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Statutes > Wyoming > Title26 > Chapter19

CHAPTER 19 - GROUP AND BLANKET DISABILITY INSURANCE

ARTICLE 1 - IN GENERAL

26-19-101. Scope and applicability of article; short title.

(a) This article applies only to group disability and blanketdisability insurance contracts.

(b) This article may be cited as the "Group and BlanketDisability Insurance Law".

(c) This article does not apply to any contract made or issuedprior to January 1, 1968, nor to any extensions, renewals, reinstatements ormodifications of or amendments to any contract whenever made.

26-19-102. "Group disability insurance" defined; eligiblegroups.

(a) "Group disability insurance" means that form ofdisability insurance covering groups of persons as described in this sectionand W.S. 26-19-110, with or without one (1) or more members of their familiesor one (1) or more of their dependents, or covering one (1) or more members ofthe families or one (1) or more dependents of the groups of persons. Except asprovided in W.S. 26-19-110, a group disability insurance policy shall not beissued for delivery in this state unless the policy is issued to:

(i) An employer or trustees of a fund established or adopted byan employer, which employer or trustee is deemed the policyholder, insuring theemployer's employees for the benefit of persons other than the employer,subject to the following requirements:

(A) All employees or any class of employees are eligible forinsurance under the terms of the policy;

(B) The policy may define "employees" to include:

(I) The officers, managers and employees of the employer;

(II) The individual proprietor or partner if the employer is anindividual proprietor or partnership;

(III) The officers, managers and employees of subsidiary oraffiliated corporations;

(IV) The individual proprietors, partners and employees ofindividuals and firms, if the business of the employer and the individual orfirm is under common control through stock ownership, contract, or otherwise;

(V) Retired employees;

(VI) Former employees;

(VII) Directors of a corporate employer;

(VIII) Elected or appointed officials;

(IX) The trustees, their employees, or both, if their duties areprincipally connected with the trusteeship.

(C) If the insured employee does not pay any part of thepremium for his insurance, the policy shall insure all eligible employees,except those who reject the coverage in writing.

(ii) An association, or a trust or the trustee of a fundestablished or adopted for the benefit of members of one (1) or moreassociations. The association shall have at the time the policy is first issueda minimum of fifty (50) persons eligible for insurance, shall have aconstitution and bylaws which provide that the association holds regularmeetings not less than annually to further the members' purposes, that theassociation, except for credit unions, collects dues or solicits contributionsfrom members, and that the members have voting privileges and representation onthe governing board and committees. Prior to marketing or offering any groupdisability insurance to an association formed for the sole purpose of obtaininginsurance, the producer shall file a written report with the department settingforth the name of the association, the insurer and its address and the offeringproducer and his address. The department shall keep the name of the associationconfidential. The provisions of the Small Employer Health InsuranceAvailability Act, W.S. 26-19-301 et seq., shall apply to all insurance issuedto an association under this section. The policy is subject to the followingrequirements:

(A) The policy may insure one (1) or more of the following orall of any class of the following for the benefit of persons other than theemployee's employer:

(I) Members of the association;

(II) Employees of the association; or

(III) Employees of members.

(B) If the covered person does not pay any part of the premiumfor his insurance, the policy shall insure all eligible persons, except thosewho reject the coverage in writing.

(iii) A trust or the trustees of a fund established or adoptedby two (2) or more employers, by one (1) or more labor unions or similaremployee organizations, or by one (1) or more employers and one (1) or morelabor unions or similar employee organizations, which trust or trustees aredeemed the policyholder, to insure employees of the employers or members of theunion or organization for the benefit of persons other than the employers,unions or organizations, subject to the following requirements:

(A) All employees of the employers, members of the unions ororganizations or any class of the employers, union members or organizationmembers are eligible for insurance under the terms of the policy;

(B) The policy may provide that the term "employees"shall include:

(I) The employees of one (1) or more subsidiary corporationsand the employees, individual proprietors and partners of one (1) or moreaffiliated corporations, proprietorships or partnerships if the business of theemployer and of the affiliated corporations, proprietorships or partnerships isunder common control;

(II) Retired or former employees;

(III) Directors of a corporate employer;

(IV) The trustees, trustees' employees, or both, if their dutiesare principally connected with the trusteeship.

(C) If the insured person does not pay any part of the premiumfor his insurance, the policy shall insure all eligible persons, except thosewho reject such coverage in writing.

(iv) Under a policy issued to any person or organization towhich a policy of group life insurance may be issued or delivered in this stateto insure any class or classes of individuals that could be insured under thegroup life policy;

(v) Repealed by Laws 1990, ch. 5, 3.

(vi) A creditor, a creditor's parent holding company or atrustee or agent designated by two (2) or more creditors, which creditor,holding company, affiliate, trustee or agent is deemed the policyholder, toinsure debtors of the creditor concerning their indebtedness, subject to thefollowing requirements:

(A) All debtors or any class of debtors of the creditor areeligible for insurance under the terms of the policy;

(B) The policy may provide that the term "debtors"shall include:

(I) Borrowers of money or purchasers or lessees of goods,services or property for which payment is arranged through a credittransaction;

(II) The debtors of one (1) or more subsidiary corporations; and

(III) The debtors of one (1) or more affiliated corporations,proprietorships or partnerships if the business of the policyholder and of theaffiliated corporations, proprietorships or partnerships is under commoncontrol.

