reglab/statecodes huggingface dataset:
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.01 - Payment of mediation fund fees

Current through June 24, 2024
(1) PURPOSE. This
			 section implements s.
			 655.61, Stats., relating
			 to the payment of mediation fund fees.
(2) FEE.
(a) Each physician subject to ch. 655,
			 Stats., except a resident, and each hospital subject to ch. 655, Stats., shall
			 pay to the commissioner an annual fee to finance the mediation system created
			 by s.
			 655.42,
			 Stats.
(b) The fund shall bill a
			 physician or hospital subject to this section under s.
			 Ins
			 17.28(4). The entire annual fee under
			 this section is due and payable 30 days after the fund mails the
			 bill.
(d) The fund shall notify the
			 medical examining board of each physician who has not paid the fee as required
			 under par. (b).
(e) The fund shall
			 notify the department of health services of each hospital which has not paid
			 the fee as required under par. (b).
(f) Fees collected under this section are not
			 refundable except to correct an administrative billing error.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.24 - Review of classification

Current through June 24, 2024
(1) Any person
			 insured by the plan or covered by the fund may petition the board for a review
			 of its classification by the plan or fund. The petition shall state the basis
			 for the petitioner's belief that its classification is incorrect. The board
			 shall refer a petition for review to either of the following:
(a) If the petitioner is a hospital or a
			 nursing home or other entity affiliated with a hospital, to a committee
			 appointed by the commissioner consisting of 2 representatives of hospitals,
			 other than the petitioner's hospital, and one other person who is knowledgeable
			 about insurance classification.
(b)
			 If the petitioner is any person other than a person specified in par. (a), to a
			 committee appointed by the commissioner consisting of 2 physicians who are not
			 directly or indirectly affiliated or associated with the petitioner and one
			 other person who is knowledgeable about insurance classification.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.25 - Wisconsin health care liability insurance plan

Current through June 24, 2024
(1) FINDINGS.
(a) Legislation has been enacted authorizing
			 the commissioner to promulgate a plan to provide health care liability
			 insurance and liability coverage normally incidental to health care liability
			 insurance for risks in this state which are equitably entitled to but otherwise
			 unable to obtain such coverage, or to call upon the insurance industry to
			 prepare plans for the commissioner's approval.
(b) Health care liability insurance,
			 liability coverage normally incidental to health care liability insurance or
			 both are not readily available in the voluntary market for the persons
			 specified in sub. (5) (a).
(c) A
			 plan for providing health care liability insurance and liability coverage
			 normally incidental to health care liability insurance should be enacted
			 pursuant to ch. 619, Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.26 - Payments for future medical expenses

Current through June 24, 2024
(1) PURPOSE. This
			 section implements s.
			 655.015,
			 Stats.
(3) DEFINITIONS. In this
			 section:
(a) "Account" means a portion of the
			 fund allocated specifically for the medical expenses of an injured
			 person.
(b) "Claimant" means the
			 injured person, the individual legally responsible for the injured person's
			 medical expenses or the injured person's legal representative.
(c) "Medical expenses" means charges for
			 medical services, nursing services, medical supplies, drugs and rehabilitation
			 services that are incurred after the date of a settlement, panel award or
			 judgment.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.27 - Filing of financial report

Current through June 24, 2024
(1) PURPOSE. This
			 section implements s.
			 655.27(3)
			 (b), (4) (d) and (5) (e), Stats., for the
			 purpose of setting standards and techniques for accounting, valuing, reserving
			 and reporting of data relating to the financial transactions of the
			 fund.
(2) DEFINITIONS. In this
			 section:
(a) "Amounts in the fund," as used
			 in s.
			 655.27(5)
			 (e), Stats., means the sum of cash and
			 invested assets as reported in a financial report under sub. (3).
(b) "Fiscal year," as used in s.
			 655.27(4)
			 (d), Stats., means a year commencing July 1
			 and ending June 30.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.275 - Claims information; confidentiality

