MANDATORY FOR HOLD HARMLESS Clause Samples

MANDATORY FOR HOLD HARMLESS. An enrollee of an HMO insurer is not liable to a health care provider for health care costs that are covered under a policy issued by that HMO insurer if any of the following are met: 1. Care is provided by a provider who is an affiliate of the HMO insurer, owns at least 5% of the voting securities of the HMO insurer, is directly or indirectly involved with the HMO insurer through direct or indirect selection of or representation by one or more board members, or is an Individual Practice Association (“IPA”) and is represented, or an affiliate is represented, by one of at least three HMO insurer board members who directly or indirectly represent one or more IPAs or affiliates of IPAs. 2. Care is provided by a provider under a contract with or through membership in an organization identified in 1. 3. To the extent the charge exceeds the amount the HMO insurer has contractually agreed to pay the provider for that health care service. 4. The care is provided to an enrolled medical assistance recipient under a Department of Health and Family Services prepaid health care policy. 5. The care is required to be provided under the requirements of s. Ins. 9.35, Wis. Adm. Code.