(C) If the insured debtor does not pay any part of the premiumfor his insurance, the policy shall insure all eligible debtors;

(D) The total amount of insurance payable for an indebtednessshall not exceed the greater of the scheduled or actual amount of unpaidindebtedness to the creditor. The insurer may exclude any payments which aredelinquent on the date the debtor is disabled as defined in the policy;

(E) The insurance may be payable to the creditor or anysuccessor to the right, title and interest of the creditor. The payment shallreduce or extinguish the unpaid indebtedness of the debtor to the extent of thepayment and any excess of the insurance is payable to the insured or the estateof the insured;

(F) Notwithstanding subparagraphs (A) through (D) of thisparagraph, insurance on agricultural credit transaction commitments may bewritten up to the amount of the loan commitment. Insurance on educationalcredit transaction commitments may be written up to the amount of the loancommitment less the amount of any repayments made on the loan.

(vii) A credit union or a trustee or agent designated by two (2)or more credit unions, which credit union, trustee or agent is deemed thepolicyholder, to insure members of the credit union for the benefit of personsother than the credit union, trustee, agent or any of their officials, subjectto the following requirements:

(A) All members or all of any class of members of the creditunion are eligible for insurance under the terms of the policy;

(B) Policy premiums shall be paid by the policyholder from thecredit union's funds and shall insure all eligible members.

(viii) A labor union or similar employee organization which unionor organization is deemed the policyholder, to insure members of the union ororganization for the benefit of persons other than the union or organization orany of its officials, representatives or agents, subject to the followingrequirements:

(A) All members or any class of members of the union ororganization are eligible for insurance under the terms of the policy;

(B) If the insured member does not pay any part of the premiumfor his insurance, the policy shall insure all eligible members, except thosewho reject such coverage in writing.

26-19-103. Repealed by Laws 1990, ch. 5, 3.

26-19-104. Repealed by Laws 1990, ch. 5, 3.

26-19-105. Readjustment of premiums; dividends.

Anygroup disability insurance contract may provide for the readjustment of therate of premium based upon the experience under the contract. If a policydividend is declared or a reduction in rate is made or continued for the firstor any subsequent year of insurance under any group disability insurance policyissued to any policyholder, the excess, if any, of the aggregate dividends orrate reductions under the policy and all other group insurance policies of thepolicyholder over the aggregate expenditure for insurance under those policiesmade from funds contributed by the policyholder, or by an employer of insuredpersons, or by a union or association to which the insured persons belong, includingexpenditures made in connection with administration of the policies, shall beapplied by the policyholder for the sole benefit of insured employees ormembers.

26-19-106. Blanket disability insurance; defined.

(a) Blanket disability insurance is that form of disabilityinsurance covering groups of persons under a policy or contract issued to:

(i) Any common carrier or to any operator, owner or lessee of ameans of transportation, who is deemed the policyholder, covering a group ofpersons who may become passengers as defined by reference to their travelstatus on the common carrier or the means of transportation;

(ii) An employer, who is deemed the policyholder, covering anygroup of employees, dependents or guests, defined by reference to specifiedhazards incident to an activity or activities or operations of thepolicyholder;

(iii) A college, school or other institution of learning, aschool district or school jurisdictional unit, or to the head, principal orgoverning board of any educational unit, who is deemed the policyholder,covering students, teachers or employees;

(iv) Any religious, charitable, recreational, educational orcivic organization, or branch thereof, which is deemed the policyholder,covering any group of members or participants defined by reference to specifiedhazards incident to an activity or operations sponsored or supervised by thepolicyholder;

(v) A sports team, camp or sponsor thereof, which is deemed thepolicyholder, covering members, campers, employees, officials or supervisors;

(vi) Any volunteer fire department, first aid, civil defense orother similar volunteer organization, which is deemed the policyholder,covering any group of members or participants defined by reference to specifiedhazards incident to an activity or operations sponsored or supervised by thepolicyholder;

(vii) A newspaper or other publisher, which is deemed thepolicyholder, covering its carriers;

(viii) An association, including a labor union, which has aconstitution and bylaws and which is deemed the policyholder, covering anygroup of members or participants defined by reference to specified hazardsincident to an activity or operations sponsored or supervised by thepolicyholder. Prior to marketing or offering any blanket disability insuranceto an association, including a labor union, formed for the sole purpose ofobtaining insurance, the producer shall file a written report with thedepartment setting forth the name of the association, the insurer and itsaddress and the offering producer and his address. The department shall keepthe name of the association confidential. The provisions of the Small EmployerHealth Insurance Availability Act, W.S. 26-19-301 et seq., shall apply to allinsurance issued to an association under this section;

(ix) Cover any other risk or class of risks which, in thecommissioner's discretion, may be properly eligible for blanket disabilityinsurance. The commissioner's discretion may be exercised on an individual riskbasis or class of risks, or both.

26-19-107. Group disability and blanket insurance standard provisions;exceptions.