Current through June 24, 2024
(1) PURPOSE. This
			 section interprets ss.
			 19.35(1)
			 (a),
			 19.85(1)
			 (f),
			 146.82,
			 655.26 and
			 655.27(4)
			 (b), Stats.
(2) OPEN RECORDS; PRIVILEGED OR CONFIDENTIAL
			 FUND RECORDS. Except as provided in s.
			 601.427(7),
			 Stats., records of the fund are subject to subch. II, Stats., and are open to
			 inspection as required under subch. II, Stats. The fund may withhold and retain
			 as confidential any record which may be withheld and retained as confidential
			 under subch. II, Stats., including, but not limited to, a record which may be
			 withheld or which is privileged under any law or the rules of evidence, as
			 attorney work product under the rules of civil procedure, as attorney-client
			 privileged material under s.
			 905.03,
			 Stats., as a medical record under ss.
			 146.81
			 to
			 146.84,
			 Stats., or as privileged under s.
			 601.465,
			 Stats.
(3) DEFINITION. In this
			 section, "confidential claims information" means any document or information
			 relating to a claim against a plan-insured health care provider in the
			 possession of the commissioner, the board or an agent thereof, including claims
			 records of the plan.
(4)
			 DISCLOSURE. Confidential claims information may be disclosed only as follows:
(a) To the medical examining board as
			 provided under s.
			 655.26,
			 Stats.
(b) As needed by the peer
			 review council, consultants and the board under s.
			 655.275,
			 Stats., and rules promulgated under that section.
(c) As provided under s.
			 804.01,
			 Stats.
(d) To an individual,
			 organization or agency required by law or designated by the commissioner or
			 board to conduct a management or financial audit.
(e) With a written authorization from the
			 plan-insured health care provider on whose behalf the claim was defended or
			 paid.
(f) To the risk manager for
			 the fund, as needed to perform the duties specified in its contract. The risk
			 manager may not disclose confidential claims information to any 3rd party,
			 unless the board expressly authorizes the disclosure. The board may authorize
			 disclosure of patient health care records subject to ss.
			 146.81
			 to
			 146.84,
			 Stats., only as provided in those sections.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.285 - Peer review council

Current through June 24, 2024
(1) PURPOSE. This section implements ss.
			 619.04(5)
			 (b) and (5m) (b),
			 655.27(3)
			 (a) 2m. and (bg) 2. and
			 655.275,
			 Stats.
(2) DEFINITIONS. In this
			 section:
(a) "Aggregate indemnity" means the
			 total amount attributable to an individual provider that is paid or owing to or
			 on behalf of claimants for all closed claims arising out of one incident or
			 course of conduct, including amounts held by the fund under s.
			 655.015,
			 Stats. "Aggregate indemnity" does not include any expenses paid in the defense
			 of the claim.
(b) "Closed claim"
			 means a medical malpractice claim against a provider, or a claim against an
			 employee of a health care provider for which the provider is vicariously
			 liable, for which there has been either of the following:
1. A final determination based on a
			 settlement, award or judgment that indemnity will be paid to or on behalf of a
			 claimant.
2. A payment to a
			 claimant by the provider or another person on the provider's behalf.
(c) "Council" means the peer
			 review council appointed under s.
			 655.275,
			 Stats.
(cg) "Health care provider"
			 has the meaning given in s.
			 146.81(1),
			 Stats.
(cr) "Patient health care
			 records" has the meaning given in s.
			 146.81(4),
			 Stats.
(d) "Provider," when used
			 without further qualification, means a health care provider subject to ch. 655,
			 Stats., who is a natural person. "Provider" does not include a hospital or
			 other facility or entity that provides health care services.
(e) "Review period" means the 5-year period
			 ending with the date of the first payment on the most recent closed claim
			 reported under s.
			 655.26,
			 Stats., for a specific provider.
(f) "Surcharge" means the automatic increase
			 in a provider's plan premium or fund fee established under s.
			 Ins
			 17.25(12m) or
			 17.28(6s) or
			 both.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.29 - Servicing agent

Current through June 24, 2024
(1) PURPOSE. This section implements s.
			 655.27(2),
			 Stats., relating to contracting for claim services for the fund.
(2) CRITERIA. The board shall establish the
			 criteria for the selection of the servicing agent prior to the expiration of
			 each contract term.
(3) SELECTION.
			 The commissioner, with the approval of the board, shall select a servicing
			 agent through the competitive negotiation process.
(4) CONTRACT TERM. The commissioner, with the
			 approval of the board, shall establish the term of the contract with the
			 servicing agent. The contract shall include a provision for its cancellation if
			 performance or delivery is not made in accordance with its terms and
			 conditions.
(5) The servicing agent
			 shall perform all of the following functions:
(am) Reporting to the claims committee of the
			 board on claim files identified by that committee, at the times and in the
			 manner specified by that committee.
(b) Establishing and revising case
			 reserves.
(c) Contracting for
			 annuity payments as part of structured settlements under guidelines adopted by
			 the board.
(d) Investigating and
			 evaluating claims.
(e) Negotiating
			 to settlement all claims made against the fund except in cases where this
			 responsibility is retained by the claims committee of the board.
(f) Filing with the commissioner and the
			 board the annual report required under s.
			 655.27(2),
			 Stats., and any other report requested by the commissioner or the
			 board.
(g) Reviewing court orders,
			 verdicts and judgments and making recommendations on appeals.
(h) All other functions specified in the
			 contract.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.30 - Peer review council assessments

