This bulletin applies to all insurers with defined network plans and preferred provider plans (PPP) doing business in Wisconsin.
The Office of the Commissioner of Insurance has received inquiries from policyholders, providers and insurers regarding continuity of care requirements contained in s. 609.24, Wis. Stat., and s. Ins 9.35 (1), Wis. Adm. Code.
Continuity of Care
Defined network plans are required to provide in-network covered benefits to an enrollee for services received from a provider regardless of whether the provider is a participating provider at the time the services are provided if the defined network plan represented in marketing materials made available to enrollees that the provider was or would be a participating provider. In cases where the services were provided by a primary care
physician (emphasis added), coverage shall continue until the end of the current plan year for enrollees who do not have an open enrollment period. For enrollees who have an open enrollment period, coverage shall be continued until the end of the plan year for which it was represented that the provider was, or would be, a participating provider. This provision applies to all plans whether or not a particular plan requires an enrollee to designate a primary care physician or provider. Section 609.24, Wis. Stat., requirements for continuity of care are tied, in part, to the type of medicine practiced by the provider and representations made by the insurer as to the "availability" of certain providers. Primary care physician is defined in s. 609.01 (4m), Wis. Stat., below.
If an enrollee is undergoing a course of treatment with a terminated participating provider who is not a "primary care physician," the defined network plan must continue to provide coverage for these services on an in-network basis for the remainder of the course of treatment or for 90 days after the provider's participation with the plan terminates, whichever is shorter. If an enrollee is undergoing maternity care and the provider's participation with the plan terminates in the 2nd or 3rd trimester of the pregnancy, the defined network plan must continue to provide coverage for these services on an in-network basis through the completion of postpartum care for the woman and infant.
Section 609.24 (1) (a) 2. and (e), Wis. Stat., requires that an insurer issuing a defined network plan include in its provider contracts a provision addressing reimbursement for services provided by providers who terminate their contract for reasons other than misconduct under this requirement. Insurers and providers should also note the hold harmless provision contained in s. 609.24 (3), Wis. Stat., and immunity provisions contained in s. 609.91, Wis. Stat.
The coverage required under s. 609.24, Wis. Stat., and s. Ins 9.35 (1), Wis. Adm. Code, need not be provided in situations where the provider no longer practices in the defined network plan's geographic service area or the insurer issuing the defined network plan terminates the provider's contract for misconduct on the part of the provider.
Insurers are strongly encouraged to review s. Ins 9.35, Wis. Adm. Code, which implements and interprets s. 609.24, Wis. Stat. The above-mentioned section of the administrative code sets forth notification requirements pertaining to continuity of care situations.
DEFINITIONS
Defined Network Plan: s. 609.01 (1b), Wis. Stat., "Defined network 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.
Primary Care Physician: s. 609.01 (4m), Wis. Stat., "Primary care physician" means a physician specializing in family medical practice, general internal medicine or pediatrics.
Primary Provider: s. 609.01 (5), Wis. Stat., "Primary provider" means a participating primary care physician, or other participating provider authorized by the defined network 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.
Persons to Contact for Additional Information
If you have questions, please put them in writing and address or e-mail them to Pam Ellefson at pam.ellefson@wisconsin.gov or Diane Dambach at
diane.dambach@wisconsin.gov.
Thank you.