609.10 Standard plan and point-of-service option plan required.

(1)

(ac) In this section, “point-of-service option plan" means a health maintenance organization or preferred provider plan that permits an enrollee to obtain covered health care services from a provider that is not a participating provider of the health maintenance organization or preferred provider plan under all of the following conditions:

1. The nonparticipating provider holds a license or certificate that authorizes or qualifies the provider to provide the health care services.

2. The health maintenance organization or preferred provider plan is required to pay the nonparticipating provider only the amount that the health maintenance organization or preferred provider plan would pay a participating provider for those health care services.

3. The enrollee is responsible for any additional costs or charges related to the coverage.

(am) Except as provided in subs. (2) to (4), an employer that offers any of its employees a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employees a standard plan that provides at least substantially equivalent coverage of health care expenses and a point-of-service option plan, as provided in pars. (b) and (c).

(b) At least once annually, the employer shall provide the employees the opportunity to enroll in the health care plans under par. (am).

(c) The employer shall provide the employees adequate notice of the opportunity to enroll in the health care plans under par. (am) and shall provide the employees complete and understandable information concerning the differences among the health maintenance organization or preferred provider plan, the standard plan and the point-of-service option plan.

(2) If, after providing an opportunity to enroll under sub. (1) (b) and the notice and information under sub. (1) (c), fewer than 25 employees indicate that they wish to enroll in the standard plan under sub. (1) (am), the employer need not offer the standard plan on that occasion.

(3) Subsection (1) does not apply to an employer that does any of the following:

(a) Employs fewer than 25 full-time employees.

(b) Offers its employees a health maintenance organization or a preferred provider plan only through an insurer that is a cooperative association organized under ss. 185.981 to 185.985 or only through an insurer that is restricted under s. 609.03 (3).

(4) Nothing in sub. (1) requires an employer to offer a particular health care plan to an employee if the health care plan determines that the employee does not meet reasonable medical underwriting standards of the health care plan.

(5) The commissioner may establish by rule standards in addition to any established under s. 609.20 for what constitutes adequate notice and complete and understandable information under sub. (1) (c).

(6) The commissioner shall promulgate rules necessary for the administration of the requirement to offer point-of-service option plans under sub. (1) (am).

History: 1985 a. 29; 1997 a. 237; 1999 a. 9; 2001 a. 16.