Current through June 24, 2024
(1) PURPOSE. This
			 section implements ss.
			 655.27(3)
			 (am) and
			 655.275(6),
			 Stats., relating to the assessment of fees sufficient to cover the costs,
			 including the costs of administration, of the patients compensation fund peer
			 review council appointed under s.
			 655.275(2),
			 Stats.
(2) ASSESSMENTS.
(a) The following fees shall be assessed
			 annually beginning with fiscal year 1986-87:
1. Against the fund, one-half of the actual
			 cost of operating the council for each fiscal year, less one-half of the
			 amounts, if any, collected under subd. 3.
2. Against the plan, one-half of the actual
			 cost of operating the council for each fiscal year, less one-half of the
			 amounts, if any, collected under subd. 3.
3. Against a private medical malpractice
			 insurer, the actual cost incurred by the council for its review of any claim
			 paid by the private insurer, if the private insurer requests a recommendation
			 on premium adjustments with respect to that claim under s.
			 655.275(5)
			 (a) 3, Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.35 - Primary coverage; requirements; permissible exclusions; deductibles

Current through June 24, 2024
(1)
			 PURPOSE. This section implements ss.
			 631.20
			 and
			 655.24,
			 Stats., relating to the approval of policy forms for health care liability
			 insurance subject to s.
			 655.23,
			 Stats.
(2) REQUIRED COVERAGE. To
			 qualify for approval under s.
			 631.20,
			 Stats., a policy shall at a minimum provide all of the following:
(a) Coverage for providing or failing to
			 provide health care services to a patient.
(b) Coverage for peer review, accreditation
			 and similar professional activities in conjunction with and incidental to the
			 provision of health care services, when conducted in good faith by an
			 insured.
(c) Coverage for
			 utilization review, quality assurance and similar professional activities in
			 conjunction with and incidental to the provision of health care services, when
			 conducted in good faith by an insured.
(d) Indemnity limits of not less than the
			 amounts specified in s.
			 655.23(4),
			 Stats.
(e) Coverage for
			 supplemental payments in addition to the indemnity limits, including attorney
			 fees, litigation expenses, costs and interest.
(f) That the insurer will provide a defense
			 of the insured and the fund until there has been a determination that coverage
			 does not exist under the policy or unless otherwise agreed to by the insurer
			 and the fund.
(g) If the policy is
			 a claims-made policy:
1. A guarantee that the
			 insured can purchase an unlimited extended reporting endorsement upon
			 cancellation or nonrenewal of the policy.
2. If the policy is a group policy, a
			 provision that any health care provider, as defined under s.
			 655.001(8),
			 Stats., whose participation in the group terminates has the right to purchase
			 an individual unlimited extended reporting endorsement.
3. A prominent notice that the insured has
			 the obligation under s.
			 655.23(3)
			 (a), Stats., to purchase the extended
			 reporting endorsement unless other insurance is available to ensure continuing
			 coverage for the liability of all insureds under the policy for the term the
			 claims-made policy was in effect.
4. A prominent notice that the insurer will
			 notify the commissioner if the insured does not purchase the extended reporting
			 endorsement and that the insured, if a natural person, may be subject to
			 administrative action by his or her licensing board.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.40 - Notice to fund of filing of action outside this state

Current through June 24, 2024
(1) PURPOSE. This
			 section implements s.
			 655.27(5)
			 (a) and (b), Stats., relating to the
			 requirement that the fund be notified of an action filed outside this state
			 within 60 days of service of process on the health care provider or the
			 employee of the health care provider and relating to the duty of the insurer or
			 self-insurer of the provider to provide an adequate defense of the fund and act
			 in good faith and in a fiduciary relationship with respect to any claim
			 affecting the fund.
(2) PRIMARY
			 INSURER OR SELF-INSURER TO GIVE NOTICE TO FUND. A primary insurer or
			 self-insurer for a health care provider or employee of a health care provider
			 shall notify the fund in writing within 60 days of the insurer or
			 self-insurer's first notice of the filing of an action outside this state
			 alleging medical malpractice against its insured health care provider or the
			 employee of its insured health care provider or within 60 days of service of
			 process on the insured health care provider or employee thereof, whichever is
			 later. The notice shall provide at a minimum the names and addresses of the
			 parties plaintiff and defendant, the court in which the action is filed, the
			 case number, and copies, if available, of the complaint in the action and
			 answer filed on behalf of the defendant provider.
(3) FAILURE TO GIVE NOTICE. If the primary
			 insurer or self-insurer fails to give notice to the fund as required in sub.
			 (2), the board shall deny fund coverage for the action filed outside this state
			 unless the primary insurer demonstrates, and the board finds, all of the
			 following:
(a) The fund was not prejudiced by
			 the failure to give notice as required, and
(b) It was not reasonably possible to give
			 notice within the time limit.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.50 - Self-insured plans for health care providers

