State Codes and Statutes

Statutes > Wyoming > Title26 > Chapter20

CHAPTER 20 - MANDATED COVERAGE

 

ARTICLE 1 - NEWBORN AND ADOPTED CHILDREN COVERAGE

 

26-20-101. Newly born and adopted child coverage required.

 

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, and individual and groupservice or indemnity type contracts issued by any insurer including anynonprofit corporation which provide coverage for a family member of the insuredor subscriber, shall also provide, as to the family members' coverage, that thehealth insurance benefits applicable for children are automatically payablewith respect to:

 

(i) A newly born child of the insured or subscriber from themoment of birth; and

 

(ii) An adopted child from the earlier of the date the petitionfor adoption is filed or entry of the child in the adoptive home, except thatwhen the child is in the custody of the state, coverage shall begin at the dateof entry of a final decree of adoption. Coverage for an adopted child shallcontinue unless the petition is denied.

 

26-20-102. Specific coverage.

 

Thecoverage for newly born children shall consist of coverage of injury orsickness including the necessary care and treatment of medically diagnosedcongenital defects and birth abnormalities. The coverage for adopted childrenshall consist of coverage of injury or sickness including the necessary careand treatment of medical conditions existing prior to the date of placement.

 

26-20-103. Premiums.

 

Ifpayment of a specific premium or subscription fee is required to providecoverage for a child, the policy or contract may require that notification ofbirth of a child or the placement for adoption of a child and payment of therequired premium or fees shall be furnished to the insurer or nonprofit serviceor indemnity corporation within thirty-one (31) days after the date of birth orafter the date coverage of a child placed for adoption begins in order to havethe coverage continue beyond the thirty-one (31) day period.

 

26-20-104. Applicability of article.

 

Therequirements of this article regarding newly born children apply to allinsurance policies and subscriber contracts delivered or issued for delivery inthis state more than one hundred twenty (120) days after May 30, 1975. Therequirements of this article regarding adopted children apply to all insurancepolicies and subscriber contracts delivered or issued for delivery in thisstate after June 8, 1989.

 

ARTICLE 2 - DIABETES COVERAGE

 

26-20-201. Diabetes coverage required.

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, individual and group serviceor indemnity type contracts issued by any insurer including any nonprofitcorporation and individual and group service contracts issued by a healthmaintenance organization, which provide coverage shall also provide coveragefor the equipment, supplies and outpatient self-management training andeducation, including medical nutrition therapy for the treatment ofinsulin-dependent diabetes, insulin-using diabetes, gestational diabetes andnoninsulin using diabetes if prescribed by a health care professional legallyauthorized to prescribe such items under law. Covered diabetes outpatientself-management training and education shall be provided by a certified,registered or licensed health care professional with expertise in diabetes. Forpurposes of this section, required covered outpatient self-management trainingand education shall be limited to:

 

(i) A one-time evaluation and training program when medicallynecessary, within one (1) year of diagnosis;

 

(ii) Additional medically necessary self-management trainingshall be provided upon a significant change in symptoms, condition or treatment.This additional training shall be limited to three (3) hours per year.

 

(b) The benefits provided under this section shall be subjectto the same annual deductibles or coinsurance established for all other coveredbenefits within a given policy. Private third-party payors may not reduce oreliminate coverage due to the requirements of this section. Enforcement of thissection shall be performed by the commissioner or his designee.

 

(c) This section shall apply to a private health benefit planas defined under W.S. 26-1-102(a)(xxxiii) delivered or issued on or after July1, 2001.

 

ARTICLE 3 - CLINICAL TRIALS COVERAGE

 

26-20-301. Clinical trials and studies coverage required.

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, individual and group serviceor indemnity type contracts issued by any insurer including any nonprofitcorporation and individual and group service contracts or certificates issuedby a health maintenance organization which provide coverage for treatment ofcancer shall also provide coverage for routine patient care costs which apolicyholder or certificate holder, or his covered dependent, receives as partof a clinical trial or study if:

 

(i) The medical treatment is provided in a phase II, phase IIIor phase IV study or clinical trial for the treatment of cancer;

 

(ii) The clinical trial or study is approved by:

 

(A) An agency of the national institutes of health as set forthin 42 U.S.C. 281(b) or a research entity that meets the NIH granting criteria;

 

(B) The United States food and drug administration as anapplication for a new investigational drug;

 

(C) The United States department of veterans affairs; or

 

(D) The United States department of defense.

