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2023 Wisconsin Statutes & Annotations › Chapter 604 - State insurance funds; general principles. › 604.03 - Composition and integrity of funds.

604.03
Composition and integrity of funds.
(1)
Composition. Each fund consists of premium payments, earnings from investments, amounts recovered from reinsurers or under subrogation or contribution claims and any other income, less losses paid and expenses properly charged to the fund. Each fund shall be separately maintained and accounted for.
(2)
Integrity of fund. Each fund is held in trust for the benefit of insureds and other proper claimants. It may not be spent for any other purposes of the state and may be borrowed by the state only pursuant to normal and usual investment practices under s. 604.05.
History:  1973 c. 117.
2023 Wisconsin Statutes & Annotations › Chapter 604 - State insurance funds; general principles. › 604.04 - Administration.

604.04
Administration.
(1)
Manager. Each fund under chs. 605 to 607 shall be administered by a manager who shall be the commissioner. In chs. 604 to 607, “manager" means the commissioner in his or her capacity as manager.
(2)
Other personnel. The manager of a fund may employ such personnel as are necessary for proper administration. To the extent practicable, the manager shall manage the funds, issue policies and prepare reports in the same way that as commissioner he or she requires other insurers to do, except that periodic annual audits may not be required. The manager may make such reasonable rules for the administration of the funds as are necessary to implement the enabling statutes.
(3)
Expenses. No full-time state officer or employee may receive additional compensation for services under chs. 604 to 607. Appropriate portions of the salaries of such persons who do work for the funds or supervise them, and other expenses including reasonable charges for state-owned or state-rented office space and the use of state-owned or state-rented office equipment shall be charged against each fund. Each fund shall pay to the commissioner amounts charged for organizational support services, which shall be credited to the appropriation account under s. 20.145 (1) (g) 2. Each fund shall also be charged a sum equivalent to the state premium tax that would be paid by a domestic mutual insurer organized or operating under ch. 611 and doing the same kind of insurance business, except that no such charge shall be made for the insurance of governmental units.
(4)
Payment procedure. Any charges against a fund under sub. (3) shall be certified by the commissioner, audited by the department of administration under s. 16.53, and paid by the secretary of administration out of the appropriate fund in accordance with procedures of the department of administration.
(5)
Advisory organization membership. The manager of a fund may have the fund join or subscribe to rate service organizations or other advisory organizations useful for the efficient operation of the fund.
(6)
Reinsurance. The manager may procure such reinsurance for the fund as he or she considers necessary for its sound operation.
(7)
Inspections. The manager may obtain such inspections and reports on risks insured in the fund as sound insurance practice requires.
(8)
Nondisclosure of personal information. The manager may refuse to disclose, and may prevent any other person from disclosing, any personally identifiable information, as defined in s. 19.62 (5), that is obtained by the manager in the course of administering a fund under chs. 605 to 607.
History:  1973 c. 117; 1979 c. 102 ss. 84, 236 (5), (13); 1981 c. 20 ss. 1759m, 2202 (26) (c); 2001 a. 65; 2003 a. 33; 2007 a. 20.
2023 Wisconsin Statutes & Annotations › Chapter 604 - State insurance funds; general principles. › 604.05 - Investments.

604.05
Investments.
Assets of all funds under chs. 605 to 607 shall be invested by the state investment board under s. 25.17. Each January 1 the secretary of administration shall credit each fund with earnings on the invested assets in each fund for the preceding 12 months. If any fund is indebted to the general fund of the state, the fund shall be charged, at the end of each calendar year, with interest on the indebtedness at the average rate earned by the state upon its deposits in public depositories during the period of indebtedness and that sum shall be credited to the general fund.
History:  1973 c. 117; 1981 c. 20 s. 2202 (26) (c); 1983 a. 368; 2003 a. 33.
2023 Wisconsin Statutes & Annotations › Chapter 604 - State insurance funds; general principles. › 604.06 - Custody of assets and liability.

604.06
Custody of assets and liability.
(1)
Custody. The secretary of administration has sole custody of all assets of funds under chs. 605 to 607.
(2)
Liability. Neither the state nor any person is liable for any obligations of the funds, and the rights of creditors are solely against the assets of the funds, except as otherwise provided in chs. 605 to 607.
History:  1973 c. 117; 1977 c. 203; 1981 c. 20 s. 2202 (26) (c); 2003 a. 33.
2023 Wisconsin Statutes & Annotations › Chapter 604 - State insurance funds; general principles. › 604.07 - Bonds.

