(1) REQUIREMENT TO PROVIDE ACCESS. (a) Subject to pars. (b) and (c) and except as provided in par. (d), a defined network plan shall, with respect to covered benefits, provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the defined network plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times: 1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period. 2. If the plan under which the enrollee has coverage has no open enrollment period, the time of the enrollee’s enrollment or most recent coverage renewal, whichever is later. (b) Except as provided in par. (d), a defined network plan shall provide the coverage required under par. (a) with respect to the services of a provider who is a primary care physician for the following period of time: 1. For an enrollee of a plan with no open enrollment period, until the end of the current plan year. 2. For an enrollee of a plan with an open enrollment period, until the end of the plan year for which it was represented that the provider was, or would be, a participating provider. (c) Except as provided in par. (d), if an enrollee is undergoing a course of treatment with a participating provider who is not a primary care physician and whose participation with the plan terminates, the defined network plan shall provide the coverage under par. (a) with respect to the services of the provider for the following period of time: 1. Except as provided in subd. 2., for the remainder of the course of treatment or for 90 days after the provider’s participation with the plan terminates, whichever is shorter, except that the coverage is not required to extend beyond the period specified in par. (b) 1. or 2., whichever applies. 2. If maternity care is the course of treatment and the enrollee is a woman who is in the 2nd or 3rd trimester of pregnancy when the provider’s participation with the plan terminates, until the completion of postpartum care for the woman and infant. (d) The coverage required under this section need not be provided or may be discontinued if any of the following applies: 1. The provider no longer practices in the defined network plan’s geographic service area. 2. The insurer issuing the defined network plan terminates or terminated the provider’s contract for misconduct on the part of the provider. (e) 1. An insurer issuing a defined network plan shall include in its provider contracts provisions addressing reimbursement to providers for services rendered under this section. 2. If a contract between a defined network plan and a provider does not address reimbursement for services rendered under this section, the insurer shall reimburse the provider according to the most recent contracted rate. (2) MEDICAL NECESSITY PROVISIONS. This section does not preclude the application of any provisions related to medical necessity that are generally applicable under the plan. (3) HOLD HARMLESS REQUIREMENTS. A provider that receives or is due reimbursement for services provided to an enrollee under this section is subject to s. 609.91 with respect to the enrollee, regardless of whether the provider is a participating provider in the enrollee’s plan and regardless of whether the enrollee’s plan is a health maintenance organization. (4) NOTICE OF PROVISIONS. A defined network plan shall notify all plan enrollees of the provisions under this section whenever a participating provider’s participation with the plan terminates, or shall, by contract, require a participating provider to notify all plan enrollees of the provisions under this section if the participating provider’s participation with the plan terminates.
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