Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 9 - Defined Network Plans
Subchapter II - Financial Standards for Health Maintenance Organizations or Limited Service Health Organizations
Section Ins 9.05 - Business plan

Universal Citation: WI Admin Code ยง Ins 9.05

Current through August 26, 2024

All applications for certificates of incorporation and certificates of authority of a health maintenance organization insurer or an insurer licensed to write only limited service health organization business shall include a proposed business plan. In addition to the items listed in ss. 611.13(2) and 613.13(1), Stats., the following information shall be contained in the business plan:

(1) ORGANIZATION TYPE.

(a) The type of health maintenance organization insurer, including whether the providers affiliated with the organization will be salaried employees, group contractors, or individual contractors.

(b) The type of limited service health organization insurer including:
1. The name and address of the insurer licensed to write only limited service health organization business and the names and addresses of individual providers, if any, who control the insurer licensed to write only limited service health organization business, and;

2. The type of organization, including information on whether providers will be salaried employees of the organization or individual or group contractors.

(2) FEASIBILITY STUDIES AND MARKETING SURVEYS. A summary of feasibility studies or marketing surveys that support the financial and enrollment projections for the health maintenance organization insurer or the insurer licensed to write only limited service health organization business. The summary shall include the potential number of enrollees in the operating territory, the projected number of enrollees for the first 5 years, the underwriting standards to be applied, and the method of marketing the organization.

(3) GEOGRAPHICAL SERVICE AREA. The geographical service area by county including a chart showing the number of primary and specialty care providers with locations and service areas by county; the method of handling emergency care, with locations of emergency care facilities; and the method of handling out-of-area services.

(4) PROVIDER AGREEMENTS. The extent to which any of the following will be included in provider agreements and the form of any provisions that do any of the following:

(a) Limit the providers' ability to seek reimbursement for covered services from policyholders or enrollees.

(b) Permit or require the provider to assume a financial risk in the health maintenance organization insurer, including any provisions for assessing the provider, adjusting capitation or fee-for-service rates, or sharing in the earnings or losses.

(c) Govern amending or terminating agreements with providers.

(5) PROVIDER AVAILABILITY. A description of how services will be provided to policyholders in each service area, including the extent to which primary care will be given by providers under contract with the health maintenance organization insurer.

(6) QUALITY ASSURANCE. A summary of comprehensive quality assurance standards that identify, evaluate and remedy problems related to access to care and continuity and quality of care. The summary shall address all of the following:

(a) A written internal quality assurance program.

(b) Written guidelines for quality of care studies and monitoring.

(c) Performance and clinical outcomes-based criteria.

(d) Procedures for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

(e) Plans for gathering and assessing data.

(f) A peer review process.

(g) A process to inform enrollees on the results of the insurer's quality assurance program.

(h) Any additional information requested by the commissioner.

(7) PLAN ADMINISTRATION. A summary of how administrative services will be provided, including the size and qualifications of the administrative staff and the projected cost of administration in relation to premium income. If management authority for a major corporate function is delegated to a person outside the organization, the business plan shall include a copy of the contract. Contracts for delegated management authority shall be filed for approval with the commissioner under ss. 611.67 and 618.22, Stats. The contract shall include all of the following:

(a) The services to be provided.

(b) The standards of performance for the manager.

(c) The method of payment including, any provisions for the administrator to participate in the profit or losses of the plan.

(d) The duration of the contract.

(e) Any provisions for modifying, terminating or renewing the contract.

(8) FINANCIAL PROJECTIONS. A summary of: current and projected enrollment; income from premiums by type of payor; other income; administrative and other costs; the projected break even point, including the method of funding the accumulated losses until the break even point is reached; and a summary of the assumptions made in developing projected operating results.

(9) FINANCIAL GUARANTEES. A summary of all financial guarantees by providers, sponsors, affiliates or parents within a holding company system, or any other guarantees which are intended to ensure the financial success of the health maintenance organization insurer. These include hold harmless agreements by providers, insolvency insurance, reinsurance or other guarantees.

(10) CONTRACTS WITH ENROLLEES. A summary of benefits to be offered enrollees including any limitations and exclusions and the renewability of all contracts to be written.

Disclaimer: These regulations may not be the most recent version. Wisconsin may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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