604.07
Bonds.
The commissioner as manager of the funds and the secretary of administration shall file surety bonds, specifically conditioned on the performance of their duties under chs. 605 to 607, in amounts required by, and with sureties approved by, the governor.
History:  1973 c. 117; 1981 c. 20 s. 2202 (26) (c); 2003 a. 33.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.01 - Definitions.

605.01
Definitions.
In this chapter, unless the context requires otherwise:
(1)
“Local governmental unit" means any local governmental association, authority, board, commission, department, independent agency, institution, office, society or other body, including any city, county, town or village board or common council, school or library board, or board of control of a cooperative educational service agency.
(2)
“Property fund" means the local government property insurance fund.
History:  1973 c. 117, 333; 1979 c. 221; 1985 a. 335.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.02 - Kinds of property insured.

605.02
Kinds of property insured.
(1)
Property of local governmental units. Any local governmental unit may insure in the property fund its property or, subject to sub. (2), property for which it may be liable in the event of damage or destruction. Property insured under this section by a local governmental unit may not also be insured in any other manner unless the manager certifies that additional insurance is necessary, or unless the local governmental unit by resolution, a certified copy of which is filed with the manager, decides to insure specified personal property with insurers authorized to do business in this state.
(2)
Requirements for nonowned property. The property fund may cover a building or structure specified in sub. (1) that is not owned by a local governmental unit only if all of the following conditions are met:
(a)
The building or structure is listed and described as a nonowned building or structure in the local governmental unit's statement of values.
(b)
The local governmental unit is contractually liable in the event that the building or structure is damaged or destroyed.
(c)
The building or structure is in the local governmental unit's care, custody, or control.
(d)
The building or structure is used for a legitimate governmental purpose.
History:  1973 c. 117; 1979 c. 221; 2007 a. 170.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.03 - Coverage to be provided.

605.03
Coverage to be provided.
(1)
General.
(a)
Mandatory coverage. Subject to par. (f), the property fund shall provide protection against fire and extended coverage perils. The coverage shall be at least as favorable as that customarily provided by policies filed with the commissioner for the use of private insurers in insuring comparable property.
(b)
Optional coverage. The fund may also provide additional protection against other named perils or may provide protection on an all-risk basis, on such terms as the manager prescribes.
(c)
Valuation basis. The fund may provide coverage on any appropriate valuation basis including actual cash value and replacement cost, and may cover loss from the lack of use of or reduction in the income from property caused by perils insured against.
(d)
Term of policy. Subject to par. (f) 1., the manager may prescribe the time periods for which coverage is to be provided.
(e)
Documents. The manager shall prepare policies and supplementary documents for the use of the fund in providing the coverage under pars. (a) and (b), but no such documents may be used by the fund if the commissioner would not approve them for the use of private insurers.
(f)
Limits on issuance, renewal, and filing claims; final distribution.
1.
No coverage under the property fund may be issued on or after July 1, 2017. No coverage may be renewed after December 31, 2017. No coverage may terminate later than December 31, 2018.
2.
All claims must be filed with the property fund by no later than July 1, 2019. No claim filed after July 1, 2019, will be covered by the fund.
3.
Upon the cessation of all operations of the property fund, the manager shall distribute any moneys remaining in the fund among the local governmental units that were insured under the fund on July 1, 2017.
(2)
Coinsurance. The manager may prescribe by rule the percentages of value or cost for which coverage may be provided.
(3)
Deductibles. The manager may prescribe by rule that small losses in any one occurrence shall not be paid.
History:  1973 c. 117; 2007 a. 168; 2017 a. 59.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.09 - Restrictions on private insurance.

605.09
Restrictions on private insurance.
After a lawful vote of the local governmental unit to insure under this chapter, no such unit may pay out any money to any private insurer nor incur any indebtedness against the unit to a private insurer for any insurance on any property of the unit or for which the unit may be legally liable if such insurance is available under this chapter, unless it is approved by the commissioner as necessary or unless it is insurance on personal property which the unit by resolution filed with the commissioner has decided to insure in insurance companies authorized to do business in this state.
History:  1973 c. 117; 1975 c. 41; 1979 c. 221.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.21 - Manner of participation in property fund.

