reglab/statecodes huggingface dataset:
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.21 - Limited exemptions

Current through June 24, 2024
(1) SILENT DISCOUNT. An insurer, with respect
				to a defined network plan:
(a) Is exempt from
				meeting the requirements under ss.
				609.22,
				609.24,
				609.32,
				609.34,
				609.36
				and
				632.83,
				Stats., and ss.
				Ins
				9.31,
				9.32(1),
				9.35,
				9.37,
				9.38,
				9.39, to
				9.40(1) (7), to
				9.42(1) (7), if the
				only owned, employed, or participating provider providing services covered
				under the plan is a silent provider network.
(b) Is exempt from meeting the requirements
				under ss.
				609.22,
				609.24,
				609.32,
				609.34,
				and
				609.36,
				Stats., and ss.
				Ins
				9.32(1),
				9.35,
				9.37,
				9.38,
				9.39, to
				9.40(1) (7), and to
				9.42(1) (7), solely with respect to services provided by the silent provider
				network, if the plan also covers services by providers that the insurer owns or
				employs, or another participating provider. An insurer is not exempt from those
				provisions with respect to a provider that is not a silent provider
				network.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.25 - Preferred provider plan same service provisions

Current through June 24, 2024
For purposes of s.
				  609.35,
				  Stats., an insurer offering a preferred provider plan covers the same services
				  when performed by a nonparticipating provider that it covers when those
				  services are performed by a participating provider only if the insurer complies
				  with all of the following:
(1) The
				insurer offering a preferred provider plan provides coverage that complies with
				either of the following:
(a) Provides coverage
				for services performed by nonparticipating providers with the insurer paying at
				a coinsurance rate of not less than 60% and the enrollee paying at a
				coinsurance rate of not more than 40%.
(b) Provides coverage for services performed
				by nonparticipating providers with the insurer paying at a coinsurance rate not
				less than 50% and the enrollee paying at a coinsurance rate of not more than
				50% and the insurer provides the enrollee with the disclosure notice that is
				compliant with sub. (5).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.26 - Preferred provider plan subject to defined network plan regulations

Current through June 24, 2024
An insurer offering 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 of a defined network plan that is not a preferred provider
				  plan including ss.
				  Ins
				  9.31, 9.32(1), 9.35(1), 9.37(4), 9.40(2) and (4), and
				  18.03(2) (c) 1., and ss.
				  609.22(2), (3), (4) and
				  (7),
				  609.32(1)
				  and
				  609.34(1),
				  Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.27 - Preferred provider plan requirements

Current through June 24, 2024
Insurers offering a preferred provider plan shall comply with
				  all the following:
(1) Except as
				provided in s.
				Ins
				9.25(2), insurers offering a
				preferred provider plan that apply a coinsurance percentage when the services
				are performed by nonparticipating providers at a different percentage than the
				coinsurance percentage that is applied when the services are performed by
				participating providers shall offer plans that have either of the following:
(a) The coinsurance differential between
				participating and nonparticipating providers performing the same services is
				30% or less.
(b) The coinsurance
				differential between participating and nonparticipating provider performing the
				same services is greater than 30% and the insurer provides the enrollee with a
				disclosure notice that is compliant with s.
				Ins
				9.25(5).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.30 - Group and blanket health insurers compliance

Current through June 24, 2024
The commissioner finds that the circumstances of offering a
				  group or blanket health insurance policy require that the insurer offering the
				  policy otherwise exempt from chs. 600 to 646, Stats., under s.
				  600.01(1)
				  (b) 3, Stats., comply with s.
				  Ins
				  9.32(2) and s.
				  609.22(2),
				  Stats., in order to provide adequate protection to Wisconsin enrollees and the
				  public. An insurer that covers 100 or more residents of this state under a
				  policy otherwise exempt under s.
				  600.01(1)
				  (b) 3, Stats., shall comply with s.
				  Ins
				  9.32(2) and s.
				  609.22(2),
				  Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.31 - Annual certification of access standards

Current through June 24, 2024
(1) An insurer
				offering a defined network plan that is not a preferred provider plan shall
				file an annual certification with the commissioner no later than August 1 of
				each year certifying compliance with the access standards of s.
				609.22, Stats.,
				and s.
				Ins
				9.32(1) for the preceding year. The
				certification shall be submitted on a form prescribed by the commissioner and
				signed by an officer of the company.
(2) An insurer offering a preferred provider
				plan shall file an annual certification with the commissioner no later than
				August 1 of each year certifying compliance with the access standards contained
				in ss.
				609.22(1), (4m), (5), (6) and
				(8), Stats., and s.
				Ins
				9.32(2) for the preceding year, on a
				form prescribed by the commissioner and signed by an officer of the company.
				The certification is to be filed within 3 months after March 1, 2006, and
				thereafter, no later than August 1 of each year.
A copy of the certification of access standards form
					 required under sub. (1), OCI26-110, and sub. (2), OCI26-111, may be obtained at
					 no cost from the Office of the Commissioner of Insurance, P.O. Box 7873,
					 Madison, WI, 53707-7873 or from the OCI website address:
http://oci.wi.gov
.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.32 - Defined network plan requirements