(a) A policy of group disability or blanket disabilityinsurance shall not be delivered in this state unless it contains in substancethe following provisions or provisions which in the commissioner's opinion aremore favorable to the persons insured or at least as favorable to the personsinsured and more favorable to the policyholder:

(i) The policy, including endorsements and a copy of theapplication, if any, of the policyholder and the persons insured constitutesthe entire contract between the parties;

(ii) Written notice of a claim shall be given to the insurerwithin twenty (20) days after the occurrence or commencement of any losscovered by the policy. Failure to give notice within the time provided by thisparagraph shall not invalidate nor reduce any claim if it is shown it was notreasonably possible to give notice and that notice was given as soon as wasreasonably possible;

(iii) The insurer shall furnish either to the person making aclaim or to the policyholder for delivery to the person making a claim theforms it usually furnishes for filing proof of loss. If the forms are notfurnished before the expiration of fifteen (15) days after giving of the noticespecified in paragraph (ii) of this subsection, the person making the claim isdeemed to have complied with the requirements of the policy as to proof of lossupon submitting, within the time fixed in the policy for filing proof of loss,written proof covering the occurrence, the character and the extent of the lossfor which claim is made;

(iv) In the case of claim for loss of time for disability,written proof of the loss shall be furnished to the insurer within ninety (90)days after the commencement of the period for which the insurer is liable.Subsequent written proofs of the continuance of the disability shall befurnished to the insurer at any intervals the insurer reasonably requires. Inthe case of claim for any other loss, written proof of the loss shall befurnished to the insurer within ninety (90) days after the date of the loss.Failure to furnish proof within the time provided by this paragraph shall notinvalidate nor reduce any claim if it is shown it was not reasonably possibleto furnish proof and that proof was furnished as soon as was reasonablypossible;

(v) Any benefits payable under the policy are payable asfollows:

(A) Benefits other than benefits for loss of time are payablenot more than forty-five (45) days after receipt of written proof of the lossand supporting evidence;

(B) Subject to proof of loss and supporting evidence, allaccrued benefits payable under a policy for loss of time are payable not lessfrequently than monthly during the continuance of the disability period forwhich the insurer is liable, and any balance remaining unpaid at thetermination of the disability period is payable immediately upon receipt ofproof and supporting evidence.

(vi) The insurer, at its own expense, may:

(A) Examine the person of the insured when and as often as itreasonably requires during the pendency of claim under the policy; and

(B) Make an autopsy if it is not prohibited by law.

(vii) No action at law or in equity shall be brought to recoverunder the policy prior to the expiration of sixty (60) days after written proofof loss is furnished in accordance with the requirements of the policy and noaction shall be brought upon the expiration of three (3) years after the timewritten proof of loss is required to be furnished;

(viii) The policyholder is entitled to a grace period ofthirty-one (31) days for the payment of any premium due except the first, andduring the grace period the policy shall continue in force unless the policyholdergave the insurer written notice of discontinuance in advance of the date ofdiscontinuance and in accordance with the terms of the policy. The policy mayprovide that the policyholder is liable to the insurer for the payment of a prorata premium for the time the policy was in force during the grace periodprovided by this paragraph;

(ix) The validity of the policy shall not be contested exceptfor nonpayment of premiums after it has been in force for two (2) years fromthe date of issue, and no statement made by any person covered under the policyrelating to insurability shall be used in contesting the validity of theinsurance with respect to which the statement was made after the insurance hasbeen in force prior to the contest for a period of two (2) years during theperson's lifetime unless the statement is contained in a written instrumentsigned by the person making the statement;

(x) A copy of the application, if any, of the policyholdershall be attached to the policy when issued. All statements made by thepolicyholder or by the persons insured are deemed representations and notwarranties. No statement made by any person insured shall be used in anycontest unless a copy of the instrument containing the statement is or has beenfurnished to the person or, in the event of the death or incapacity of theinsured person, to the individual's beneficiary or personal representative;

(xi) The additional exclusions or limitations, if any,applicable under the policy concerning a disease or physical condition of aperson, not otherwise excluded from the person's coverage by name or specificdescription effective on the date of the person's loss, which existed prior tothe effective date of the person's coverage under the policy shall be specified. The exclusion or limitation shall not exclude coverage for a period beyondtwelve (12) months following the individual's effective date of coverage andshall only relate to conditions for which medical advice, diagnosis, care ortreatment was recommended or received during the six (6) months immediatelypreceding the effective date of coverage. In determining whether a preexistingcondition provision applies to an insured or dependent, all private or publichealth benefit plans shall credit the time the person was previously covered bya private or public health benefit plan if the previous coverage was continuousto a date not more than ninety (90) days prior to the effective date of the newcoverage exclusive of any applicable waiting period. In the case of apreexisting conditions limitation allowable in the succeeding carrier's plan,the level of benefits applicable to preexisting conditions of persons becomingcovered by the succeeding carrier's plan during the period of time thislimitation applies under the new plan shall be the lesser of:

(A) The benefits of the new plan determined without applicationof the preexisting conditions limitation; or

(B) The benefits of the prior plan.