605.21
Manner of participation in property fund.
(1)
Placing insurance. Subject to s. 605.03 (1) (f), the property fund shall insure property described in s. 605.02 after receipt from the clerk of the local governmental unit of a certified copy of the resolution authorizing insurance in the property fund. The clerk shall report to the manager each policy then in force upon such property, stating the property covered by the policy and the dates of issue and of expiration, the amounts and rates of insurance and the premiums. Property already insured shall become insured by the property fund as existing policies expire or are canceled. Thereafter the insurance on all property described in s. 605.02 shall be provided. Premiums shall be certified by the manager to the clerk of the appropriate unit.
(2)
Premium payment. Upon receipt of certification of premium due, the premium shall be paid into the state treasury for the benefit of the property fund, within 30 days after the date of certification or the effective date of the policy, whichever is the later. Premiums for property insured effective at a later date shall be paid within 30 days after the effective date of each addition. The amount of a premium in default shall be a special charge against the local governing unit, and be included in the next certification of state taxes and charged and collected as other special charges are collected, with interest from the due date at a rate set by the commissioner by rule or, in the absence of a rule, at twice the most common prime rate charged by major banks in this state.
(3)
Withdrawal from the property fund. Any local governmental unit may terminate its insurance in the property fund by a majority vote, and upon certifying such action to the manager the insurance in force in the fund shall terminate upon expiration of the policy unless the unit specifies an earlier date for termination. In case of removal or sale of property, the board may terminate the insurance on that property without terminating its entire insurance in the property fund.
(4)
Insurance of personal property. All personal property of the local governing unit is insured and premiums therefor must be paid under this section except to the extent that coverage is excluded by resolution under s. 605.02 (1).
History:  1973 c. 117, 333; 1979 c. 102, 221; 2007 a. 170; 2015 a. 90; 2017 a. 59.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.22 - Property fund rates and assets.

605.22
Property fund rates and assets.
(1)
Rate determination. The property fund's annual premium rates shall be actuarially determined to be sufficient to maintain a ratio of net premiums written to surplus of no less than 200 percent. The rate standards under s. 625.11 shall apply to property fund rates.
(2)
Assessments. The property fund shall levy an assessment on local governmental units participating in the fund whenever the ratio of net premiums written to surplus is greater than 225 percent. Assessments shall be levied on all insured local governmental units participating in the fund in the fiscal year ending immediately prior to the date of the notice of assessment. Assessments shall be levied at the same rate according to each insured local governmental unit's proportional share of direct premiums written in the fund's fiscal year that ended immediately prior to the date of the notice of assessment. The date on which the assessment is due shall be specified in the notice of assessment and may not be less than 60 days after the date of the notice of assessment. The property fund shall collect unpaid assessments in the manner provided for collection of unpaid premiums under s. 605.21 (2). If an insured local governmental unit does not pay an assessment within 60 days after the assessment is due, the fund shall terminate coverage for that local governmental unit. If a local governmental unit cancels its coverage and a refund of premiums is due to the local governmental unit, the refund due shall be reduced by the amount of any unpaid assessment. A local governmental unit that fails to pay an assessment when due may not participate in the property fund until the past due assessment is paid.
(3)
Dividends. The property fund shall pay a dividend to its insured local governmental units whenever the ratio of net premiums written to surplus is less than 45 percent, provided that, following the payment of the dividend, the ratio of net premiums written to surplus does not exceed 100 percent and the amount of surplus is not less than $3,000,000. Dividends shall be paid to all insured local governmental units participating in the property fund in the fiscal year that ended immediately prior to the date of the notice of the dividend. Dividends shall be paid at the same rate according to each insured local government unit's proportional share of premiums written in the fund's fiscal year that ended immediately prior to the date of the notice of the dividend.
History:  2015 a. 325.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.23 - Adjustment of losses.

