Wisconsin Statutes & Annotations
Chapter 609 - Defined network plans.
609.01 - Definitions.

609.01 Definitions. In this chapter:
(1b) “Defined network plan" means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with, or employed by the insurer offering the health benefit plan.
(1c) “Emergency medical condition" has the meaning given in s. 632.85 (1) (a).
(1d) “Enrollee" means, with respect to a defined network plan, preferred provider plan, or limited service health organization, a person who is entitled to receive health care services under the plan.
(1g)
(a) Except as provided in par. (b), “health benefit plan" means any hospital or medical policy or certificate.
(b) “Health benefit plan" does not include any of the following:
1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.
2. Coverage issued as a supplement to liability insurance.
3. Liability insurance, including general liability insurance and automobile liability insurance.
4. Worker's compensation or similar insurance.
5. Automobile medical payment insurance.
6. Credit-only insurance.
7. Coverage for on-site medical clinics.
8. Other similar insurance coverage, as specified in regulations issued by the federal department of health and human services, under which benefits for medical care are secondary or incidental to other insurance benefits.
9. If provided under a separate policy, certificate or contract of insurance, or if otherwise not an integral part of the policy, certificate or contract of insurance: limited-scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those benefits; and such other similar, limited benefits as are specified in regulations issued by the federal department of health and human services under section 2791 of P.L. 104-191.
10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply:
a. The benefits are provided under a separate policy, certificate or contract of insurance.
b. There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.
c. Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.
11. Other insurance exempted by rule of the commissioner.
(1j) “Health care costs" means consideration for the provision of health care, including consideration for services, equipment, supplies and drugs.
(1m) “Health care plan" has the meaning given under s. 628.36 (2) (a) 1.
(2) “Health maintenance organization" means a health care plan offered by an organization established under ch. 185 or 193, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers participating in the plan.
(3) “Limited service health organization" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers participating in the plan.
(3m) “Participating" means, with respect to a physician or other provider, under contract with a defined network plan, preferred provider plan, or limited service health organization to provide health care services, items or supplies to enrollees of the defined network plan, preferred provider plan, or limited service health organization.
(3r) “Physician" has the meaning given in s. 448.01 (5).
(4) “Preferred provider plan" means a health care plan offered by an organization established under ch. 185, 193, 611, 613, or 614 or issued a certificate of authority under ch. 618 that makes available to its enrollees, without referral and for consideration other than predetermined periodic fixed payments, coverage of either comprehensive health care services or a limited range of health care services, regardless of whether the health care services are performed by participating or nonparticipating providers.
(4m) “Primary care physician" means a physician specializing in family medical practice, general internal medicine or pediatrics.
(5) “Primary provider" means a participating primary care physician, or other participating provider authorized by the defined network plan, preferred provider plan, or limited service health organization to serve as a primary provider, who coordinates and may provide ongoing care to an enrollee.
(5m) “Provider" means a health care professional, a health care facility or a health care service or organization.
(7) “Standard plan" means a health care plan other than a health maintenance organization or a preferred provider plan.
History: 1985 a. 29; 1989 a. 23; 1997 a. 237; 2001 a. 16; 2005 a. 441 ss. 107, 108; 2007 a. 96.
Under this section, an HMO enrollee has no personal liability for the costs of covered health care received. A hospital only has recourse against the HMO and may not assert its lien rights under this section against insurance proceeds paid by a tortfeasor's insurer to the HMO enrollee. Dorr v. Sacred Heart Hospital, 228 Wis. 2d 425, 597 N.W.2d 462 (Ct. App. 1999), 98-1772.
Sections 609.01 and 609.91 do not prohibit HMOs from asserting contractual subrogation rights with respect to actual medical expenses incurred by an HMO for medical care covered by the HMO's contract with an enrollee. Sub. (2) says that an HMO is an entity that makes available to its enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services but does not put in place a general limitation on all sources of funds available to HMOs. Torres v. Dean Health Plan, Inc. 2005 WI App 89, 282 Wis. 2d 725, 698 N.W.2d 107, 03-3274.

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