(xii) If the premiums or benefits vary by age, a provision shallspecify an equitable adjustment of premiums, benefits, or both, to be made ifthe age of a covered person has been misstated and containing a clear statementof the method of adjustment to be used;

(xiii) The insurer shall issue to the policyholder for delivery toeach person insured a certificate containing a statement of the insuranceprotection to which that person is entitled, to whom the insurance benefits arepayable and of any family member's or dependent's coverage;

(xiv) Benefits for loss of life of the person insured are payableto the beneficiary designated by the person insured or if the policy containsconditions pertaining to family status the beneficiary may be the family memberspecified by the policy terms. Payment of benefits for loss of life of theperson insured is subject to the provisions of the policy in the event nodesignated or specified beneficiary is living at the death of the personinsured. All other benefits of the policy are payable to the person insured. The policy may provide that if any benefit is payable to the estate of a personor to a person who is a minor or otherwise not competent to give a validrelease, the insurer may pay the benefit, up to an amount not exceeding fivethousand dollars ($5,000.00), to any relative by blood, marriage or adoption ofthe person deemed by the insurer to be equitably entitled to the benefits;

(xv) For a policy insuring debtors, the insurer shall furnishthe policyholder for delivery to each debtor insured under the policy acertificate of insurance describing the coverage and specifying that thebenefits payable shall first be applied to reduce or extinguish theindebtedness;

(xvi) Repealed By Laws 1997, ch. 120, 2.

(xvii) If issued or delivered on or after January 1, 1999, thepolicy shall provide a notice on the face of the policy of not less thanfourteen (14) point bold type, as to the extent to which the policy includescomprehensive adult wellness benefits as defined in subsection (h) of thissection. To insure that the disclosure has been made, the notice shall includespace for the signature of the policyholder and the sales representative on thedisclosure statement. The disclosure statement must be signed by the applicantand sales representative at the time of the policy application. No policy shallbe represented as containing comprehensive adult wellness benefits unless thepolicy meets the criteria specified under subsection (h) of this section. Ifcoverage is included, the notice shall make reference to the exact locationwithin the policy where the level and extent of coverage is described indetail. If coverage is not included, the notice shall state that the policydoes not contain comprehensive adult wellness benefits as defined by law. Thisstatement shall also be placed in a prominent location on any materials used inrepresenting the policy, including sales materials. The department of insuranceshall prescribe the form and content of the notice required under thisparagraph. This paragraph does not apply to any policy with a deductible offive thousand dollars ($5,000.00) or more.

(b) W.S. 26-19-107(a)(xi), (xiii) and (xiv) shall not apply topolicies insuring debtors.

(c) The standard provisions for individual disability insurancepolicies shall not apply to group disability insurance policies.

(d) If any provision of this section is entirely or partiallyinapplicable to or inconsistent with the coverage provided by a particular formof policy, the insurer with the approval of the commissioner shall omit fromthe policy any inapplicable provision or part of a provision and shall modifyany inconsistent provision or part of the provision to conform the policyprovision with the coverage provided by the policy.

(e) Repealed By Laws 1997, ch. 120, 2.

(f) No policy of group or blanket disability insurance shalltreat the following as a preexisting condition:

(i) Pregnancy existing on the effective date of coverage;

(ii) Genetic information, in the absence of a diagnosis of acondition related to the genetic information.

(g) A policy of group or blanket disability insurance shall notestablish rules for eligibility, including continued eligibility, of anyindividual to enroll under the policy based on any of the following health statusrelated factors in relation to the employee or an eligible dependent:

(i) Health status;

(ii) Medical condition, including both physical and mentalillness;

(iii) Claims experience;

(iv) Receipt of health care;

(v) Medical history;

(vi) Genetic information;

(vii) Evidence of insurability, including conditions arising outof acts of domestic violence;

(viii) Disability.

(h) As used in paragraph (a)(xvii) of this section,"comprehensive adult wellness benefits" means benefits not subject topolicy deductibles, which provide a minimum benefit equal to eighty percent(80%) of the reimbursement allowance under the private health benefit plan witha maximum of twenty percent (20%) coinsurance by the insured and which providea benefit structure to the insured equal to a minimum of one hundred fiftydollars ($150.00) per insured adult per calendar year, or a benefit structureof similar actuarial value to the insured. In addition, the benefits shall atminimum provide for testing procedures and for the examination of adultpolicyholders and their spouses for breast cancer, prostate cancer, cervicalcancer and diabetes.

(j) All group and blanket disability insurance policiesproviding coverage on an expense incurred basis, group service or indemnitytype contracts issued by a nonprofit corporation, group service contractsissued by a health maintenance organization, all self-insured grouparrangements to the extent not preempted by federal law and all managed healthcare delivery entities of any type or description, that are delivered, issuedfor delivery, continued or renewed on or after July 1, 2001, and providingcoverage to any resident of this state shall provide benefits or coverage for:

(i) A pelvic examination and pap smear for any nonsymptomaticwomen covered under the policy or contract;

(ii) A colorectal cancer examination and laboratory tests forcancer for any nonsymptomatic person covered under the policy or contract;

(iii) A prostate examination and laboratory tests for cancer forany nonsymptomatic man covered under the policy or contract; and

(iv) A breast cancer examination including a screening mammogramand clinical breast examination for any nonsymptomatic person covered under thepolicy or contract.

(k) To encourage public health and diagnostic healthscreenings, the services covered under subsection (j) of this section shall beprovided with no deductible due and payable. A health plan shall, at a minimum,be liable for eighty percent (80%) of the reimbursement allowance of the healthplan up to a maximum of two hundred fifty dollars ($250.00) per adult insuredper year. A patient shall be liable for coinsurance up to twenty percent (20%)if such coinsurance is required pursuant to the patient's health care coverage.Coverage may be in addition to any other preventive care services. Thissubsection shall apply to private health benefit plans as defined by W.S.26-1-102(a)(xxxiii) except that it shall not apply to high deductible policieswhere the deductible equals or exceeds one thousand dollars ($1,000.00) perperson or per family per year or policies qualifying as federal medical savingsaccounts.