605.23
Adjustment of losses.
(1)
Payment for losses. Subject to s. 605.03 (1) (f) 2., the manager shall determine within a reasonable time any loss on insured property owned by a local governmental unit or for which the unit is liable and promptly certify the amount to the department of administration, which shall issue a warrant on the property fund payable to the treasurer of the local governmental unit for the amount of the loss less any applicable amounts under s. 605.03 (2) or (3).
(2)
Appraisal in case of disagreement. If there is disagreement between the manager and the local governmental unit as to the amount of the loss or damage to property covered by the property fund, the amount shall be determined by appraisal, upon the demand of the local governmental unit. The manager and the claimant shall each select a competent and disinterested appraiser and notify the other of the selection within 20 days of the demand. If either party fails to select an appraiser within the allotted time, the other party may request a court of record to appoint an appraiser. The appraisers shall first select a competent and disinterested umpire. If they do not agree on one within 15 days, then either party may request a judge of a court of record in the county in which the property is located to select a competent and disinterested umpire and the judge shall do so promptly. The appraisers shall then appraise the loss and damage, stating separately the actual cash value or other applicable basis of valuation and the loss or damage to each item. If they fail to agree they shall submit their differences to the umpire. An itemized award in writing of any 2 of the 3 when filed with the manager shall determine the amount of the insured value and of loss or damage. Each appraiser shall be paid by the party selecting that appraiser and other expenses of appraisal and of the umpire shall be paid by the parties equally.
(3)
Considerations in ascertaining loss. The basic criterion for ascertaining the amount of any loss to property under this chapter is actual cash value, unless the property is insured for replacement cost. Obsolescence and plans for demolition are factors to be considered in determining actual cash value, and replacement cost shall not be paid if there are plans for demolition of the property.
History:  1973 c. 117; 1979 c. 102, 221; 2017 a. 59.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.24 - Recovery of losses from other parties.

605.24
Recovery of losses from other parties.
(1)
Suit by attorney general. Upon the request of the manager, the attorney general may proceed in the courts of any jurisdiction to recover from any responsible party other than an insured or any person using or dealing with the property in the course of the person's employment for the insured, for any loss or damage to any property covered by insurance under this chapter. Any recovery less expenses shall be paid into the property fund, but if the amount recovered less expenses exceeds that paid out by the fund, the difference shall be paid to the insured.
(2)
Collection of reinsurance. The manager shall collect reinsurance due and pay the amount collected into the property fund.
(3)
Right over against 3rd persons. The property fund may name other persons as additional persons protected under s. 605.02, but unless it does so the fund shall have any right of recovery by subrogation or otherwise against such persons that a private insurer would have and shall not lose such right because the governmental unit protected has after commencement of the coverage waived any right of recovery it would otherwise have had, or has thereafter contracted to assume the risk that general law would have placed elsewhere.
History:  1973 c. 117; 1979 c. 102 s. 236 (15); 2005 a. 253.
There is nothing in either chs. 604 or 605, or anywhere else, that prohibits the Fund from voluntarily contracting away sub. (3) protection. Wisconsin State Local Government Property Insurance Fund v. Thomas A. Mason Company, 2008 WI App 49, 308 Wis. 2d 512, 748 N.W.2d 476, 07-1112.
2023 Wisconsin Statutes & Annotations › Chapter 605 - Local government property insurance fund. › 605.30 - Inadequacy of fund.

605.30
Inadequacy of fund.
If the property fund does not have sufficient assets to pay claims that are due, the secretary of administration shall transfer from the general fund to the property fund an amount sufficient to pay the losses and shall pay the losses. The property fund shall thereafter repay the general fund this amount and the secretary of administration shall transfer the amount as soon as there are assets in the property fund.
History:  1973 c. 117; 2003 a. 33.
2023 Wisconsin Statutes & Annotations › Chapter 607 - State life insurance fund. › 607.02 - Scope of operation.

607.02
Scope of operation.
(1)
Types of policies permitted. Subject to sub. (2), the life fund may issue to any resident of the state any kind of life insurance with any riders or endorsements thereto that would be filed with the commissioner for issuance by private insurers authorized to do a life insurance business in this state. Coverages may be combined and granted in the same policy by the life fund to the same extent as by a private life insurer.
(2)
Limits on policies from fund. No policies may be issued on any one risk exceeding $10,000 for residents of this state.
History:  1973 c. 117; 2007 a. 168.
2023 Wisconsin Statutes & Annotations › Chapter 607 - State life insurance fund. › 607.03 - Nature of fund.

607.03
Nature of fund.
Unless expressly provided otherwise, the life fund is subject as an insurer to chs. 600 to 646, except for chs. 610 to 618, 645, and 646, and is subject to all other laws applicable to insurers issuing life insurance, specifically including of the soldiers' and sailors' civil relief act of 1940, P.L. 76-861, and amendments thereto or reenactments thereof. Any policy entitled to benefits under that act shall be deemed amended to conform thereto. This section shall remain in force concurrently with that act of congress and amendments thereto or reenactments thereof.
History:  1973 c. 117; 1979 c. 89 s. 543; 2001 a. 38.
2023 Wisconsin Statutes & Annotations › Chapter 607 - State life insurance fund. › 607.07 - Examination and underwriting.