Current through June 24, 2024
(1) PURPOSE. This
			 section implements s.
			 655.23(3)
			 (a), Stats.
(2) DEFINITIONS. In this section:
(a) "Actuarial" means prepared by an actuary
			 meeting the requirements of s.
			 Ins
			 6.12 who has experience in the field of medical
			 malpractice liability insurance.
(am) "Affiliated health care providers" means
			 two or more health care providers delivering services as described in s.
			 655.002(1),
			 Stats., and who satisfy all of the following:
1. The health care providers are either legal
			 entities or are employed by one or more separate legal entities over which
			 operating control is exercised by a common controlling legal entity. The
			 controlling legal entity need not be a health care provider.
2. The incomes of the health care providers
			 are consolidated with the controlling legal entity in audited financial
			 statements prepared under generally accepted accounting principles.
(b) "Level of confidence" means a
			 percentage describing the probability that a certain funding level will be
			 adequate to cover actual losses.
(c) "Occurrence coverage" means coverage for
			 acts or omissions occurring during the period in which a self-insured plan is
			 in effect.
(d) "Office" means the
			 office of the commissioner of insurance.
(e) "Provider," when used without
			 modification, means a health care provider as defined in s.
			 655.001(8),
			 Stats., or affiliated health care providers as defined in par. (am),
			 responsible for the establishment and operation of a self-insured
			 plan.
(f) "Risk margin" means the
			 amount that must be added to estimated liabilities to achieve a specified
			 confidence level.
(g) "Self-insured
			 plan" means a method, other than through the purchase of insurance, by which a
			 provider may furnish professional liability coverage which meets the
			 requirements of ch. 655, Stats.
(h)
			 "Year" means the self-insured plan's fiscal year.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter I - Definitions › Section Ins 18.01 - Definitions

Current through June 24, 2024
In this chapter:
(1)
				"Commissioner" means the "commissioner of insurance" of this state or the
				commissioner's designee.
(2)
				"Complaint" means any expression of dissatisfaction expressed to the insurer by
				the insured, or an insured's authorized representative, about an insurer or its
				providers with whom the insurer has a direct or indirect contract.
(2m) "Coverage denial determination" has the
				meaning as defined in s.
				632.835(1)
				(ag), Stats., and includes, for individual
				insurance products, a policy reformation or change in premium charged based
				upon underwriting or claims information greater than 25% from the premium in
				effect during the period of contestability except to the extent the
				modification is due to the applicant's age or a rate increase applied by the
				insurer to all similar individual policy forms applied uniformly.
(3) "Expedited grievance" means a grievance
				where any of the following applies:
(a) The
				duration of the standard resolution process will result in serious jeopardy to
				the life or health of the insured or the ability of the insured to regain
				maximum function.
(b) In the
				opinion of a physician with knowledge of the insured's medical condition, the
				insured is subject to severe pain that cannot be adequately managed without the
				care or treatment that is the subject of the grievance.
(c) A physician with knowledge of the
				insured's medical condition determines that the grievance shall be treated as
				an expedited grievance.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter II - Grievance Procedures › Section Ins 18.02 - Definitions

Current through June 24, 2024
In addition to the definitions in s.
				  632.83,
				  Stats., in this subchapter:
(1)
				"Health benefit plan" has the meaning provided in s.
				632.83,
				Stats., and includes Medicare supplement and Medicare replacement plans as
				defined in s.
				600.03(28p) and
				(28r), Stats., and s.
				Ins
				3.39(3) (v) and (w). Health benefit
				plan includes Medicare cost and select plans but does not include Medicare
				Advantage plans.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter II - Grievance Procedures › Section Ins 18.03 - Grievances

Current through June 24, 2024
(1) DEFINITION AND EXPLANATION OF THE
				GRIEVANCE PROCEDURE.
(a) Each insurer offering
				a health benefit plan shall incorporate within its policies, certificates and
				outlines of coverage the definition of a grievance as stated in s.
				Ins
				18.01(4).
(b) An insurer offering a health benefit plan
				shall develop an internal grievance and expedited grievance procedure that
				shall be described in each policy and certificate issued to insureds at the
				time of enrollment or issuance.
(c)
				In accordance with s.
				632.83(2)
				(a), Stats., an insurer that offers a health
				benefit plan shall investigate each grievance.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter II - Grievance Procedures › Section Ins 18.04 - Right of the commissioner to request OCI complaints be handled as grievances

