Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.38

Current through October 28, 2024

Section Ins 9.38 - Policy and certificate language requirements

Each policy form marketed or each certificate issued to an enrollee by an insurer offering a defined network plan or limited service health organization plan shall contain all of the following:

(1) DEFINITIONS. A definition of geographical service area, emergency care, urgent care, out-of-area service, dependent and primary provider, if these terms or terms of similar meaning are used in the policy or certificate and have an effect on the benefits covered by the plan. The definition of geographical service area need not be stated in the text of the policy or certificate if such definition is adequately described in an attachment that is given to all enrollees along with the policy or certificate.

(2) DISCLOSURE OF EXCLUSIONS, LIMITATIONS AND EXCEPTIONS. Clear disclosure of any provision that limits benefits or access to services in the exclusions, limitations, and exceptions sections of the policy or certificate. Among the exclusions, limitations and exceptions that shall be disclosed are those relating to:

(a) Emergency and urgent care.

(b) Restrictions on the selection of primary or referral providers.

(c) Restrictions on changing providers during the contract period.

(d) Out-of-pocket costs including copayments and deductibles.

(e) Any restrictions on coverage for dependents who do not reside in the service area.

(3) DISCLOSURE OF MANDATED BENEFITS. Clear disclosure of all benefit mandates outlined in Wisconsin statutes.

(4) DISCLOSURE OF PROCEDURES AND EMERGENCY CARE NOTIFICATION. Insurers offering a defined network plan shall do all of the following in a manner consistent with s. 609.22, Stats.:

(a) Provide a description of the procedure for an enrollee to obtain any required referral, including the right to a standing referral, and notice that any enrollee may request the criteria for the standing referral.

(b) Provide a description of the procedure for any enrollee to obtain a second opinion from a participating plan provider consistent with s. 609.22(5), Stats.

(c) Consistent with s. 609.22(6), Stats., and s. Ins 9.32(1) (d), an insurer offering a defined network plan may require enrollees to notify the insurer of emergency room usage, but in no case may the insurer offering a defined network plan require notification less than 48 hours after receiving services or before it is medically feasible for the enrollee to provide the notice, whichever is later. An insurer offering a defined network plan may impose no greater penalty than assessing a deductible that may not exceed the lesser of 50% of covered expenses for emergency treatment or $250.00 for failing to comply with emergency treatment notification requirements.

Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.38

Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (intro.), (4) (intro.) and (c) Register February 2006 No. 602, eff. 3-1-06.