Section 609.91. Restrictions on recovering health care costs.

 

(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.

(d) The liability is for the portion of health care costs that exceeds the amount that the health maintenance organization insurer has agreed, in a contract with the provider of the health care, to pay the provider for that health care.

(1m)   Immunity of medical assistance recipients. An enrollee, policyholder or insured under a policy issued by an insurer to the department of health services under s. 49.45 (2) (b) 2. to provide prepaid health care to medical assistance recipients is not liable for health care costs that are covered under the policy.

(1p)   Immunity for certain medicare recipients. An enrollee, policyholder, or insured under a policy issued by an insurer under Part C of Medicare under 42 USC 1395w-21 to 1395w-28 or Part D of Medicare under 42 USC 1395w-101 to 1395w-152 to provide prepaid health care, fee-for-service health care, or drug benefits to enrollees of Part C or Part D of Medicare is not liable for health care costs that are covered under the policy.

(2)   Prohibited recovery attempts. No person may bill, charge, collect a deposit from, seek remuneration or compensation from, file or threaten to file with a credit reporting agency or have any recourse against an enrollee, policyholder or insured, or any person acting on their behalf, for health care costs for which the enrollee, policyholder or insured, or person acting on their behalf, is not liable under sub. (1) , (1m) , or (1p) .

(3)   Deductibles, copayments and premiums. Subsections (1) to (2) do not affect the liability of an enrollee, policyholder or insured for any deductibles, copayments or premiums owed under the policy or certificate issued by the health maintenance organization insurer or by the insurer described in sub. (1m) or (1p) .

(4)   Conditions not affecting the immunity. The immunity of an enrollee, policyholder or insured for health care costs, to the extent of the immunity provided under this section and ss. 609.92 to 609.935 , is not affected by any of the following:

(a) An agreement, other than a notice of election or termination of election in accordance with s. 609.92 or 609.925 , entered into by the provider, the health maintenance organization insurer, the insurer described in sub. (1m) or (1p) or any other person, at any time, whether oral or written and whether implied or explicit, including an agreement that purports to hold the enrollee, policyholder or insured liable for health care costs.

(b) A breach of or default on an agreement by the health maintenance organization insurer, the insurer described in sub. (1m) or (1p) or any other person to compensate the provider, directly or indirectly, for health care costs, including health care costs for which the enrollee, policyholder or insured is not liable under sub. (1) , (1m) , or (1p) .

(c) The insolvency of the health maintenance organization insurer or any person contracting with the health maintenance organization insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the health maintenance organization insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b) , under ch. 645 , despite whether the health maintenance organization insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee or policyholder is not liable under sub. (1) .

(cm) The insolvency of the insurer described in sub. (1m) or (1p) or any person contracting with the insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b) , under ch. 645 , despite whether the insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrollee, policyholder or insured is not liable under sub. (1m) or (1p) .

(d) The inability of the provider or other person who is owed compensation for health care costs to obtain compensation from the health maintenance organization insurer, the insurer described in sub. (1m) or (1p) , or any other person for health care costs for which the enrollee, policyholder or insured is not liable under sub. (1) , (1m) , or (1p) .

(e) The failure of a health maintenance organization insurer to comply with s. 609.94 .

(f) Any other conditions or agreements, other than a notice of election or termination of election in accordance with s. 609.92 or 609.925 , existing at any time.

1989 a. 23 ; 1995 a. 27 s. 9126 (19) ; 1997 a. 237 ; 2007 a. 20 s. 9121 (6) (a) ; 2009 a. 342 . 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. This section is replete with language immunizing enrollees and limiting their liability, but does not speak to the sources of funds available to HMOs, except to the extent that it limits funds HMOs may obtain from enrollees. Torres v. Dean Health Plan, Inc. 2005 WI App 89 , 282 Wis. 2d 725 , 698 N.W.2d 107 , 03-3274 .