Current through June 24, 2024
The commissioner may require an insurer offering a health
				  benefit plan to treat and process an OCI complaint as a grievance as
				  appropriate, if the commissioner provides a written description of the
				  complaint to the insurer. The insurer shall process the OCI complaint as a
				  grievance in compliance with s.
				  Ins
				  18.03.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter II - Grievance Procedures › Section Ins 18.05 - Expedited grievance procedure

Current through June 24, 2024
Section
				  Ins 18.03(2) to (4) and
				  (6) does not apply to expedited grievances.
				  For these situations, an insurer offering a health benefit plan shall develop a
				  separate expedited grievance procedure. An expedited grievance shall be
				  resolved as expeditiously as the insured's health condition requires but not
				  more than 72 hours after receipt of the grievance. An insurer offering a health
				  benefit plan, upon written request, shall mail or electronically mail a copy of
				  the insured's complete policy to the insured or the insured's authorized
				  representative as expeditiously as the grievance is handled.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter II - Grievance Procedures › Section Ins 18.06 - Reporting requirements

Current through June 24, 2024
An insurer offering a health benefit plan shall comply with
				  all of the following requirements:
(1)
				Each record of each complaint and grievance submitted to the insurer shall be
				kept and retained for a period of at least 3 years. These records shall be
				maintained at the insurer's home or principal office and shall be available for
				review during examinations by or on request of the commissioner or
				office.
(2) Submit a grievance
				experience report required by s.
				632.83(2)
				(c), Stats., to the commissioner by March 1
				of each year. The report shall provide information on all grievances received
				during the previous calendar year. The report shall be in a form prescribed by
				the commissioner and, at a minimum, shall classify grievances into the
				following categories:
(a) Plan administration
				including plan marketing, policyholder service, billing, underwriting and
				similar administrative functions.
(b) Benefit services including denial of a
				benefit, denial of experimental treatment, quality of care, refusal to refer
				insureds or to provide requested services.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.10 - Definitions

Current through June 24, 2024
In addition to the definitions in s.
				  632.835(1),
				  Stats., in this subchapter:
(1)
				"Adverse determination" has the meaning as defined in s.
				632.835(1)
				(a), Stats. This includes the denial of a
				request for a referral for out-of-network services when the insured requests
				health care services from a provider that does not participate in the insurer's
				provider network because the clinical expertise of the provider may be
				medically necessary for treatment of the insured's medical condition and that
				expertise is not available in the insurer's provider network.
(2) "Experimental treatment determination"
				means a determination by or on behalf of an insurer that issues a health
				benefit plan to which all of the following apply:
(a) A proposed treatment has been
				reviewed.
(b) Based on the
				information provided, the treatment under par. (a) is determined to be
				experimental under the terms of the health benefit plan.
(c) Based on the information provided, the
				insurer that issued the health benefit plan denied the treatment under par. (a)
				or payment for the treatment under par. (a).
(d) Pursuant to s.
				632.835(5)
				(c), Stats., the cost or expected cost of the
				denied treatment or payment exceeds, or will exceed during the course of the
				treatment, the amount published in accordance with s.
				Ins
				18.105.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.105 - Annual CPI adjustment for independent review eligibility

Current through June 24, 2024
(1) PUBLICATION AND
				EFFECTIVE DATE. The commissioner shall publish to the office of the
				commissioner of insurance website on or before December 1 of each year the
				consumer price index for urban consumers as determined by the U.S. Department
				of Labor and publish the adjusted dollar amount in accordance with s.
				632.835(5)
				(c), Stats. The adjusted dollar amount
				published each December shall be used by insurers offering health benefit plans
				when complying with s.
				Ins 18.10(2)
				(d) and s.
				632.835(1)
				(a) 4, Stats., effective the following
				January 1.
(2) DETERMINATION OF
				ADJUSTED RATES. Insurers offering health benefit plans shall apply the adjusted
				dollar amount published annually by the commissioner that is required to be met
				in accordance with s.
				632.835(1)
				(a) 4. and (b) 4., Stats., as follows:
(a) For adverse determinations when treatment
				was received by the insured, the insurer shall use the date treatment was
				received to determine the proper adjusted dollar amount that is required to be
				met in accordance with s.
				632.835(1)
				(a) 4, Stats.
(b) For adverse determinations when a course
				of treatment was received by the insured or terminated by the insurer, the
				insurer shall use later of the following dates to determine the proper adjusted
				dollar amount that is required to be met in accordance with s.
				632.835(1)
				(a) 4, Stats.:
1. The last date treatment was received by
				the insured; or,
2. The date the
				insurer mailed written notification to the insured, or the insured's authorized
				representative, that the course of treatment was terminated or
				denied.
(c) For
				experimental treatment determinations the insurer shall use the date the
				insurer mailed written notification to the insured, or the insured's authorized
				representative, that for the proposed treatment the insurer has either denied
				the treatment or denied payment for the treatment, to determine the proper
				adjusted dollar amount that is required to be met in accordance with s.
				632.835(1)
				(b) 4, Stats., and s.
				Ins 18.10(2)
				(d).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.12 - Independent review organization procedures

