For purposes of s. 609.35, Stats., an insurer offering a preferred provider plan covers the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider only if the insurer complies with all of the following:

1. (1) The insurer offering a preferred provider plan provides coverage that complies with either of the following:

   1. (a) Provides coverage for services performed by nonparticipating providers with the insurer paying at a coinsurance rate of not less than 60% and the enrollee paying at a coinsurance rate of not more than 40%.
   2. (b) Provides coverage for services performed by nonparticipating providers with the insurer paying at a coinsurance rate not less than 50% and the enrollee paying at a coinsurance rate of not more than 50% and the insurer provides the enrollee with the disclosure notice that is compliant with sub. (5).

2. (2) The insurer offering a preferred provider plan equally applies material exclusions regardless if the services are performed by either participating or nonparticipating providers. The insurer may exceed the coinsurance differential in s. Ins 9.27 (1), or the deductible differential in s. Ins 9.27 (2), or the co-payment differential in s. Ins 9.27 (3) to the extent the insurer reasonably determines the cost sharing is necessary to encourage enrollees to use participating providers or centers of excellence for transplant or other unique disease treatment services or preventive health care services limited to immunizations pursuant to s. 632.895 (14), Stats., and the services as covered benefits greater than the minimum required for specific mandated benefits under ss. 632.895 and 632.89, Stats., when the insurer at the time of solicitation and within the policy, does either or both, as applicable, of the following:

   1. (a) Provides a disclosure to enrollees that identify the centers of excellence and the specific covered benefits that are covered at a different rate if provided by a health care provider that is recognized and identified as a center of excellence.
   2. (b) Clearly and prominently discloses that either immunizations or expanded benefits above mandated minimum coverage, or both, are covered when performed by participating providers or with greater disparity than permitted in s. Ins 9.27 (1) through (3).
3. (3) The insurer offering a preferred provider plan provides coverage of services without use of any financial incentives other than maximum limits, out-of-pocket limits and those incentives described in this section and s. Ins 9.27 to encourage the use of participating providers.
4. (4) The insurer offering a preferred provider plan may use utilization management, including preauthorization or similar methods, for denying access to or coverage of services of nonparticipating providers with just cause and without such frequency as to indicate a general business practice.

5. (5) An insurer required to provide a disclosure notice under sub. (1) shall provide the disclosure notice to the applicant at the time of solicitation, and shall include in a prominent location within the certificate of coverage issued under a group policy and in a prominent location in an individual policy, the following form and in not less than 11-point bold font:

   “NOTICE: LIMITED BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a nonparticipating provider for a covered service, benefit payments to such non-participating provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy’s fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the policy. YOU RISK PAYING MORE THAN THE COINSURANCE, DEDUCTIBLE AND CO-PAYMENT AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Nonparticipating providers may bill enrollees for any amount up to the billed charge after the plan has paid its portion of the bill. Participating providers have agreed to accept discounted payment for covered services with no additional billing to the enrollee other than co-payment, coinsurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling [the toll free telephone] number on your identification card [or visiting [the company’s] website].

6. (6) The insurer files a report with the commissioner certifying compliance with this section on a form prescribed by the commissioner and signed by an officer of the company.
7. (7) The insurer does not require a referral to obtain coverage for care from either a participating or nonparticipating provider and complies with ss. Ins 9.27 and 9.32 (2).
8. (8) This section first applies to an insurer offering a preferred provider plan beginning on January 1, 2007. This section does not apply to an insurer with respect to a preferred provider plan issued prior to January 1, 2007 and periodically renewed after December 31, 2006.

History

History: CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; emerg. cr. (8), eff. 9-1-06; CR 06-083: am. (4) Register December 2006 No. 612, eff. 1-1-07; CR 06-118: cr. (8) Register April 2007 No. 616, eff. 5-1-07.