607.07
Examination and underwriting.
(1)
Medical examinations. No medical examination need be required on an application for a policy. The manager may require a medical examination or other medical information in accordance with usual practices in the life insurance business. An application for a policy shall be reviewed after all required medical information is provided to the manager.
(2)
Underwriting approval. The manager or the manager's designee shall pass upon all applications for insurance. If the application is accepted, the premium shall be paid into the life fund and a policy shall be issued, signed by the manager, promising payment out of the life fund without further liability on the part of the state.
History:  1973 c. 117; 1975 c. 39 s. 732 (2); 1979 c. 102 s. 236 (19); 1987 a. 247.
2023 Wisconsin Statutes & Annotations › Chapter 607 - State life insurance fund. › 607.15 - Surplus distribution.

607.15
Surplus distribution.
The net profits of the life fund shall be distributed annually among the policyholders, except that so far as is practicably possible, the ratio of surplus to assets shall be kept between 7 percent and 10 percent.
History:  1973 c. 117.
2023 Wisconsin Statutes & Annotations › Chapter 607 - State life insurance fund. › 607.21 - Payments from life fund.

607.21
Payments from life fund.
In addition to the payments under s. 604.04 (3), and the payments which become due under its policies, the life fund shall pay:
(1)
A fee, to be determined by the manager, to the medical examiner for each medical examination made under s. 607.07 (1);
(2)
The actual expense of inspection reports;
(3)
The actual expense of adjustment of any loss or the defense or prosecution of any action; and
(4)
A fee equal to 2 percent of net premiums collected to the department of administration for general services rendered by state administrative and legislative agencies which are not otherwise charged to the fund.
History:  1973 c. 117.
2023 Wisconsin Statutes & Annotations › Chapter 607 - State life insurance fund. › 607.22 - Policy loans.

607.22
Policy loans.
(1)
General. Loans may be made on a policy to an aggregate amount which, together with accumulated interest at rates to be fixed from time to time by the commissioner, and applicable to all policies then in force, does not exceed the cash surrender value on the next policy anniversary on the basis of the premiums then paid. Any premium not paid when due shall be charged as a policy loan. When the unpaid loan and interest equals the cash surrender value, the policy shall terminate, but before that time the whole or any part of a loan may be repaid.
(2)
Existing policies. The interest on loans on policies issued before April 1, 1977, shall be set under sub. (1) but may not exceed 6 percent. The interest on loans on policies issued on or after April 1, 1977, shall be set under sub. (1) but may not exceed 8 percent.
History:  1973 c. 117; 1987 a. 247.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.001 - Joint ventures; legislative findings.

609.001
Joint ventures; legislative findings.
(1)
The legislature finds that increased development of health maintenance organizations, preferred provider plans and limited service health organizations may have the effect of putting small, independent health care providers at a competitive disadvantage with larger health care providers. In order to avoid monopolistic situations and to provide competitive alternatives, it may be necessary for those small, independent health care providers to form joint ventures. The legislature finds that these joint ventures are a desirable means of health care cost containment to the extent that they increase the number of entities with which a health maintenance organization, preferred provider plan or limited service health organization may choose to contract and to the extent that the joint ventures do not violate state or federal antitrust laws.
(2)
The legislature finds that competition in the health care market will be enhanced by allowing employers and organizations which otherwise act independently to join together in a manner consistent with the state and federal antitrust laws for the purpose of purchasing health care coverage for employees and members. These joint ventures will allow purchasers of health care coverage to obtain volume discounts when they negotiate with insurers and health care providers. These joint ventures should result in an improved business climate in this state because of reduced costs for health care coverage.
History:  1985 a. 29.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.03 - Indication of operations.

