, OCI's mission is to lead the way in informing and protecting the public and responding to its insurance needs.