Current through June 24, 2024
(1) An insurer
				offering a defined network plan that is not a preferred provider plan shall do
				all of the following:
(a) Provide covered
				benefits by plan providers with reasonable promptness with respect to
				geographic location, hours of operation, waiting times for appointments in
				provider offices and after hours care. The hours of operation, waiting times,
				and availability of after hours care shall reflect the usual practice in the
				local area. Geographic availability shall reflect the usual medical travel
				times within the community.
(b)
				Have sufficient number and type of plan providers to adequately deliver all
				covered services based on the demographics and health status of current and
				expected enrollees served by the plan.
(c) Provide 24-hour nationwide toll-free
				telephone access for its enrollees to the plan or to a Wisconsin participating
				provider for authorization for care which is covered by the plan.
(d) Provide as a covered benefit the
				emergency services rendered during the treatment of an emergency medical
				condition, as defined by s.
				632.85,
				Stats., by a nonparticipating provider as though the services was provided by a
				participating provider, if the insurer provides coverage for emergency medical
				services and the enrollee cannot reasonably reach a participating provider or,
				as a result of the emergency, is admitted for inpatient care subject to any
				restriction which may govern payment to a participating provider for emergency
				services. The insurer shall pay the nonparticipating provider at the rate the
				insurer pays a nonparticipating provider after applying any co-payments,
				coinsurance, deductibles or other cost-sharing provisions that apply to
				participating providers.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.33 - Enrollee election of nonparticipating provider reimbursement

Current through June 24, 2024
Nothing in s.
				  Ins
				  9.32 changes there imbursement payable or the amounts
				  due, including co-payments, coinsurance, deductibles and other cost-sharing
				  provisions from an enrollee when the enrollee of a preferred provider plan that
				  is not a defined network plan elects to utilize the services of a
				  nonparticipating provider when a participating provider is available in
				  accordance with s.
				  Ins 9.32(2) (a)
				  and (b) and the requirements of s.
				  Ins 9.32(2)
				  (d), are provided to the
				  enrollee.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.35 - Continuity of care

Current through June 24, 2024
(1) In addition to the requirements of s.
				609.24,
				Stats., an insurer offering a defined network plan shall do one of the
				following:
(a) Upon termination of a provider
				from a defined network plan, the insurer offering a defined network plan shall
				appropriately notify all enrollees of the termination, provide information on
				substitute providers, and at least identify the terminated providers within a
				separate section of the annual provider directory. In addition, the insurer
				shall comply with all of the following as appropriate:
1. If the terminating provider is a primary
				care provider and the insurer offering a defined network plan requires
				enrollees to designate a primary care provider, the insurer shall notify each
				enrollee who designated the terminating provider of the termination no later
				than 30 days prior to the termination or 15 days following the date the insurer
				received the provider's termination notice, whichever is later, and shall
				describe each enrollee's options for receiving continued care from the
				terminated provider.
2. If the
				terminating provider is a specialist and the insurer offering a defined network
				plan requires a referral, the insurer shall notify each enrollee authorized by
				referral to receive care from the specialist of the termination no later than
				30 days prior to the termination or 15 days following the date the insurer
				received the provider's termination notice, whichever is later, and describe
				each enrollee's options for receiving continued care from the terminated
				provider.
3. If the terminating
				provider is a specialist and the insurer offering a defined network plan does
				not require a referral, the provider's contract with the insurer shall comply
				with the requirements of s.
				609.24,
				Stats., and require the provider to post a notification of termination with the
				plan in the provider's office no later than 30 days prior to the termination or
				15 days following the date the insurer received the provider's termination
				notice, whichever is later.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.36 - Gag clauses

Current through June 24, 2024
(1) No contract between an insurer offering a
				defined network plan and a participating provider may limit the provider's
				ability to disclose information, to or on behalf of an enrollee, about the
				enrollee's medical condition.
(2) 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 and within the scope of the provider's
				professional license. An insurer offering a defined network plan may not
				penalize the participating provider nor 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. An insurer offering a defined network plan
				may not retaliate against a provider for advising an enrollee of treatment
				options that are not covered benefits under the plan.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.37 - Notice requirements