(m) In addition to the prohibitions on the use of geneticinformation provided in paragraph (g)(vi) of this section, an insurer offeringa policy of group or blanket disability insurance shall not, based on thegenetic testing information of an individual or a family member of anindividual:

(i) Deny eligibility;

(ii) Adjust premium rates;

(iii) Adjust contribution rates;

(iv) Request or require predictive genetic testing informationconcerning an individual or a family member of the individual, except theinsurer may request, but not require, predictive genetic testing information ifneeded for diagnosis, treatment or payment. As part of a request under thisparagraph, the plan or issuer shall provide a description of the procedures inplace to safeguard confidentiality of the information.

26-19-108. Group disability and blanket insurance standard provisions;application and certificate need not be furnished.

Anindividual application need not be required from a person covered under ablanket disability policy or contract, nor is it necessary for the insurer tofurnish each person a certificate.

26-19-109. To whom benefits are payable.

(a) Any benefits under any group or blanket disability policyor contract are payable to the person insured, or to his designated beneficiaryor beneficiaries, or to his estate, except that if the person insured is aminor or otherwise not competent to give a valid release, the benefits may bemade payable to his parent, guardian or other person actually supporting him.The policy may provide that any indemnities provided by the policy because ofhospital, nursing, medical or surgical services, at the insurer's option andunless the insured requests otherwise in writing not later than the time offiling proofs of loss, may be paid directly to the hospital or person renderingthe services. The policy may not require that the service be rendered by aparticular hospital or person. Any payment made under the policy discharges theinsurer's obligation with respect to the amount of insurance so paid.

(b) Any group disability policy which contains provisions forthe insurer to pay benefits for expenses incurred for hospital, nursing,medical or surgical services for members of the family or dependents of aperson insured may provide for the continuation of the benefit provisionsentirely or partially after the death of the person insured.

26-19-110. Additional disability insurance groups; requirements.

(a) Group disability insurance offered to a resident under agroup disability insurance policy issued to a group other than one described inW.S. 26-19-102 is subject to the following requirements:

(i) A group disability insurance policy shall not be deliveredin this state unless the commissioner finds that:

(A) The issuance of the group policy is not contrary to thebest interest of the public;

(B) The issuance of the group policy would result in economiesof acquisition or administration;

(D) The insurer possesses and maintains capital and surplusrequirements provided by W.S. 26-3-108 and reserve requirements provided byW.S. 26-6-107.

(ii) Group disability insurance coverage shall not be offered inthis state by an insurer under a policy issued in another state unless thecommissioner determines the requirements of paragraph (i) of this subsectionare met and the insurer files with the commissioner:

(A) A copy of the group master contract;

(B) A copy of the statute of the state where the group policyis issued that authorizes the issuance of the group policy;

(D) Copies of all supportive material used by the insurer tosecure approval of the group in the state where the group policy is issued.

(iii) If the commissioner fails to make the determinationprovided by paragraph (ii) of this subsection within forty-five (45) days offiling by the insurer of the documents required by paragraph (ii) of thissubsection, the requirements of paragraph (i) of this subsection are deemed tobe met.

26-19-111. Notice of compensation.

(a) The insurer shall distribute to prospective insureds awritten notice that compensation shall or may be paid for a program of groupinsurance which would qualify under W.S. 26-19-102(a)(ii) or 26-19-110, ifcompensation of any kind shall or may be paid to:

(i) A policyholder or sponsoring or endorsing entity in thecase of group policy; or

(ii) A sponsoring or endorsing entity in the case of individual,blanket or franchise policies marketed by means of direct responsesolicitation.

(b) Notice required by this section shall be distributed:

(i) Whether compensation is direct or indirect; and

(ii) Whether compensation is:

(A) Paid to or retained by the policyholder or sponsoring orendorsing entity; or

(B) Paid to or retained by a third party at the direction ofthe policyholder, sponsoring or endorsing entity or an entity affiliated by wayof ownership, contract or employment.

(c) The notice required by this section shall be placed on oraccompany any application or enrollment form provided to prospective insureds.

(d) As used in this section:

(i) "Direct response solicitation" means asolicitation through a sponsoring or endorsing entity by the mails, telephoneor other mass communications media; and

(ii) "Sponsoring or endorsing entity" means anorganization which has arranged for the offering of a program of insurance in amanner which communicates that eligibility for participation in the program isdependent upon affiliation with the organization or that it encouragesparticipation in the program.

26-19-112. Dependent group disability insurance.

Exceptfor a policy issued under W.S. 26-19-102(a)(vi), a group disability insurancepolicy may be extended to insure the employees' or members' or any class ofemployees' or members' family members or dependents. If the employee or memberdoes not pay any part of the premium for the family members or dependentscoverage, the policy shall insure all eligible employees, members or any classof employees or members.

26-19-113. Continuation of group coverage after termination ofemployment or membership.

