1. (1) Contracts and licensing. Except as provided in sub. (3), for MA certification, a health maintenance organization or prepaid health plan shall enter into a written contract with the department to provide services to enrolled recipients and shall be licensed by the Wisconsin commissioner of insurance.

2. (2) Requirements for health maintenance organizations. For MA certification, an HMO shall:

   1. (a) Meet the requirements of 42 CFR 434.20 (c);
   2. (b) Make services it provides to individuals eligible under MA accessible to these individuals, within the area served by the organization, to the same extent that the services are made accessible under the MA state plan to individuals eligible for MA who are not enrolled with the organization; and

   3. (c) Make adequate provision against the risk of insolvency, which is satisfactory to the department and which ensures that individuals eligible for benefits under MA are not held liable for debts of the organization in case of the organization’s insolvency.

      Note: For covered health maintenance organization and prepaid health plan services, see s. DHS 107.28.

3. (3) Care organizations providing the family care benefit. A care management organization under contract with the department under s. DHS 10.42 is not required to be licensed by the Wisconsin commissioner of insurance if both of the following apply:

   1. (a) The organization enrolls only individuals who are eligible under s. 46.286, Stats.
   2. (b) The services offered by the organization do not include hospital or physician services.

History

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (3), Register, October, 2000, No. 538, eff. 11-1-00; correction in (3) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.