Current through June 24, 2024
(1) PROVIDED INFORMATION. Prior to enrolling
				members, insurers offering a defined network plan shall provide to prospective
				group or individual policyholders information on the plan including all of the
				following:
(a) Covered services.
(b) A definition of emergency and out-of-area
				coverage.
(c) Cost sharing
				requirements.
(d) Enrollment
				procedures.
(e) Limitations on
				benefits including limitations on choice of providers and the geographical area
				serviced by the plan.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.38 - Policy and certificate language requirements

Current through June 24, 2024
Each policy form marketed or each certificate issued to an
				  enrollee by an insurer offering a defined network plan or limited service
				  health organization plan shall contain all of the following:
(1) DEFINITIONS. A definition of geographical
				service area, emergency care, urgent care, out-of-area service, dependent and
				primary provider, if these terms or terms of similar meaning are used in the
				policy or certificate and have an effect on the benefits covered by the plan.
				The definition of geographical service area need not be stated in the text of
				the policy or certificate if such definition is adequately described in an
				attachment that is given to all enrollees along with the policy or
				certificate.
(2) DISCLOSURE OF
				EXCLUSIONS, LIMITATIONS AND EXCEPTIONS. Clear disclosure of any provision that
				limits benefits or access to services in the exclusions, limitations, and
				exceptions sections of the policy or certificate. Among the exclusions,
				limitations and exceptions that shall be disclosed are those relating to:
(a) Emergency and urgent care.
(b) Restrictions on the selection of primary
				or referral providers.
(c)
				Restrictions on changing providers during the contract period.
(d) Out-of-pocket costs including copayments
				and deductibles.
(e) Any
				restrictions on coverage for dependents who do not reside in the service
				area.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.39 - Disenrollment

Current through June 24, 2024
(1) DISCLOSURE. The health maintenance
				organization or limited service health organization shall clearly disclose in
				the policy and certificate any circumstances under which the health maintenance
				organization or limited service health organization may disenroll an
				enrollee.
(2) ENROLLEE
				DISENROLLMENT CRITERIA. Except as provided in s.
				632.897,
				Stats., the health maintenance organization or limited service health
				organization may only disenroll an enrollee if one of the following occurs:
(a) The enrollee has failed to pay required
				premiums by the end of the grace period.
(b) The enrollee has committed acts of
				physical or verbal abuse that pose a threat to providers or other members of
				the organization.
(c) The enrollee
				has allowed a nonmember to use the health maintenance or limited service health
				organization's certification card to obtain services or has knowingly provided
				fraudulent information in applying for coverage.
(d) The enrollee has moved outside of the
				geographical service area of the organization.
(e) The enrollee is unable to establish or
				maintain a satisfactory physician-patient relationship with the physician
				responsible for the enrollee's care. Disenrollment of an enrollee under this
				paragraph shall be permitted only if the health maintenance organization or
				limited service health organization can demonstrate that it did all of the
				following:
1. Provided the enrollee with the
				opportunity to select an alternate primary care physician.
2. Made a reasonable effort to assist the
				enrollee in establishing a satisfactory patient-physician
				relationship.
3. Informed the
				enrollee that he or she may file a grievance on this matter.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.40 - Required quality assurance and remedial action plans

Current through June 24, 2024
(1) In this section
				"quality assurance" means the measurement and evaluation of the quality and
				outcomes of medical care provided.
(2)
(a) By
				April 1, 2000, an insurer, with respect to a defined network plan that is not a
				preferred provider plan shall submit a quality assurance plan consistent with
				the requirements of s.
				609.32, Stats.,
				to the commissioner, except as provided in par. (b). The insurers shall submit
				a quality assurance plan that is consistent with the requirements of s.
				609.32, Stats.,
				by April 1 of each subsequent year. The quality assurance plan shall be
				designed to reasonably assure that health care services provided to enrollees
				of the defined network plan meet the quality of care standards consistent with
				prevailing standards of medical practice in the community. The quality
				assurance plan shall document the procedures used to train employees of the
				defined network plan in the content of the quality assurance plan.
(b) Insurers offering a defined network plan
				that is not also a preferred provider plan or health maintenance organization
				plan shall submit a quality assurance plan consistent with the requirements of
				par. (a) and s.
				609.32, Stats.,
				to the commissioner by April 1, 2007, and April 1 of each subsequent
				year.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.41 - Right of the commissioner to request OCI complaints be handled as grievances