609.03
Indication of operations.
(1)
Certificate of authority. An insurer may apply to the commissioner for a new or amended certificate of authority that limits the insurer to engaging in only the types of insurance business described in sub. (3).
(2)
Statement of operations. If an insurer is a cooperative association organized under ss. 185.981 to 185.985, the insurer may apply to the commissioner for a statement of operations that limits the insurer to engaging in only the types of insurance business described in sub. (3).
(3)
Restrictions on operations.
(a)
An insurer that has a new or amended certificate of authority under sub. (1) or a statement of operations under sub. (2) may engage in only the following types of insurance business:
1.
As a health maintenance organization.
2.
As a limited service health organization.
3.
In other insurance business that is immaterial in relation to, or incidental to, the insurer's business under subd. 1. or 2.
(b)
The commissioner may, by rule, define “immaterial" or “incidental", or both, for purposes of par. (a) 3. as a percentage of premiums, except the percentage may not exceed 10 percent of the total premiums written by the insurer.
(4)
Removing restrictions. An amendment to a certificate of authority or statement of operations that removes the limitation imposed under this section is not effective unless the insurer, on the effective date of the amendment, complies with the capital, surplus and other requirements applicable to the insurer under chs. 600 to 645.
History:  1989 a. 23.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.05 - Primary provider and referrals.

609.05
Primary provider and referrals.
(1)
Except as provided in subs. (2) and (3), a limited service health organization, preferred provider plan, or defined network plan shall permit its enrollees to choose freely among participating providers.
(2)
Subject to s. 609.22 (4) and (4m), a limited service health organization, preferred provider plan, or defined network plan may require an enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.
(3)
Except as provided in ss. 609.22 (4m), 609.65, and 609.655, a limited service health organization, preferred provider plan, or defined network plan may require an enrollee to obtain a referral from the primary provider designated under sub. (2) to another participating provider prior to obtaining health care services from that participating provider.
History:  1985 a. 29; 1987 a. 366; 1989 a. 121; 1997 a. 237; 1999 a. 9; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.17 - Reports of disciplinary action.

609.17
Reports of disciplinary action.
Every limited service health organization, preferred provider plan, and defined network plan shall notify the medical examining board or appropriate affiliated credentialing board attached to the medical examining board of any disciplinary action taken against a participating provider who holds a license or certificate granted by the board or affiliated credentialing board.
History:  1985 a. 340; 1993 a. 107; 1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.20 - Rules for preferred provider and defined network plans.

609.20
Rules for preferred provider and defined network plans.
(1m)
The commissioner may promulgate rules relating to preferred provider plans and defined network plans for any of the following purposes, as appropriate:
(a)
To ensure that enrollees are not forced to travel excessive distances to receive health care services.
(b)
To ensure that the continuity of patient care for enrollees meets the requirements under s. 609.24.
(c)
To define substantially equivalent coverage of health care expenses for purposes of s. 609.10 (1) (am).
(d)
To ensure that employees offered a health maintenance organization or a preferred provider plan that provides comprehensive services under s. 609.10 (1) (am) are given adequate notice of the opportunity to enroll, as well as complete and understandable information under s. 609.10 (1) (c) concerning the differences among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan, as defined in s. 609.10 (1) (ac), including differences among providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization.
(2m)
Any rule promulgated under this chapter shall recognize the differences between preferred provider plans and other types of defined network plans, take into account the fact that preferred provider plans provide coverage for the services of nonparticipating providers, and be appropriate to the type of plan to which the rule applies.
History:  1985 a. 29; 1997 a. 237; 1999 a. 9; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.205 - Public health emergency for COVID-19.

609.205
Public health emergency for COVID-19.
(1)
In this section, “COVID-19” means an infection caused by the SARS-CoV-2 coronavirus.
(2)
All of the following apply to a defined network plan or preferred provider plan during the state of emergency related to public health declared under s. 323.10 on March 12, 2020, by executive order 72, and for the 60 days following the date that the state of emergency terminates:
(a)
The plan may not require an enrollee to pay, including cost sharing, for a service, treatment, or supply provided by a provider that is not a participating provider in the plan's network of providers more than the enrollee would pay if the service, treatment, or supply is provided by a provider that is a participating provider. This subsection applies to any service, treatment, or supply that is related to diagnosis or treatment for COVID-19 and to any service, treatment, or supply that is provided by a provider that is not a participating provider because a participating provider is unavailable due to the public health emergency.
(b)
The plan shall reimburse a provider that is not a participating provider for a service, treatment, or supply provided under the circumstances described under par. (a) at 225 percent of the rate the federal Medicare program reimburses the provider for the same or a similar service, treatment, or supply in the same geographic area.
(3)
During the state of emergency related to public health declared under s. 323.10 on March 12, 2020, by executive order 72, and for the 60 days following the date that the state of emergency terminates, all of the following apply to any health care provider or health care facility that provides a service, treatment, or supply to an enrollee of a defined network plan or preferred provider plan but is not a participating provider of that plan:
(a)
The health care provider or facility shall accept as payment in full any payment by a defined network plan or preferred provider plan that is at least 225 percent of the rate the federal Medicare program reimburses the provider for the same or a similar service, treatment, or supply in the same geographic area.
(b)
The health care provider or facility may not charge the enrollee for the service, treatment, or supply an amount that exceeds the amount the provider or facility is reimbursed by the defined network plan or preferred provider plan.
(4)
The commissioner may promulgate any rules necessary to implement this section.
History: 2019 a. 185.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.30 - Provider disclosures.