(a) A non-COBRA group policy or certificate of insurance on amaster policy of a group delivered or issued for delivery in this state on orafter July 1, 1995, issued by any insurance company, nonprofit health servicecorporation, health maintenance organization or any other insurer that provideshospital, surgical or major medical expense insurance or any accommodation ofthese coverages on an expense incurred basis, but not a policy that providesbenefits for specific diseases or for accidental injuries only, shall providethat employees, members or their covered eligible dependents whose insuranceunder the group policy would otherwise terminate because of termination ofemployment or membership or eligibility for coverage are entitled to continuetheir hospital, surgical and major medical insurance under that group policy,for themselves, their eligible dependents or both, subject to all of the grouppolicy's terms and conditions applicable to those forms of insurance and to thefollowing conditions:

(i) Continuation is only available to an employee or member whohas been continuously insured under the group policy and for similar benefitsunder any group policy which it replaced, during the entire three (3) monthperiod ending with the termination of eligibility;

(ii) Continuation is not available for any person who is:

(A) Covered by medicare, excluding his spouse or dependent childrenwho shall be entitled to continuation; or

(B) Covered by any other insured or uninsured arrangement whichprovides hospital, surgical or medical coverage for individuals in a group.

(iii) Continuation need not include dental or vision care benefitsor any other benefits provided under the group policy in addition to itshospital, surgical or major medical benefits unless the insurer previouslyincluded such benefits and the insured requests such benefits;

(iv) An employee or member who wishes continuation of coverageshall request the continuation in writing within the thirty-one (31) day periodfollowing the date of termination of coverage;

(v) An employee or member electing continuation shall pay tothe insurer, third party administrator, group policyholder or the employer, asdesignated by the employer, on a monthly basis in advance, the amount ofcontribution required by the policyholder or employer, but not more than onehundred two percent (102%) of the group rate for the insurance being continuedunder the group policy on the due date of each payment. The employer'sdesignation with regard to whom the electing employee or member shall pay hiscontribution shall be made in writing prior to the date the first contributionby the employee or member is due. The employee's or member's written electionof continuation, together with the first contribution required to establishcontributions on a monthly basis in advance, shall be given to the insurer,third party administrator, policyholder or employer within thirty-one (31) daysof the date the employee's or member's insurance would otherwise terminate;

(vi) Continuation of insurance under the group policy for anyperson terminates when the person fails to satisfy paragraph (ii) of thissubsection or, if earlier, at the first to occur of the following:

(A) The date twelve (12) months after the date the employee'sor member's insurance under the policy would otherwise have terminated becauseof termination of employment or membership;

(B) If the employee or member fails to make timely payment of arequired contribution, the end of the period for which contributions were made;

(C) The date on which the group policy is terminated or, in thecase of an employee, the date the employer terminates participation under thegroup policy. However, if this subparagraph applies and the coverage ceasingby reason of the termination is replaced by similar coverage under anothergroup policy, the following apply:

(I) The employee or member may become covered under that othergroup policy for the balance of the period that the employee or member wouldhave remained covered under the prior group policy in accordance with thisparagraph had a termination described in this subparagraph not occurred;

(II) The minimum level of benefits to be provided by the othergroup policy is the applicable level of benefits of the prior group policyreduced by any benefits payable under that prior group policy;

(III) The prior group policy shall continue to provide benefitsto the extent of its accrued liabilities and extensions of benefits as if thereplacement had not occurred.

(vii) A notification of the continuation privilege shall beincluded in each certificate of coverage;

(viii) Upon termination of the continuation period, the member,surviving spouse or dependent is entitled to exercise any option which isprovided in the group plan to elect a conversion policy. The member electing aconversion policy shall notify the carrier of the election and pay the requiredpremium within thirty-one (31) days of the termination of the continuedcoverage under the group contract.

(b) As used in subsection (a) of this section,"non-COBRA" means any group policy or certificate of insurance on amaster policy of a group policy which is not subject to continuation of rightsas provided under the federal Consolidated Omnibus Budget Reconciliation Act of1985, as amended.

ARTICLE 2 - GROUP COVERAGE REPLACEMENT ACT

26-19-201. Purpose and scope of article.

(a) The purpose of this article is to:

(i) Provide for continuance of coverage for all participantswhen a succeeding carrier's contract replaces a prior plan's benefits; and

(ii) Prohibit the imposition of preexisting conditionlimitations under certain circumstances.

(b) This article is applicable to all insurance policies andsubscriber contracts issued or provided by an insurance company or a nonprofitservice corporation on a group or group-type basis covering persons asemployees of employers or as members of unions, associations, multiple employertrusts or organizations, or any arrangement subject to the jurisdiction of theinsurance department.

26-19-202. Definitions.

(a) As used in this article:

(i) "Carrier" means an insurance company, nonprofitservice corporation, trust, association or other arrangement subject to thejurisdiction of the insurance department;

(ii) "Group-type basis" means a benefit plan whichmeets the following conditions:

(A) Coverage is provided through insurance policies orsubscriber contracts to classes of employees or members defined in terms ofconditions pertaining to employment or membership or any other arrangementsubject to the jurisdiction of the insurance department;

(B) The coverage is not available to the general public and canbe obtained and maintained only because of the covered person's membership inconnection with the particular organization or group;

(C) There are arrangements for bulk payment of premiums orsubscription charges to the insurer, nonprofit service corporation, associationor trust;

(D) There is sponsorship of the plan by the employer, union,association, trust or organization; and

(E) Individually underwritten and issued guaranteed renewablepolicies shall not be considered "group-type basis" under thisparagraph even though purchased through payroll deduction.

