609.91 Restrictions on recovering health care costs.

431 words·~2 min read·/wi/chapter-609/609-91-5

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(1)Immunity of enrollees and policyholders. Except as provided in sub.

(1m)or

(1p), an enrollee or policyholder of a health maintenance organization insurer is not liable for health care costs that are incurred on or after January 1, 1990, and that are covered under a policy or certificate issued by the health maintenance organization insurer, if any of the following applies:

(a)The health care is provided by a provider who satisfies any of the following:

1. Is an affiliate of the health maintenance organization insurer.

2. Owns at least 5 percent of the voting securities of the health maintenance organization insurer.

3. Is entitled, alone or with one or more affiliates, to solely select one or more board members of the health maintenance organization insurer, or has an affiliate that is entitled to solely select one or more board members of the health maintenance organization insurer.

4. Is entitled to have one or more board members of the health maintenance organization insurer serve exclusively as a representative of the provider, one or more of the provider’s affiliates or the provider and its affiliates, except this subdivision does not apply to an individual practice association or an affiliate of an individual practice association.

5. Is an individual practice association that is represented, or its affiliate is represented, on the board of the health maintenance organization insurer, and at least 3 of the board members of the health maintenance organization represent one or more individual practice associations.

(am)The health care is provided by a provider under a contract with, or through membership in, a person who satisfies par.

(a)1. , 2. , 3. , 4. or 5.

(b)The health care is provided by a provider who is not subject to par.

(a)or

(am)and who does not elect to be exempt from this paragraph under s. 609.92 , and the health care satisfies any of the following:

1. Is provided by a hospital or an individual practice association.

2. Is physician services provided under a contract with the health maintenance organization insurer or by a participating provider of the health maintenance organization insurer.

3. Is services, equipment, supplies or drugs that are ancillary or incidental to services described in subd. 2. and are provided by the contracting provider or participating provider.

(c)The health care is provided by a provider who is not subject to par.

(a),

(am)or

(b)with regard to that health care and who elects under s. 609.925 to be subject to this paragraph.