Common use of Commercial HMO Insurance Clause in Contracts

Commercial HMO Insurance. Members who have commercial HMO insurance may be eligible for an exemption from a BadgerCare Plus or Medicaid SSI HMO if the commercial HMO does not participate in BadgerCare Plus or Medicaid SSI. In addition, members who have commercial insurance that limits them to a restricted provider network (e.g., PPOs, PHOs, etc.) may be eligible for an exemption from enrollment in a BadgerCare Plus or Medicaid SSI HMO. The HMO may request assistance from the Department’s contracted Enrollment Specialist in situations where the member has commercial insurance that limits the members to providers outside the HMO’s network. When the Department’s member eligibility file indicates commercial HMO coverage limiting a member to providers outside the BadgerCare Plus and/or Medicaid SSI HMO network and the member seeks services from the BadgerCare Plus and/or Medicaid SSI HMO network providers, the BadgerCare Plus and/or Medicaid SSI HMO network providers may refuse to provide services to that member and refer him/her to their commercial network, except in the case of an emergency.