Current through June 24, 2024
An insurer offering a defined network plan, preferred
				  provider plan or limited service health organization shall treat and process an
				  OCI complaint as a grievance at the request of the commissioner. The
				  commissioner will provide a written description of the OCI complaint to the
				  insurer.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Subchapter III - Market Conduct Standards for Defined Network Plans, Preferred Provider Plans and Limited Service Health Organizations › Section Ins 9.42 - Compliance program requirements

Current through June 24, 2024
(1) All insurers
				offering a defined network plan, preferred provider plan or limited service
				health organization except to the extent otherwise exempted under this chapter
				or by statute, are responsible for compliance with ss.
				609.22,
				609.24,
				609.30,
				609.32,
				609.34,
				609.36,
				and
				632.83,
				Stats., applicable sections of this subchapter and other applicable sections
				including but not limited to s.
				Ins
				9.07. Insurers offering a defined network plan,
				preferred provider plan or limited service health organization, to the extent
				they are required to comply with those provisions, shall establish a compliance
				program and procedures to verify compliance. Nothing in this section shall
				affect the availability of the privilege established under s.
				146.38,
				Stats.
(2) The insurers shall
				establish and operate a compliance program that provides reasonable assurance
				that:
(a) The insurer is in compliance with
				ss.
				609.22,
				609.24,
				609.30,
				609.32,
				609.34,
				609.36,
				632.83,
				and
				632.83,
				Stats., this subchapter and other applicable sections including but not limited
				to s.
				Ins
				9.07.
(b)
				Any violations of ss.
				609.22,
				609.24,
				609.30,
				609.32,
				609.34,
				609.36,
				and
				632.83,
				Stats., this subchapter or any applicable sections including but not limited to
				s.
				Ins
				9.07 a redetected and timely corrections are taken by
				the insurer.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Appendix A - AUDITOR'S SPECIAL PROCEDURES REPORT ON THE SCHEDULE OF COVERED EXPENSES

Current through June 24, 2024
Board of Directors
XYZ Health Maintenance Organization Insurer
We have performed the following special procedures with respect
				to the Schedule of Covered Expenses for XYZ health maintenance organization
				insurer ("HMO insurer"), for the year ended December 31, XXXX. It is understood
				that this report is solely to assist you in complying with ch. Ins 9, Wis. Adm.
				Code, and ch. 609, Wis. Stats., and our report is not to be used for any other
				purpose. Our procedures and findings are as follows:
a. A randomly selected sample was taken from all medical and
				hospital expenses paid during the calendar year to test the attribute that the
				expenses reported on the provider's IRS 1099-MISC forms (or other supporting
				documentation for providers not issued an IRS-1099-MISC form) trace to the
				Schedule of Covered Expenses for those providers included on the Schedule of
				Covered Expenses.
b. A comparison was made between the Schedule of Covered
				Expenses and the Election of Exemption notices by providers to verify that
				providers which had given notice of their Election of Exemption prior to
				December 31, XXXX, and which had not also given notice of their Termination of
				Election prior to December 31, XXXX, are excluded from the Schedule of Covered
				Expenses.
A review of the assumptions and methods of the HMO insurer in
				establishing the amount of covered expenses included in the Incurred But Not
				Reported line of the Schedule of Covered Expenses was undertaken to determine
				if the company's estimate is reasonably estimated based on the HMO insurer's
				historical data and best information available to the HMO insurer.
Because the procedures do not constitute an examination made in
				accordance with generally accepted auditing standards, we do not express an
				opinion on any of the accounts or items referred to above. The following
				summarizes our findings as a result of the procedures referred to above.
FINDINGS REPORTED HERE
Had we performed any additional procedures, other matters might
				have come to our attention that would have been reported to you. This report
				relates only to the items specified above and does not extend to any financial
				statements of the HMO insurer taken as a whole.
Date CPA Signature
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Appendix B - AUDITOR'S REPORT ON THE SCHEDULE OF COVERED EXPENSES

Current through June 24, 2024
Date
BOARD OF DIRECTORS
XYZ Health Maintenance Organization Insurer
We have audited, in accordance with generally accepted auditing
				standards, Financial Statements of XYZ health maintenance organization insurer
				("HMO insurer"), for the year ended December 31, XXXX, and have issued our
				report thereon dated XXXXXXXXXX XX, XXXX. We have also audited the accompanying
				Schedule of Covered Expenses for XYZ HMO insurer as of December 31, XXXX. This
				schedule is the responsibility of management of XYZ HMO insurer. Our
				responsibility is to express an opinion on this schedule based on our
				audit.
We conducted our audit in accordance with generally accepted
				auditing standards. Those standards require that we plan and perform the audit
				to obtain reasonable assurance about whether the aforementioned schedule is
				free of material misstatement. An audit includes examining, on a test basis,
				evidence supporting the amounts and disclosures in the aforementioned schedule.
				An audit also includes assessing the accounting principles used and any
				significant estimates made by management, as well as evaluating the overall
				schedule presentations. We believe that our audit provides reasonable basis for
				our opinion.
In our opinion, the schedule referred to above presents fairly,
				in all material respects, covered expenses for the year ended December 31,
				XXXX.
Date CPA Signature
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 9 - Defined Network Plans › Appendix D - PREFERRED PROVIDER PLAN NOTICE TO ENROLLEES

