Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Appendix C - Notice re hold-harmless provisions

Current through June 24, 2024
NOTICE THIS NOTICE DESCRIBES HOLD-HARMLESS PROVISIONS WHICH
				AFFECT YOUR ABILITY TO SEEK RECOURSE AGAINST HEALTH MAINTENANCE ORGANIZATION
				INSURER ENROLLEES FOR PAYMENT FOR SERVICES
Section
				609.94,
				Wis. Stats., requires each health maintenance organization insurer ("HMO
				insurer"), to provide a summary notice to all of its participating providers of
				the statutory limitations and requirements in §§
								609.91
				to
				609.935,
				and §
								609.97(1),
				Wis. Stats.
SUMMARY
Under Wisconsin law a health care provider may not hold HMO
				insurer enrollees or policyholders ("enrollees") liable for costs covered under
				an HMO insurer policy if the provider is subject to statutory provisions which
				"hold harmless" the enrollees. For most health care providers application of
				the statutory hold-harmless is "mandatory" or it applies unless the provider
				elects to "opt-out." A provider permitted to "opt-out" must file timely notice
				with the Wisconsin Office of the Commissioner of Insurance ("OCI").
Some types of provider care are subject to the hold-harmless
				statutes only if the provider voluntarily "opts-in." An HMO insurer may
				partially satisfy its regulatory capital and surplus requirements if health
				care providers elect to remain subject to the statutory hold-harmless
				provisions.
This notice is only a summary of the law. Every effort has been
				made to accurately describe the law. However, if this summary is inconsistent
				with a provision of the law or incomplete, the law will control.
Filings for exemption with OCI must be on the prescribed form
				in order to be effective.
HOLD HARMLESS
A health care provider who is subject to the statutory
				hold-harmless provisions is prohibited from seeking to recover health care
				costs from an enrollee. The provider may not bill, charge, collect a deposit
				from, seek remuneration or compensation from, file or threaten to file with a
				credit reporting agency or have any recourse against an enrollee or any person
				acting on the enrollee's behalf, for health care costs for which the enrollee
				is not liable. The prohibition on recovery does not effect the liability of an
				enrollee for any deductibles or copayments, or for premiums owed under the
				policy or certificate issued by the HMO insurer.
A. MANDATORY FOR HOLD HARMLESS.
An enrollee of an HMO insurer is not liable to a health care
				provider for health care costs that are covered under a policy issued by that
				HMO insurer if any of the following are met:
1. Care is provided by a provider who is an affiliate of the
				HMO insurer, owns at least 5% of the voting securities of the HMO insurer, is
				directly or indirectly involved with the HMO insurer through direct or indirect
				selection of or representation by one or more board members, or is an
				Individual Practice Association ("IPA") and is represented, or an affiliate is
				represented, by one of at least three HMO insurer board members who directly or
				indirectly represent one or more IPAs or affiliates of IPAs.
2. Care is provided by a provider under a contract with or
				through membership in an organization identified in 1.
3. To the extent the charge exceeds the amount the HMO insurer
				has contractually agreed to pay the provider for that health care
				service.
4. The care is provided to an enrolled medical assistance
				recipient under a Department of Health Services prepaid health care
				policy.
5. The care is required to be provided under the requirements
				of s.
				Ins 9.35, Wis.
				Adm. Code.
B. "OPT-OUT" HOLD HARMLESS.
If the conditions described in A do not apply, the provider
				will be subject to the statutory hold harmless unless the provider files timely
				election with OCI to be exempt if the health care meets any of the
				following:
1. Provided by a hospital or an IPA.
2. A physician service, or other provider services, equipment,
				supplies or drugs that are ancillary or incidental to such services and are
				provided under a contract with the HMO insurer or are provided by a provider
				selected by the HMO insurer.
3. Provided by a provider, other than a hospital, under a
				contract with or through membership in an IPA that has not elected to be
				exempt. Note that only the IPA may file election to exempt care provided by its
				member providers from the statutory hold harmless. (See Exemptions and
				Elections, No. 4.)
C. "OPT-IN" HOLD HARMLESS.
If a provider of health care is not subject to the conditions
				described in A or B, the provider may elect to be subject to the statutory
				hold-harmless provisions by filing a notification with OCI stating that the
				provider elects to be subject with respect to any specific HMO insurer. A
				provider may terminate such a notice of election by stating the termination
				date in that notice or in a separate notification.