609.30
Provider disclosures.
(1)
Plan may not contract. A defined network plan may not contract with a participating provider to limit the provider's disclosure of information, to or on behalf of an enrollee, about the enrollee's medical condition or treatment options.
(2)
Plan may not penalize or terminate. A participating provider may discuss, with or on behalf of an enrollee, all treatment options and any other information that the provider determines to be in the best interest of the enrollee. A defined network plan may not penalize or terminate the contract of a participating provider because the provider makes referrals to other participating providers or discusses medically necessary or appropriate care with or on behalf of an enrollee.
History:  1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.32 - Quality assurance.

609.32
Quality assurance.
(1)
Standards; other than preferred provider plans. A defined network plan that is not a preferred provider plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate, and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following:
(a)
An ongoing, written internal quality assurance program.
(b)
Specific written guidelines for quality of care studies and monitoring.
(c)
Performance and clinical outcomes-based criteria.
(d)
A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.
(e)
A plan for gathering and assessing data.
(f)
A peer review process.
(1m)
Procedure for remedial action; preferred provider plans. A preferred provider plan shall develop a procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.
(2)
Selection and evaluation of providers.
(a)
A defined network plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider's license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider.
(b)
A defined network plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider's initial acceptance for participation. The reevaluation shall include all of the following:
1.
Updating the previous review criteria.
2.
Assessing the provider's performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.
(c)
A defined network plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.
History:  1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.34 - Clinical decision-making; medical director.

609.34
Clinical decision-making; medical director.
(1)
A defined network plan that is not a preferred provider plan shall appoint a physician as medical director. The medical director shall be responsible for clinical protocols, quality assurance activities, and utilization management policies of the plan.
(2)
A preferred provider plan may contract for services related to clinical protocols and utilization management. A preferred provider plan or its designee is required to appoint a medical director only to the extent that the preferred provider plan or its designee assumes direct responsibility for clinical protocols and utilization management policies of the plan. The medical director, who shall be a physician, shall be responsible for such protocols and policies of the plan.
History:  1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.35 - Applicability of requirements to preferred provider plans.

609.35
Applicability of requirements to preferred provider plans.
Notwithstanding ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1), a preferred provider plan that does not cover the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider is subject to the requirements under ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1).
History:  2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.36 - Data systems and confidentiality.

609.36
Data systems and confidentiality.
(1)
Information and data reporting.
(a)
A defined network plan shall provide to the commissioner information related to all of the following:
1.
The structure of the plan.
2.
Health care benefits and exclusions.
3.
Cost-sharing requirements.
4.
Participating providers.
(b)
Subject to sub. (2), the information and data reported under par. (a) shall be open to public inspection under ss. 19.31 to 19.39.
(2)
Confidentiality. A defined network plan shall establish written policies and procedures, consistent with ss. 51.30, 146.82, and 252.15, for the handling of medical records and enrollee communications to ensure confidentiality.
History:  1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.38 - Oversight.

609.38
Oversight.
The office shall perform examinations of insurers that issue defined network plans consistent with ss. 601.43 and 601.44. The commissioner shall by rule develop standards for defined network plans for compliance with the requirements under this chapter.
History:  1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.70 - Chiropractic coverage.

609.70
Chiropractic coverage.
Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (3).
History:  1987 a. 27; 1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.75 - Adopted children coverage.

609.75
Adopted children coverage.
Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.896. Coverage of health care services obtained by adopted children and children placed for adoption may be subject to any requirements that the limited service health organization, preferred provider plan, or defined network plan imposes under s. 609.05 (2) and (3) on the coverage of health care services obtained by other enrollees.
History:  1989 a. 336; 1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.78 - Coverage of treatment for the correction of temporomandibular disorders.