Current through June 24, 2024
(1) Independent
				review organizations shall have, and demonstrate compliance with, written
				policies and procedures governing all aspects of both the standard review and
				expedited review processes as described in s.
				632.835,
				Stats., including all of the following:
(a) A
				regulatory compliance program that does all of the following:
1. Tracks applicable independent review laws
				and regulations.
2. Ensures the
				organization's compliance with applicable laws.
3. Maintains a current list of potential
				conflicts of interest updated on no less than a quarterly basis in addition to
				conducting a conflict review at the time of each case referral to the
				organization.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.13 - Standards of independent review

Current through June 24, 2024
(1) For coverage
				denial determinations other than experimental treatment determinations,
				independent review organizations shall consider any of the following:
(a) Medical or scientific evidence including
				evidence that is determined to be an efficacious treatment or strategy as
				defined at s.
				Ins 3.36(3)
				(c).
(b) Legal basis.
(c) The applicable insurance
				contract.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.14 - Approval of independent review organizations

Current through June 24, 2024
(1) In addition to
				meeting the requirements established s.
				632.835(4)
				(a), Stats., any independent review
				organization seeking approval to conduct independent reviews shall submit an
				application for approval on a form prescribed by the commissioner and include
				with the form all documentation and information necessary for the commissioner
				to determine if the independent review organization is unbiased and satisfies
				s.
				Ins
				18.12.
(2)
				The independent review organization shall submit informational materials to the
				commissioner as part of the application. Materials will be maintained in the
				office for public review.
(3) The
				independent review organization shall submit the application fee in accordance
				with s.
				601.31(1)
				(Lp), Stats., at the time of the application
				to an identified lock box address.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.16 - Independent review organization reporting requirements

Current through June 24, 2024
(1) An independent
				review organization shall maintain records on all independent review activity
				during each calendar year and submit a report to the commissioner, on a form
				prescribed by the commissioner, by March 1 of each year for the prior calendar
				year's experience. Records shall be maintained so that, at a minimum, they
				satisfy the reporting requirements to the commissioner and shall be retained
				for at least 3 years.
(2) The
				annual report shall include all of the following information on an aggregate
				basis, by insurer and by insurer and insurance product name:
(a) The total number of requests for
				independent review received.
(b)
				The total number of requests for independent review declined and the reason for
				the declination, including whether the request was a qualified request or
				within the scope of the health benefit plan policy.
(c) The total number of requests for
				expedited independent review that the independent review organization declined
				to handle in an expedited timeframe, including whether the request was a
				qualified request or within the scope of the health benefit plan
				policy.
(d) The number of
				independent reviews that were done in an expedited manner and the results of
				those reviews.
(e) The number of
				requests for independent review resolved and, of those resolved, the number
				resolved upholding the coverage denial determination by the insurer and the
				number resolved reversing the coverage denial determination by the insurer.
(em) The names and specialty of
				the reviewers participating in reviews conducted during the year. The listing
				shall include the name of any attorney or actuary or the respective firm, who
				participated in the reviews.
(f)
				The average length of time for resolution.
(g) A detailed summary of cases including a
				synopsis of facts, rationale for decision and key evidence relied upon to reach
				the reviewer's decision. The summary shall also include the types of cases or
				coverage for which an independent review was sought.
(h) The cost of reviews both in the aggregate
				and on a case by case basis.
(i)
				The number of independent reviews that were terminated as the result of
				reconsideration by the insurer offering a health benefit plan of its coverage
				denial determination after the receipt of additional information from the
				insured, the insured's authorized representative, or other appropriate
				sources.
(j) Any other information
				the commissioner requests.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.18 - Independent review organization fees