Current through June 24, 2024
IMPORTANT NOTICE
You are strongly encouraged to contact us to verify the status
				of the providers involved in your care including, for example, the
				anesthesiologist, radiologist, pathologist, facility, clinic or laboratory,
				when scheduling appointments or elective procedures to determine whether each
				provider is a participating or nonparticipating provider. Such information may
				assist in your selection of provider(s) and will likely affect the level of
				co-payment, deductible and amount of co-insurance applicable to the care you
				receive. The information contained in this directory may change during your
				plan year. Please contact [insert 800 and direct dial phone number of insurer]
				to learn more about the participating providers in your network and the
				implications, including financial, if you decide to receive your care from
				nonparticipating providers.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 10 - Continuing care facilities › Section Ins 10.10 - Continuing care contracts

Current through June 24, 2024
(1) PURPOSE. The
			 purpose of this section is to interpret s.
			 100.18
			 and ch. 647, Stats., by establishing guidelines and standards for the filing
			 and review of continuing care contracts.
(2) SCOPE. This section applies to all
			 contracts entered into by providers subject to ch. 647, Stats.
(3) DEFINITIONS. The definitions in s.
			 647.01, Stats., apply
			 to this section.
(4) FILING AND
			 APPROVAL OF CONTINUING CARE CONTRACT FORMS.
(a) No provider may enter into a continuing
			 care contract with any resident or prospective resident unless the contract
			 form prepared for general use has been filed with and approved by the
			 commissioner. A contract form filed with the commissioner need not include the
			 rules, regulations and procedures the provider uses for the day-to-day
			 operation of the facility. The filing shall be deemed approved if it is not
			 disapproved within 30 days after filing. The commissioner may disapprove a
			 contract form upon a finding that it violates a statute or a rule promulgated
			 by the commissioner.
(b) A provider
			 shall file each amended contract form with the commissioner within 30 days
			 after any change is made in that contract.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 11 - Insurance Security Fund Board › Section Ins 11.02 - Reports

Current through June 24, 2024
(1) PURPOSE. The purpose of this section is
			 to establish reporting for administration of the insurance security
			 fund.
(2) REPORTS TO INSURERS
			 SUBJECT TO ASSESSMENT. The board from time to time at the direction of the
			 chairperson shall make a report of its activities and of the income and
			 disbursements of each account of the fund to all authorized insurers subject to
			 assessment.
(3) ANNUAL AUDITED
			 FINANCIAL REPORTS. The board shall submit an audited financial report to the
			 commissioner each year not later than 120 days after the insurance security
			 fund's fiscal year.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 13 - Town Mutual Insurance › Section Ins 13.01 - Other rules applicable to town mutual insurers

Current through June 24, 2024
The following chapter and sections of the Wisconsin
				Administrative Code are applicable to town mutual insurers:
(1) Chapter
			 Ins 5 RULES OF PROCEDURE FOR
			 HEARINGS.
(2) Section
			 Ins
			 6.07 INSURANCE POLICY LANGUAGES
			 IMPLIFICATION.
(3) Section
			 Ins
			 6.11 INSURANCE CLAIMS SETTLEMENT PRACTICES.
(4) Section
			 Ins
			 6.20 INVESTMENTS OF INSURANCE COMPANIES.
(5) Section
			 Ins
			 6.52 BIOGRAPHICAL DATA RELATING TO COMPANY OFFICERS
			 AND DIRECTORS.
(6) Section
			 Ins 6.72 RISK
			 LIMITATIONS.
(7) Section
			 Ins
			 6.76 GROUNDS FOR DISAPPROVAL OF AND AUTHORIZED CLAUSES
			 FOR FIRE, INLAND MARINE AND OTHER PROPERTY INSURANCE FORMS.
(8) Chapter
			 Ins 7 FORMS.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 13 - Town Mutual Insurance › Section Ins 13.02 - Definitions, usages, synonyms and abbreviations