26-19-203. Continuance of coverage where one carrier's contractreplaces a plan of similar benefits of another carrier.

(a) In those instances in which one (1) carrier's contractreplaces a plan of similar benefits of another carrier:

(i) The prior carrier remains liable only to the extent of itsaccrued liabilities and extensions of benefits. The position of the priorcarrier shall be the same whether the group policy holder or other entitysecures replacement coverage from a new carrier, self-insures or foregoes theprovision of coverage;

(ii) The succeeding carrier is liable under the followingcircumstances:

(A) Each person covered under the prior carrier's plan shall beeligible for complete coverage in accordance with the succeeding carrier's planof benefits, which shall include coverage for ninety (90) days for anycomplication caused as a result of a condition for which benefits were paidunder the prior plan within ninety (90) days prior to termination of thatplan. Copayment and deductible levels for coverage required under thissubparagraph may be applied in a manner consistent with those provided by thesucceeding carrier's plan;

(B) In the case of a preexisting conditions limitation includedin the succeeding carrier's plan, the level of benefits applicable topreexisting conditions of persons becoming covered by the succeeding carrier'splan in accordance with this paragraph during the period of time thislimitation applies under the new plan shall be the lesser of:

(I) The benefits of the new plan determined without applicationof the preexisting conditions limitations; or

(II) The benefits of the prior plan.

(C) In any situation where a determination of the priorcarrier's benefit is required by the succeeding carrier, at the succeedingcarrier's request the prior carrier shall furnish a statement of the benefitsavailable or pertinent information, sufficient to permit verification of thebenefit determination or the determination itself by the succeeding carrier. For the purposes of this section, benefits of the prior plan will be determinedin accordance with all of the definitions, conditions and covered expense provisionsof the prior plan rather than those of the succeeding plan. The benefitdetermination will be made as if coverage had not been replaced by thesucceeding carrier.

26-19-204. Violations; penalty.

Anyperson who violates any of the provisions of this article shall be subject tothe penalties provided by W.S. 26-1-107.

ARTICLE 3 - SMALL EMPLOYER HEALTH INSURANCE AVAILABILITY

26-19-301. Short title.

Thisact shall be known and may be cited as the "Small Employer HealthInsurance Availability Act."

26-19-302. Definitions.

(a) As used in this act:

(i) "Actuarial certification" means a writtenstatement by a member of the American Academy of Actuaries or other individualacceptable to the commissioner that a small employer carrier is in compliancewith the provisions of W.S. 26-19-304, based upon the person's examination,including a review of the appropriate records and of the actuarial assumptionsand methods used by the small employer carrier in establishing premium ratesfor applicable health benefit plans;

(ii) "Base premium rate" means, for each class ofbusiness as to a rating period, the lowest premium rate charged or that couldhave been charged under a rating system for that class of business, by thesmall employer carrier to small employers with similar case characteristics forhealth benefit plans with the same or similar coverage;

(iii) "Basic health benefit plan" means a low costhealth benefit plan developed pursuant to W.S. 26-19-308;

(iv) "Board" means the board of directors of theprogram;

(v) "Carrier" means any person who provides anyhealth benefit plan in this state subject to state insurance regulation andincludes, but is not limited to, an insurance company, a fraternal benefitsociety, a prepaid hospital or medical care plan, a health maintenanceorganization and a multiple employer welfare arrangement. For purposes of thisact, companies that are affiliated companies or that are eligible to file aconsolidated tax return shall be treated as one (1) carrier except that anyinsurance company, health service corporation, hospital service corporation ormedical service corporation that is an affiliate of a health maintenanceorganization located in this state, or any health maintenance organizationlocated in this state which is an affiliate of an insurance company, healthservice corporation, hospital service corporation or medical servicecorporation may treat the health maintenance organization as a separate carrierand each health maintenance organization that operates only one (1) healthmaintenance organization in an established geographic service area of thisstate may be considered a separate carrier;

(vi) "Case characteristics" means demographic or otherobjective characteristics of a small employer, as determined by a smallemployer carrier, that are considered by the small employer carrier in thedetermination of premium rates for the small employer, provided, however, thatclaim experience, health status and duration of coverage since issue are not casecharacteristics for the purposes of this act;

(vii) "Class of business" means all of a distinctgrouping of small employers as shown on the records of the small employercarrier, and provided:

(A) A distinct grouping may only be established by the smallemployer carrier on the basis that the applicable health benefit plans:

(I) Are marketed and sold through individuals and organizationswhich are not participating in the marketing or sale of other distinctgroupings of small employers for such small employer carrier;

(II) Have been acquired from another small employer carrier as adistinct grouping of plans; or

(III) Are provided through an association with membership of notless than two (2) small employers.

(B) A small employer carrier may establish no more than two (2)additional groupings under each subdivision (I) through (III) of subparagraph(A) of this paragraph on the basis of underwriting criteria which are expectedto produce substantial variation in the health care costs;

(C) The commissioner may approve the establishment ofadditional distinct groupings upon application to the commissioner and afinding by the commissioner that such action would enhance the efficiency andfairness of the small employer marketplace.

