Fact Sheet on Managed Care Consumer Protections in Wisconsin
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The Wisconsin Office of the Commissioner of Insurance has prepared the following information on managed care consumer protections in Wisconsin. If you have questions or problems with your managed care plan, please contact:
Office of the Commissioner of Insurance
P. O. Box 7873
Madison WI 53707-7873
(608) 266-0103 (in Madison)
Wisconsin provides additional safeguards for persons whose health insurance is delivered through a managed care plan. When combined with existing statutes, Wisconsin offers significant consumer protections. And in some cases, the protections extend to all health insurance products offered in Wisconsin.
How is managed care defined?
A managed care plan is defined as any health benefit plan that requires or creates incentives for an enrollee to use providers that are owned, managed, or under contract with the insurer offering the health benefit plan. Under Wisconsin insurance law, these plans are called defined network plans.
Under this definition, health insurance products such as preferred provider plans (PPPs), health maintenance organizations (HMOs), and most network type of health plans would be considered managed care and would be required to conform to the consumer protection laws. Health insurance products known as limited service health organizations (LSHOs) that cover benefits for specific services, such as dental-only or vision-only, are also subject to some provisions of this law.
Some self-insured plans, also called ERISA policies, are exempt from any state insurance regulation, including the managed care provisions. To determine if you are covered by an ERISA plan, contact your employer.
When did these changes go into effect?
Most of the changes described in this fact sheet went into effect with policies that renewed on or after January 1, 1999.
What consumer protections are offered?
The consumer protections covered in Wisconsin law include:
Grievance processIf you disagree with your managed care plan’s decisions, you have the right to file a grievance with the plan and have it resolved within 30 days. If you have an urgent health care situation, the grievance must be resolved more quickly. The plan must give you written information about the process for filing a grievance.
Access to providersAn HMO plan must have enough providers available to give you a reasonable choice of providers. Preferred provider plans must have enough providers available to provide covered services, but are not required to provide a choice of participating providers. Plans are not required to permit you to see any provider you wish.
Standing referral to specialistsIf warranted by your health condition, a managed care plan that requires referrals must give you a standing referral to a specialist provider. The plan must also tell you under what conditions a standing referral will be granted and how to apply.
Second opinionsEvery managed care plan must cover a second opinion from another provider within the managed care plan network.
Emergency careEvery health benefit plan offered in Wisconsin that covers emergency care, including managed care plans, must cover services required to stabilize a condition that a reasonably prudent layperson would consider to be an emergency, without prior authorization. Health plans are permitted to charge a reasonable copayment or coinsurance for this benefit.
Continuity of careIf your managed care plan represented a primary care physician (defined as internal medicine, pediatrics, or family practice) as being available during your open enrollment period, they must make the physician available to you at no additional cost for the entire plan year. A specialist provider must be made available for the lesser of the course of treatment or 90 days. If you are in your second trimester of pregnancy, the provider must be available through post-partum care. The exceptions to this statute are for a provider who is no longer practicing in the managed care plan service area or who was terminated from the plan for cause.
Gag clausesA managed care plan may not limit your health care provider’s disclosure of information regarding all of your treatment options. However, this does not mean that all treatment options are necessarily covered by your managed care plan. If you are unsure about whether a particular treatment is covered, you should contact your managed care plan directly.
Quality assurance plansHMO plans are required to develop and implement a quality assurance plan.
What other protections are available to me as a health care consumer?
If your health insurance plan limits coverage of an experimental treatment, procedure, drug, or device, the insurer is required to clearly disclose those limitations in the policy. Additionally, the insurer must have a process for you to request a timely review of a denied experimental treatment.
If your health insurer limits coverage of drugs to those on a pre-approved list, often called a formulary, the insurer must have a process for your physician to present medical evidence to request coverage of a drug that is not on the approved list.
What do I do if I am unhappy with my managed care plan’s decisions?
First, you should discuss your concerns with your managed care plan. Make sure you keep good notes of the discussions you have. If you are unable to resolve your concerns through discussion, you have the right to file a grievance with the plan. The plan must provide you with information on how to file a grievance. In some cases, you may request that an independent review organization review your managed care plan’s decision.
If, at any time, you are unhappy with your plan’s decision, you have the right to file a complaint with the Office of the Commissioner of Insurance (OCI). You may contact the office at the address listed on the front page.
How do I get more information?
OCI publishes a brochure specific to managed care plans, Consumer’s Guide to Managed Care Health Plans in Wisconsin. It is available by calling our toll-free number or on the agency’s Web site, oci.wi.gov.
For information on how to file insurance complaints, call:
(608) 266-0103 (in Madison)
For your convenience, a complaint form is included on OCI's Web site.
Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873
(please indicate your name, phone number, and e-mail address)