CONDITIONS NOT AFFECTING IMMUNITY
An enrollee's immunity under the statutory hold harmless is not
				affected by any of the following:
1. Any agreement entered into by a provider, an HMO insurer, or
				any other person, whether oral or written, purporting to hold the enrollee
				liable for costs (except a notice of election or termination permitted under
				the statute).
2. A breach of or default on any agreement by the HMO insurer,
				an IPA, or any other person to compensate the provider for health care costs
				for which the enrollee is not liable.
3. The insolvency of the HMO insurer or any person contracting
				with the HMO insurer, or the commencement of insolvency, delinquency or
				bankruptcy proceedings involving the HMO insurer or other persons which would
				affect compensation for health care costs for which an enrollee is not liable
				under the statutory hold harmless.
4. The inability of the provider or other person who is owed
				compensation to obtain compensation for health care costs for which the
				enrollee is not liable.
5. Failure by the HMO insurer to provide notice to providers of
				the statutory hold-harmless provisions.
6. Any other conditions or agreement existing at any
				time.
EXEMPTIONS AND ELECTIONS
Hospitals, IPAs, and providers of physician services who may
				"opt-out" may elect to be exempt from the statutory hold harmless and
				prohibition on recovery of health care costs under the following conditions and
				with the following notifications:
1. If the hospital, IPA, or other provider has a written
				contract with the HMO insurer, the provider must within thirty (30) days after
				entering into that contract provide a notice to OCI of the provider's election
				to be exempt from the statutory hold-harmless and recovery limitations for care
				under the contract.
2. If the hospital, IPA, or other provider does not have a
				contract with an HMO insurer, the provider must notify OCI that it intends to
				be exempt with respect to a specific HMO insurer and must provide that notice
				for the period January 1, 1990, to December 21, 1990, at least sixty (60) day
				before the health care costs are incurred; and must provide that notice for
				health care costs incurred on and after January 1, 1991, at least 90 days in
				advance.
3. A provider who submits a notice of election to be exempt may
				terminate that election by stating a termination date in the notice or by
				submitting a separate termination notice to OCI.
4. The election by an IPA to be exempt from the statutory
				provisions, or the failure of an IPA to so elect, applies to costs of health
				care provided by any provider, other than a hospital, under contract with or
				through membership in the IPA. Such a provider, other than a hospital, may not
				exercise an election separately from the IPA. Similarly, an election by a
				clinic to be exempt from the statutory limitations and restrictions or the
				failure of the clinic to elect to be exempt applies to costs of health care
				provided by any provider through the clinic. An individual provider may not
				exercise an election to be exempt separate from the clinic.
5. The statutory hold-harmless "opt-out" provision applies to
				physician services only if the services are provided under a contract with the
				HMO insurer or if the physician is a selected provider for the HMO insurer,
				unless the services are provided by a physician for a hospital, IPA or clinic
				which is subject to the statutory hold-harmless "opt-out" provision.
NOTICES
All notices of election and termination must be in writing and
				in accordance with rules promulgated by the Commissioner of Insurance. All
				notices of election or termination filed with OCI are not affected by the
				renaming, reorganization, merger, consolidation or change in control of the
				provider, HMO insurer, or other person. However, OCI may promulgate rules
				requiring an informational filing if any of these events occur.
Notices to the Office of the Commissioner of Insurance must be
				written, on the prescribed form, and received at the Office's current
				address:
P. O. Box 7873, Madison, WI 53707-7873
HMO INSURER CAPITAL AND SECURITY SURPLUS
Each HMO insurer is required to meet minimum capital and
				surplus standard ("compulsory surplus requirements"). These standards are
				higher if the HMO insurer has fewer than 90% of its liabilities covered by the
				statutory hold-harmless. Specifically, beginning January 1, 1992, the
				compulsory surplus requirement shall be at least the greater of $750,000 or 6%
				of the premiums earned by the HMO insurer in the last 12 months if its covered
				liabilities are less than 90%, or 3% of the premiums earned by the HMO insurer
				in the last 12 months if its covered liabilities are 90% or more. In addition
				to capital and surplus, an HMO insurer must also maintain a security surplus in
				the amount set by the Commissioner of Insurance.
FINANCIAL INFORMATION
An HMO insurer is required to file financial statements with
				OCI. You may request financial statements from the HMO insurer. OCI also
				maintains files of HMO insurer financial statements that can be inspected by
				the public.