(viii) Repealed by Laws 1995, ch. 94, 3.

(ix) "Dependent" means:

(A) A spouse or unmarried child under the age of nineteen (19)years;

(B) An unmarried child who is a full-time student under the ageof twenty-three (23);

(D) Any other individual defined to be a dependent in thehealth benefit plan covering the employee.

(x) "Eligible employee" means an employee who workson a full-time basis, with a normal work week of thirty (30) or more hours andhas met any applicable waiting period requirements. The term includes a soleproprietor, a partner of a partnership or an independent contractor, if thesole proprietor, partner or independent contractor is included as an employeeunder a health benefit plan of a small employer, but does not include employeeswho work on a part-time, temporary, seasonal or substitute basis;

(xi) "Established geographic service area" means ageographical area approved by the commissioner in conjunction with thecarrier's certificate of authority to transact insurance in this state, withinwhich the carrier is authorized to provide coverage;

(xii) "Health benefit plan" means any hospital ormedical policy or certificate, major medical expense insurance, hospital ormedical service plan contract or health maintenance organization subscribercontract. "Health benefit plan" does not include accident-only,credit, dental, vision, Medicare supplement, long-term care or disabilityincome insurance, coverage issued as a supplement to liability insurance,worker's compensation or similar insurance or automobile medical-paymentinsurance, nor does it include policies or certificates of specified disease,hospital confinement indemnity or limited benefit health insurance if thecarrier offering the policies or certificates certifies to the commissionerthat policies or certificates described in this paragraph are being offered andmarketed as supplemental health insurance and not as a substitute for hospitalor medical expense insurance or major medical expense insurance;

(xiii) Repealed by Laws 1993, ch. 83, 2.

(xiv) "Index rate" means, for each class of business asto a rating period for small employers with similar case characteristics, thearithmetic average of the applicable base premium rate and the correspondinghighest premium rate;

(xv) "Late enrollee" means an eligible employee ordependent who requests enrollment in a health benefit plan of a small employerfollowing the initial enrollment period provided under the terms of the healthbenefit plan, provided that the initial enrollment period shall be a period ofat least thirty (30) days. An eligible employee or dependent shall not beconsidered a late enrollee if:

(A) The individual:

(I) Was covered under a public or private health insurance orother health benefit arrangement at the time the individual was eligible toenroll;

(II) Has lost coverage under a public or private healthinsurance or other health benefit arrangement as a result of termination ofemployment or eligibility, the termination of the other plan's coverage, deathof a spouse, divorce, legal separation or termination of employer contribution;and

(III) Requests enrollment within thirty (30) days after terminationof coverage provided under a public or private health insurance or other healthbenefit arrangement.

(B) The individual is employed by an employer which offersmultiple health benefit plans and the individual elects a different plan duringan open enrollment period; or

(C) A court has ordered coverage be provided for a spouse orminor child under a covered employee's health benefit plan and request forenrollment is made within thirty (30) days after issuance of the court order.

(xvi) "New business premium rate" means, for each classof business as to a rating period, the lowest premium rate charged or offered,or which could have been charged or offered, by the small employer carrier tosmall employers with similar case characteristics for newly issued healthbenefit plans with the same or similar coverage;

(xvii) "Participating carrier" means all small employercarriers issuing health benefit plans in this state. "Participatingcarrier" shall also include any carrier that maintains an existing healthbenefit plan covering eligible employees of one (1) or more small employers;

(xviii) "Plan of operation" means the plan of operationof the program, including articles, bylaws and operating rules adopted by theboard pursuant to W.S. 26-19-307;

(xix) "Preexisting condition provision" means a policyprovision that excludes coverage for charges or expenses incurred during aspecified period following the insured's effective date of coverage, as to acondition which, during a specified period immediately preceding the effectivedate of coverage, medical advice, diagnosis, care or treatment was recommendedor received;

(xx) "Program" means the Wyoming small employer healthreinsurance program created by W.S. 26-19-307;

(xxi) "Rating period" means the calendar period forwhich premium rates established by a small employer carrier are assumed to bein effect, as determined by the small employer carrier;

(xxii) "Small employer" means any person, firm,corporation, partnership or association who is actively engaged in businesswho, on at least fifty percent (50%) of its working days during the precedingcalendar quarter, employed at least two (2) but no more than fifty (50)eligible employees, the majority of whom were employed within this state orwere residents of Wyoming. In determining the number of eligible employees,companies which are affiliated companies, or which are eligible to file acombined tax return for purposes of any state taxation, shall be considered one(1) employer;

(xxiii) "Small employer carrier" means any carrier thatoffers health benefit plans covering eligible employees of one (1) or moresmall employers;

(xxiv) "Standard health benefit plan" means a healthbenefit plan developed pursuant to W.S. 26-19-308;

(xxv) "Taft-Hartley trust" means a trust formedpursuant to a collective bargaining agreement under the federal LaborManagement Relations Act of 1947;

(xxvi) "Affiliation period" means a period which, underthe terms of the health insurance coverage offered by a health maintenanceorganization, must expire before the health insurance coverage becomeseffective. The health maintenance organization is not required to providehealth care services or benefits during an affiliation period and no premiums shallbe charged to the participant or beneficiary for any coverage during theper