609.78
Coverage of treatment for the correction of temporomandibular disorders.
Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (11).
History:  1997 a. 27, 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.79 - Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care.

609.79
Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care.
Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (12).
History:  1997 a. 27, 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.80 - Coverage of mammograms.

609.80
Coverage of mammograms.
Defined network plans are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be subject to any requirements that the defined network plan imposes under s. 609.05 (2) and (3) on the coverage of other health care services obtained by enrollees.
History:  1989 a. 129; 1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.81 - Coverage related to HIV infection.

609.81
Coverage related to HIV infection.
Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 631.93. Defined network plans are subject to s. 632.895 (9).
History:  1989 a. 201; 1989 a. 359 s. 389; 1997 a. 237; 2001 a. 16.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.83 - Coverage of drugs and devices.

609.83
Coverage of drugs and devices.
Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, and 632.895 (16t) and (16v).
History:  1997 a. 237; 2001 a. 16; 2017 a. 305; 2019 a. 185; 2021 a. 9.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.86 - Coverage of hearing aids, cochlear implants, and related treatment for infants and children.

609.86
Coverage of hearing aids, cochlear implants, and related treatment for infants and children.
Defined network plans are subject to s. 632.895 (16).
History:  2009 a. 14.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.925 - Election to be subject to restrictions.

609.925
Election to be subject to restrictions.
(1)
Notice of election. Except as provided in s. 609.93, a provider described in s. 609.91 (1) (c) is subject to s. 609.91 (1) (c) for purposes of recovering health care costs arising from health care provided by the provider, if the provider files with the office a written notice stating that the provider elects to be subject to s. 609.91 (1) (c) with respect to a specified health maintenance organization insurer. The notice shall comply with the rules, if any, promulgated under s. 609.935. The notice is effective on the date that it is received by the office or the date specified in the notice, whichever is later.
(2)
Termination of election. A provider may terminate a notice of election under sub. (1) by stating the termination date in the notice of election or in a separate written termination notice filed with the office. The termination notice shall comply with the rules, if any, promulgated under s. 609.935. The termination date may not be earlier than 90 days after the office receives notice of termination, whether included in the notice of election or in a separate termination notice.
(3)
Effective period of election. Section 609.91 applies to health care costs incurred on and after the effective date of the notice under sub. (1) or January 1, 1990, whichever is later, and until the termination date of the notice.
History:  1989 a. 23.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.93 - Scope of election by an individual practice association or clinic.

609.93
Scope of election by an individual practice association or clinic.
(1)
Individual practice association. The election by an individual practice association under s. 609.92 to be exempt from s. 609.91 (1) (b) or the failure of the individual practice association to so elect applies to health care costs arising from health care provided by any provider, other than a hospital, under a contract with, or through membership in, the individual practice association. A provider, other than a hospital, may not exercise an election under s. 609.92 or 609.925 separately from an individual practice association with respect to health care costs arising from health care provided under a contract with, or through membership in, the individual practice association.
(2)
Clinics.
(a)
The election by a clinic under s. 609.92 to be exempt from s. 609.91 (1) (b) with respect to services described in s. 609.91 (1) (b) 2. and 3. or the failure of the clinic to so elect, or the election by a clinic under s. 609.925 to be subject to s. 609.91 (1) (c) or the failure of the clinic to so elect, applies to health care costs arising from health care provided by any provider through the clinic. A provider may not exercise an election under s. 609.92 or 609.925 separately from the clinic with respect to health care costs provided through the clinic.
(b)
The commissioner may, by rule, specify the types of health care facilities or organizations that qualify as clinics for purposes of this subsection.
History:  1989 a. 23.
2023 Wisconsin Statutes & Annotations › Chapter 609 - Defined network plans. › 609.935 - Notices of election and termination.

609.935
Notices of election and termination.
(1)
In accordance with rules. If the commissioner promulgates rules governing the form or manner of filing a notice of election or termination notice under s. 609.92 or 609.925, a notice of election or termination notice filed after the rules take effect is not effective unless filed in accordance with the applicable rules.
(2)
Effect of certain changes. The effectiveness of a notice of election or termination notice filed with the office under s. 609.92 or 609.925 is not affected by the renaming, reorganization, merger, consolidation or change in control of the provider, health maintenance organization insurer or any other person. The commissioner may, by rule, require a provider to amend a notice of election or termination notice if any of the events in this subsection or other changes affecting the accuracy of the information occur.
History:  1989 a. 23.