Current through June 24, 2024
(1) "Admitted
			 assets" as used in this chapter includes the total of ledger assets, plus the
			 total of nonledger assets, less the total assets not admitted as determined in
			 the annual report filed with the office of the commissioner of
			 insurance.
(2) "Gross income" as
			 used in this chapter includes premiums written and assessments collected on
			 direct business and from reinsurance assumed, policy and membership fees,
			 interest and dividend income from investments, gains on investments, rental
			 income from real estate investments and miscellaneous income.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 13 - Town Mutual Insurance › Section Ins 13.04 - Undertaking to pay premiums and assessments and contract forms

Current through June 24, 2024
(1)
			 PURPOSES. This rule is promulgated to implement, and set forth procedural
			 requirements necessary to carry out the purpose and provisions of ss.
			 612.51,
			 612.52
			 and
			 612.54,
			 Stats.
(2) SCOPE. This rule shall
			 apply to all corporations organized or operating under ch. 612,
			 Stats.
(3) UNDERTAKING TO PAY
			 PREMIUMS AND ASSESSMENTS. The undertaking to pay premiums and assessments to be
			 signed by all prospective members shall be in form and substance substantially
			 as follows, and may be a part of the application:
UNDERTAKING TO PAY PREMIUMS AND ASSESSMENTS
I, of , in consideration of insurance on my buildings and
				personal property, insured to myself, my heirs and assigns by the Insurance
				Company, bind myself, and to the extent of their interest in the property my
				heirs and assigns, to pay to the company the premiums for such insurance and,
				within the period of time stated in the notice of assessment, my share of all
				legal assessments, if any, levied by the company, together with all legal costs
				and charges incurred in legal proceedings to collect any assessment levied upon
				me and statutory penalties for nonpayment, according to the statutes and the
				terms and conditions in the policy and any renewals thereof or of the insurance
				thereunder. My property covered by the insurance, both personal and real, shall
				be liable for that share, waiving all exemptions.
Dated this day of , 20
Witness
Agent
Applicants
(4) TOWN MUTUAL POLICY FORMS. Town mutual
			 policy forms shall conform to ss.
			 Ins
			 6.07 and
			 6.76, and shall include provisions
			 substantially as follows relating to articles of incorporation and bylaws and
			 notice of annual meeting:
(a)
ARTICLES OF INCORPORATION AND BYLAWS
It is hereby mutually understood and agreed by and between
				this company and the insured, that this policy is made and accepted with
				reference to the Articles of Incorporation and Bylaws, which are hereby
				declared to be part of this contract. This provision applies whether or not the
				Articles of Incorporation and Bylaws are included in this policy.
(b)
NOTICE
The insured is notified that by virtue of this Policy he or
				she is a member of the Insurance Company, of _________________, County,
				Wisconsin, and that the annual meetings of said company are held
				in_______________, County, Wisconsin, on the (date) in (month) of each year at
				_____o'clock__M.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 13 - Town Mutual Insurance › Section Ins 13.05 - Accounting records, accounting controls and reports

Current through June 24, 2024
(1) PURPOSE. This
			 rule is intended to implement and interpret s.
			 601.41,
			 Stats., for the purpose of setting minimum standards and techniques for
			 accounting and reporting of data relating to company financial transactions and
			 other operations.
(2) SCOPE. This
			 rule shall apply to all town mutual insurers organized or operating under ch.
			 612, Stats.
(3) ACCOUNTING RECORDS.
			 The following journals, ledgers and subsidiary records or similar records from
			 which the data indicated may be obtained shall be maintained:
(a) Policy Register: A register or other
			 records which shall contain the policy number, policyholder's name, effective
			 date of policy, term of policy, risk in force, amount of risk in force
			 reinsured, premium amount, policy fee, reinsurance premium, and provision for
			 miscellaneous data.
(b) Cash
			 Receipts Journal: A journal which shall contain the date, payor, amount
			 received, identification, and reference to the general ledger account and
			 amount affected. All cash received by the company shall be recorded in the
			 journal.
(c) Cash Disbursements
			 Journal: A journal which shall contain the date, payee, check number, amount of
			 check, and a reference to the general ledger account and amount affected. All
			 cash disbursed by the company shall be recorded in the journal.
(d) General Journal: A journal for recording
			 entries for all transactions affecting ledger items, which are not recorded in
			 the cash receipts journal or cash disbursements journal. The general journal
			 shall contain the date of the transaction, an explanation, the ledger account
			 affected, and the amount of the transaction.
(e) General Ledger: A ledger which shall have
			 an account for each asset and liability, surplus, income and expense items of
			 the company. Each account shall contain an account title and/or number, a date
			 for each transaction, a description, debit amounts, credit amounts and an
			 account balance.
(f) Loss Claim
			 Register: A register for recording all claims filed with the company. It shall
			 list all claims in claim number order and contain the claimant's and
			 policyholder's name, policy number, date of loss, date that loss was reported
			 to the company, cause of the loss, estimated amount of the loss, and the date
			 the claim was settled and the amount of loss payments, if any. Claims closed
			 without payment should be so noted.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 13 - Town Mutual Insurance › Section Ins 13.06 - Surplus requirements