Current through June 24, 2024
(1) A certified
				independent review organization shall submit its fee schedule in accordance
				with s.
				632.835(4)
				(ap), Stats., to the commissioner for review
				and approval.
(2) Fee schedules
				shall be based on prevailing rates in the industry demonstrated by supporting
				credible documentation including actual costs for conducting the reviews. Fee
				schedules shall be on a per case basis according to categories established by
				the commissioner. The fee schedule shall include a category for the fee payable
				for a review that is terminated because the insurer voluntarily reverses its
				decision because of information first received by the insurer after the review
				is requested.
(3) An insurer
				offering a health benefit plan shall pay the fee submitted by the independent
				review organization within 30 days of receipt of a written invoice or billing
				record from the independent review organization.
(4) The independent review organization may
				only charge the fees in accordance with the fee schedule that is approved by
				the commissioner.
(6) If an
				independent review organization determines the matter is not within its
				authority to review, it may not charge for that determination.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 19 - Wisconsin Healthcare Stability Plan › Section Ins 19.01 - Purpose

Current through June 24, 2024
The commissioner implements 2017 Wis. Act 138 for the purposes
				of establishing the Wisconsin Healthcare Stability Plan. The commissioner will
				seek to maximize federal funding for the Wisconsin Healthcare Stability Plan.
				The commissioner shall design and adjust the payment parameters with the goal
				to stabilize or reduce premium rates, increase participation by health
				insurers, improve access to health care providers and services, and mitigate
				the impact of high-risk individuals participating in the individual health
				insurance market.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 19 - Wisconsin Healthcare Stability Plan › Section Ins 19.02 - Definitions

Current through June 24, 2024
In addition to definitions contained in s.
				601.80,
				Stats., the following definitions shall apply in this chapter:
(1) "Audit" has the meaning provided under s.
			 601.83(5)
			 (f), Stats., and includes a verification and
			 compliance audit conducted by OCI.
(2) "CMS" means the Centers for Medicare
			 & Medicaid Services within the U.S. department of health and human
			 services.
(3) "Commissioner" has
			 the meaning provided under s.
			 600.03(11),
			 Stats.
(4) "Compliant plan" means
			 an individual health benefit plan offered by an eligible health carrier that
			 conforms with regulations set forth in the Affordable Care Act, as applicable,
			 or an individual health benefit plan that provides substantially similar
			 benefits as required by the Affordable Care Act effective July 1, 2018, as
			 defined by the office.
(5)
			 "Eligible health carrier" means an insurer offering a compliant plan either on
			 or off the federally facilitated marketplace that was issued after January 1,
			 2014, and is not a grandfathered plan or transitional plan. A transitional plan
			 is a health plan in effect on October 1, 2013, and is in compliance with CMS
			 and guidance issued by the office. A grandfathered plan is a health plan that
			 has been continuously offered since March 23, 2010, and in compliance with
			 CMS.
(6) "Enrolled individual"
			 means an insured member of an eligible health carrier during the applicable
			 benefit year for at least one day and who has paid all premium owed for the
			 period in which claims eligible for reinsurance payment were incurred or the
			 eligible health carrier is obligated to pay under law.
(7) "External Data Gathering Environment" or
			 "EDGE server" means the server developed by the CMS in conjunction with the
			 federally facilitated marketplace for health care insurers to submit claims
			 information on enrolled individuals for claims paid for covered services or
			 treatments.
(7m) "Office" or "OCI"
			 has the meaning provided under s.
			 600.03(34),
			 Stats.
(8) "Secure file transfer
			 portal" or "FTP" means a manner of securely transferring requested information
			 from the eligible health carrier to the commissioner in a manner specified by
			 the commissioner.
(10) "Wisconsin
			 Healthcare Stability Plan" or "WIHSP" means the Wisconsin healthcare stability
			 plan created under s.
			 601.83,
			 Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 19 - Wisconsin Healthcare Stability Plan › Section Ins 19.03 - Payment parameters

Current through June 24, 2024
The commissioner shall annually establish the payment
				parameters for future benefit years through an established procedure that
				includes all of the following components:
(1) The commissioner shall request, under s.
			 601.42,
			 Stats., all eligible health carriers to submit data and information from prior
			 and current benefit years including: compliant plan membership, premium
			 experience at a metal and federally facilitated marketplace status level,
			 advanced premium tax credit enrollee information, and other information as
			 requested by the commissioner.
(2)
			 The commissioner shall publish the preliminary payment parameters and a public
			 hearing notice in the Wisconsin Administrative Register and to the OCI website.
			 The commissioner shall hold a public hearing seeking public comment regarding
			 the preliminary payment parameters for the subsequent benefit year.
(3) The commissioner shall set the final
			 payment parameters after consultation with an actuarial firm, consideration of
			 comments received from the public hearing, the goals established in s.
			 601.83(2),
			 Stats., and any additional information as appropriate.
(4) The commissioner shall publish the final
			 payment parameters in the Wisconsin Administrative Register and to the OCI
			 website by May 15 of the calendar year prior to the applicable benefit
			 year.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 19 - Wisconsin Healthcare Stability Plan › Section Ins 19.07 - Eligible claims

