Section 9.21. Limited exemptions.

 

(1)   Silent discount. An insurer, with respect to a defined network plan:

(a) Is exempt from meeting the requirements under ss. 609.22 , 609.24 , 609.32 , 609.34 , 609.36 and 632.83 , Stats., and ss. Ins 9.31 , 9.32 (1) , 9.35 , 9.37 , 9.38 , 9.39 , 9.40 (1) to (7) , 9.42 (1) to (7) , if the only owned, employed, or participating provider providing services covered under the plan is a silent provider network.

(b) Is exempt from meeting the requirements under ss. 609.22 , 609.24 , 609.32 , 609.34 , and 609.36 , Stats., and ss. Ins 9.32 (1) , 9.35 , 9.37 , 9.38 , 9.39 , 9.40 (1) to (7) , and 9.42 (1) to (7) , solely with respect to services provided by the silent provider network, if the plan also covers services by providers that the insurer owns or employs, or another participating provider. An insurer is not exempt from those provisions with respect to a provider that is not a silent provider network.

(2)   De minimus limited exception. Insurers offering a defined network plan are exempt from meeting the requirements under ss. 609.22 (1) to (4) and (8) , 609.32 and 609.34 , Stats., ss. Ins 9.32 (1) , 9.40 (1) to (7) , and 9.42 (6) and (7) , with respect to a defined network plan, if the insurer meets all of the following requirements.

(a) The insurer offering a defined network plan provides comprehensive benefits to insureds of at least 80% coverage for in-plan providers.

(b) The insurer's only financial incentive to the insureds to utilize participating providers is a co-insurance differential of not more than 10% between in-plan versus off-plan providers. Except for the co-insurance differential of no greater than 10%, all benefits, deductibles and co-payments must be the same regardless of whether the insured obtains benefits, services or supplies from in-plan or off-plan providers.

(c) The insurer makes no representation regarding quality of care.

(d) The insurer makes no representation that the defined network plan is a preferred provider plan or that the defined network plan directs or is responsible for the quality of health care services. Nothing in this paragraph prevents an insurer from describing the availability or limits on availability of participating providers or the extent or limits of coverage under the defined network plan if participating or non-participating providers are utilized by an insured.

(e) The insurer, at the time an application is solicited, does all of the following.

1. Discloses to a potential applicant, and allows the applicant a reasonable opportunity to review, a directory which reasonably and clearly discloses the availability and location of providers:

a. Within reasonable travel distance from the principle location of the place of employment of employees likely to enroll under the plan, if the applicant is an employer; or

b. Within reasonable travel distance from the residence of the proposed insured, for any other application.

2. Obtains on the application, or on an addendum to the application, the applicant's signed acknowledgement that the applicant:

a. Has reviewed the disclosure under subd. 1. ;

b. Understands that participating providers may or may not be available to provide services and that the insurer is not required to make participating providers available; and

c. Understands that the plan will provide reduced benefits if the insured uses a non-participating provider.

3. Provides to each applicant a copy of the provider directory at the time the policy is issued.

4. The insurer provides access to translation services for the purpose of providing information concerning benefits, to the greatest extent possible, if a significant number of enrollees of the plan customarily use languages other than English.

History: Cr. Register, February, 2000, No. 530 , eff. 3-1-00; correction in (1) (a) made under s. 13.93 (2m) (b) 7., Stats., Register November 2001 No. 551 ; CR 05-059 : renum. from Ins 9.32 and am. (1) (a) and (b), (2) (a) and (d) Register February 2006 No. 602 , eff. 3-1-06.