Current through June 24, 2024
(1) PURPOSE. This rule implements and
			 interprets ss.
			 612.31 and
			 612.33, Stats., for
			 the purpose of setting minimum surplus requirements as a condition for the
			 transaction of specified types of business.
(2) SCOPE. This rule shall apply to all town
			 mutual insurers subject to ch. 612, Stats.
(3) NONPROPERTY INSURANCE.
(a) If a town mutual insurer retains any
			 portion of a risk covered by nonproperty insurance, the town mutual shall
			 obtain reinsurance on that nonproperty business with an insurer authorized to
			 do business in this state. The maximum aggregate liability for incurred losses
			 on nonproperty coverage retained by a town mutual insurer for any calendar year
			 or contract year may not exceed the lesser of $200,000 or 20% of its surplus as
			 of the preceding December 31.
(b) A
			 town mutual may retain nonproperty insurance coverage not to exceed a
			 proportional share of each limit of liability as shown in the following
			 schedule:
Surplus as of the Preceding December
							 31
Proportional Share of each Limit of Liability
							 Retained
$1,000,000 or greater
15%
$800,000 to $999,999
12%
$600,000 to $799,999
9%
$400,000 to $599,999
6%
$200,000 to $399,999
3%
Under $200,000
0%
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 13 - Town Mutual Insurance › Section Ins 13.08 - Valuation of liabilities

Current through June 24, 2024
(1) PURPOSE. This rule implements and interprets s. 623.04, Stats., for the
								 purpose of determining liabilities for financial statements filed with the commissioner.
(2) SCOPE. This rule shall apply to all town mutual insurers subject to ch.
								 612, Stats.
(3) UNEARNED PREMIUM RESERVE. The financial
								 statements of town mutuals which charge advance premiums shall show as a liability an unearned premium
								 reserve. The unearned premium reserve must be calculated on all advance premiums, on the original or
								 full-term premium basis, less advance premiums on risks assumed by other insurers under reinsurance contract.
								 The minimum unearned premium reserves shall be calculated on the premiums in force as follows:
(a) One year policies or policies on which premiums are paid annually.
1. 50% of the net advanced premium.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 13 - Town Mutual Insurance › Section Ins 13.09 - Reinsurance

Current through June 24, 2024
(1) PURPOSE. This rule implements and
			 interprets s.
			 612.33, Stats., for
			 the purpose of setting rules or guidelines for permitted and prohibited
			 reinsurance and required reinsurance.
(2) SCOPE. This rule shall apply to all town
			 mutual insurers subject to ch. 612, Stats.
(3) DEFINITIONS. For the purpose of this
			 section only:
(a) ``Maximum attachment point"
			 means the amount of losses, expressed as a percentage of net premiums written,
			 which constitutes the limit of the town mutual's retention under the aggregate
			 excess of loss reinsurance required by sub. (4).
(b) ``Net premiums written" means gross
			 premiums written less premiums ceded for reinsurance inuring to the benefit of
			 an aggregate excess of loss reinsurance contract. Reinsurance premiums ceded
			 for aggregate excess of loss reinsurance, reinsurance premiums paid or
			 recovered related to coverage for other years, and dividends paid to
			 policyholders shall not be considered in determining net premiums
			 written.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 14 - Vehicle Protection Product Warranties › Section Ins 14.01 - Purpose and scope

Current through June 24, 2024
(1) PURPOSE. This section interprets ss.
			 100.203,
			 600.01(1)
			 (b) 11., 601.31 (1) (km) and 632.185, Stats.
			 The commissioner finds that a warrantor issuing a vehicle protection product
			 warranty is doing the business of insurance, subject to full application of
			 chs. 600 to 646, Stats. If the warrantor issuing a vehicle protection product
			 warranty registers and complies with this rule and the applicable statutes,
			 only those sections of chs. 600 to 646, Stats., as expressly provided in the
			 enabling statutes will apply.
(2)
			 SCOPE.
(a) This chapter applies to all
			 vehicle protection product warranties operating or offering a vehicle
			 protection plan in this state.
(b)
			 This chapter does not apply to licensed insurers who operate or offer to
			 operate a vehicle protection plan pursuant to an authorization to transact
			 insurance in this state.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 14 - Vehicle Protection Product Warranties › Section Ins 14.10 - Initial registration