Current through June 24, 2024
For claims to be eligible for reinsurance payment, the
				eligible health carrier shall comply with s.
				601.83,
				Stats., and submit claims that comply with the following criteria:
(1) The claims that were paid for as covered
			 benefits by the eligible health carrier under the terms and conditions of the
			 carrier's compliant plan for the applicable benefit year including but not
			 limited to medical, surgical, and prescription drug services and
			 treatments.
(2) The claims that
			 were paid by the eligible health carrier after January 1, of the applicable
			 benefit year and before April 30, of the following calendar year, or a date
			 established by the commissioner.
(3) The cumulative amount of the claims paid
			 that exceeds the applicable attachment point. Claims reported shall not include
			 any amount of cost sharing required to be paid by the enrolled individual or
			 the person responsible for the payment of the enrolled individual's cost
			 sharing. Cost sharing may include any of the following; deductibles,
			 co-insurance, co-payment, visit fees, or similar costs.
(4) The cumulative amount of paid claims
			 shall be reduced by any reimbursement received by the eligible health carrier
			 for the enrolled individual through subrogation, recoupment of overpayments
			 from providers, application of negotiated rates reductions with providers, or
			 recoupment of third-party payment including workers compensation or civil
			 litigation.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 19 - Wisconsin Healthcare Stability Plan › Section Ins 19.10 - Reporting requirements

Current through June 24, 2024
All eligible health carriers shall provide all requested
				information as ordered by the commissioner pursuant to s.
				601.42,
				Stats. Information collected under ss. Ins 19.07 and 19.11 may be used on an
				aggregate basis by the commissioner to satisfy federal and state reporting
				requirements. Additional data may be requested to inform federal and state
				reports including: second lowest cost silver rates by rating area demonstrating
				rates with and without reinsurance payments, actual average premium rates for
				compliant plans, and actual enrollment for compliant plans.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 19 - Wisconsin Healthcare Stability Plan › Section Ins 19.11 - Quarterly reporting requirements

Current through June 24, 2024
(1) Eligible health
			 carriers shall provide the information required by this section to the
			 commissioner within 45-days from the end of each financial quarter. The data
			 shall be extracted from the health carrier's claims systems or similar database
			 that tracks enrolled individual's claims.
(2) Each quarterly report shall be
			 transmitted to the commissioner, pursuant to s.
			 601.42,
			 Stats., through a secure file transfer portal in a format designated by the
			 commissioner. Instructions for submission of required information shall be
			 provided to the eligible health carriers by the commissioner. Information in
			 the report shall include all of the following:
(a) The total number of enrolled individuals
			 as of the last day of the applicable quarter.
(b) The total amount of claims paid by the
			 eligible health carrier in the applicable quarter.
(c) A unique identifier for each enrolled
			 individual whose claims are submitted for reinsurance.
(d) For each identified enrolled individual,
			 the total amount of eligible claims paid, consistent with s. Ins
			 19.07.
(e) The dollar amount of
			 paid claims eligible for reinsurance payment for each identified enrolled
			 individual.
(f) Any additional
			 information requested by the commissioner.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 19 - Wisconsin Healthcare Stability Plan › Section Ins 19.12 - Final annual report and affirmations

Current through June 24, 2024
(1) Eligible health
			 carriers shall provide a final annual report to the commissioner by or before
			 May 15 of each calendar year after the applicable benefit year, or a date
			 established by the commissioner. The final annual report shall be completed
			 using data as submitted to CMS through the health carrier's EDGE server that is
			 compliant with all applicable EDGE server requirements. In the event the EDGE
			 server data is no longer available, the eligible health carrier shall use data
			 extracted from the health carrier's claims systems or similar database that
			 tracks enrolled insured's validated claims.
(2) The final annual report shall be
			 transmitted to the commissioner through a secure FTP in a format designated by
			 the commissioner. Instructions for submission of required information shall be
			 provided to the eligible health carriers by the commissioner. The information
			 shall include all of the following:
(a) The
			 final total number of enrolled individuals for the applicable benefit year
			 utilizing the same unique identifiers as contained in quarterly
			 reports.
(b) The final total dollar
			 amount of claims incurred in the applicable benefit year that were paid by the
			 eligible health carrier no later than April 30 of the next calendar year, or a
			 date established by the commissioner.
(c) The final dollar amount of eligible
			 claims for each identified enrolled individual.
(d) Any additional information requested by
			 the commissioner.