Current through June 24, 2024
A fee of $250 shall be paid to the Office of the Commissioner
				of Insurance at the time the initial warrantor registration form (OCI 21-050)
				is filed with the Office of the Commissioner of Insurance.
This form may be obtained at no charge from the Office of the
				  Commissioner of Insurance, P. O. Box 7873, Madison WI 53707-7873 or on the web
				  at
http://oci.wi.gov/ociforms/21-050.pdf
.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 14 - Vehicle Protection Product Warranties › Section Ins 14.20 - Annual renewal registration

Current through June 24, 2024
(1)The annual
			 warrantor renewal registration form (OCI 21-051) and an annual fee of $250
			 shall be filed and paid at the Office of the Commissioner of Insurance on or
			 before April 30 of each year.
(2)If
			 the renewal form and fee are not filed and paid on or before April 30, a late
			 filing fee of an $100 is due. For each consecutive 7 day period after April 30
			 that the form and fee are not filed or paid, an additional $100 is
			 due.
This form may be obtained at no charge from the Office of the
				  Commissioner of Insurance, P. O. Box 7873, Madison WI 537077873 or on the web
				  at http://oci.wi.gov.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 15 - Exemptions from application of insurance code › Section Ins 15.01 - Warranty plans

Current through June 24, 2024
(1) PURPOSE. This section interprets ss.
			 600.01(1)
			 (b) 5, 601.04(2), (3) and (4) and 600.03(25)
			 (a), Stats., by substituting requirements more specifically appropriate to the
			 characteristics of the business of the issuance of warranties in lieu of the
			 full application of chs. 600 to 646, Stats. The commissioner finds that the
			 making of a contract relating to repair, replacement or restoration to a
			 prescribed condition of any good, product or object is the transaction of
			 insurance, subject to full application of chs. 600 to 646, Stats., unless the
			 person making the contract submits to the jurisdiction of the commissioner and
			 to the provisions of this section.
(2) SCOPE.
(a) Subject to sub. (3), this section applies
			 to all warrantors operating or offering to operate a warranty plan in this
			 state.
(b) This section does not
			 apply to licensed insurers who operate or offer to operate a warranty plan
			 pursuant to an authorization to transact insurance in this state or who issue
			 mechanical breakdown coverage insurance policies in this state.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 16 - Regulatory Structures › Section Ins 16.01 - Annual billings for the examination of domestic insurers

Current through June 24, 2024
(1) PURPOSE. The
			 purpose of this section is to develop a framework for the regular annual
			 billing of domestic insurers, except for town mutuals and cooperative
			 associations organized under s.
			 185.981,
			 Stats., to fund the costs of administering examinations as prescribed by s.
			 601.44,
			 Stats., and to interpret and implement s.
			 601.45,
			 Stats.
(2) SCOPE. The billing
			 structure established by sub. (4) shall apply to all domestic insurers as
			 defined by s.
			 600.03(17),
			 Stats., with the exception of town mutuals and cooperative associations
			 organized under s.
			 185.981,
			 Stats.
(3) BILLING FOR EXAMINATION
			 CHARGES.
(a) On February 1, 1981, and
			 annually thereafter, each domestic insurer subject to the provisions of this
			 rule shall be billed an amount equivalent to such insurer's share of the
			 estimated cost of conducting the insurer examinations program during that
			 year.
(b) All other insurers and
			 licensees, including town mutual insurers and cooperative associations
			 organized under s.
			 185.981,
			 Stats., shall be billed on a charge-back basis for the full cost of their
			 examinations, including actual salaries and expenses of examinations and other
			 apportionable expenses.
(c)
			 Domestic insurers which request an examination, the end of the period of which
			 is to be within 3 years of the end of the period of the insurer's last
			 examination, shall be billed on a charge-back basis for the full cost of the
			 conduct of such an examination. This cost shall be in addition to the annual
			 billing of the insurer as determined by sub. (6) and is excluded from the
			 limitations established under sub. (7).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 17 - Health Care Liability Insurance Patients Compensation Fund › Section Ins 17.001 - Definitions

Current through June 24, 2024
In this chapter:
(1)
			 "Board" means the board of governors established under s.
			 619.04(3),
			 Stats.
(1m) "Commissioner" means
			 the commissioner of insurance or deputy commissioner acting under s.
			 601.11(1)
			 (b), Stats.
(2) "Fund" means the patients compensation
			 fund established under s.
			 655.27(1),
			 Stats.
(3) "Hearing" means a
			 contested case, as defined in s.
			 227.01(3),
			 Stats.
(4) "Plan" means the
			 Wisconsin health care liability insurance plan, a nonprofit, unincorporated
			 association established under s.
			 619.01(1)
			 (a), Stats.