 

(iii) The medical treatment is provided by a licensed health careprovider practicing within the scope of the provider's license and the facilityand personnel providing the treatment have the experience and training toprovide the treatment in a competent manner; and

 

(iv) The participant in the clinical trial or study, beforecommencing participation, has signed a statement of consent indicating that theparticipant has been informed of:

 

(A) The procedure to be undertaken;

 

(B) Alternative methods of treatment; and

 

(C) The general nature and extent of risks associated withparticipation in the clinical trial or study.

 

(b) Coverage for medical treatment required by this sectionshall be limited to routine patient care costs.

 

(c) The coverage required by this section does not include:

 

(i) Any portion of the clinical trial or study that iscustomarily paid for by a government or a biotechnical, pharmaceutical ormedical industry;

 

(ii) Coverage for any drug or device that is paid for by themanufacturer, distributor or provider of the drug or device;

 

(iii) Health care services that are customarily provided by thesponsors of the clinical trial or study free of charge to the participants inthe trial or study;

 

(iv) Extraneous expenses related to participation in theclinical trial or study including, without limitation, travel, housing andother expenses that a participant or person accompanying a participant mayincur;

 

(v) Any item or service that is provided solely to satisfy aneed or desire for data collection or analysis that is not directly related tothe clinical management of the patient;

 

(vi) Any costs for the management of research relating to theclinical trial or study.

 

(d) Nothing in this section shall:

 

(i) Preclude an insurer from excluding coverage for any claimarising from the practice of medicine or other health care by a person withoutan applicable physician or health care provider license;

 

(ii) Preclude an insurer from asserting the right to subrogatefor expenses arising from complications caused by a drug or device that issubsequently approved for usage upon completion of the clinical trial;

 

(iii) Provide a private cause of action against any healthinsurer described in subsection (a) of this section for damages arising as aresult of compliance with this section.

 

(e) For purposes of this section:

 

(i) "Clinical trial" means any experiment in which adrug is administered to, dispensed to or used by one (1) or more humansubjects. For purposes of this paragraph, an experiment is any use of a drugexcept for the use of a marketed drug in the course of medical practice;

 

(ii) "Routine patient care cost" means:

 

(A) A medical service or treatment that is a benefit under ahealth plan that would be covered if the patient were receiving standard cancertreatment; or

 

(B) A drug provided to a patient during a cancer clinicaltrial, other than the drug that is the subject of the clinical trial, if thedrug has been approved by the federal food and drug administration for use intreating the patient's particular condition.

 

State Codes and Statutes

Statutes > Wyoming > Title26 > Chapter20

CHAPTER 20 - MANDATED COVERAGE

 

ARTICLE 1 - NEWBORN AND ADOPTED CHILDREN COVERAGE

 

26-20-101. Newly born and adopted child coverage required.

 

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, and individual and groupservice or indemnity type contracts issued by any insurer including anynonprofit corporation which provide coverage for a family member of the insuredor subscriber, shall also provide, as to the family members' coverage, that thehealth insurance benefits applicable for children are automatically payablewith respect to:

 

(i) A newly born child of the insured or subscriber from themoment of birth; and

 

(ii) An adopted child from the earlier of the date the petitionfor adoption is filed or entry of the child in the adoptive home, except thatwhen the child is in the custody of the state, coverage shall begin at the dateof entry of a final decree of adoption. Coverage for an adopted child shallcontinue unless the petition is denied.

 

26-20-102. Specific coverage.

 

Thecoverage for newly born children shall consist of coverage of injury orsickness including the necessary care and treatment of medically diagnosedcongenital defects and birth abnormalities. The coverage for adopted childrenshall consist of coverage of injury or sickness including the necessary careand treatment of medical conditions existing prior to the date of placement.

 

26-20-103. Premiums.

 

Ifpayment of a specific premium or subscription fee is required to providecoverage for a child, the policy or contract may require that notification ofbirth of a child or the placement for adoption of a child and payment of therequired premium or fees shall be furnished to the insurer or nonprofit serviceor indemnity corporation within thirty-one (31) days after the date of birth orafter the date coverage of a child placed for adoption begins in order to havethe coverage continue beyond the thirty-one (31) day period.

 

26-20-104. Applicability of article.

 

Therequirements of this article regarding newly born children apply to allinsurance policies and subscriber contracts delivered or issued for delivery inthis state more than one hundred twenty (120) days after May 30, 1975. Therequirements of this article regarding adopted children apply to all insurancepolicies and subscriber contracts delivered or issued for delivery in thisstate after June 8, 1989.

 

ARTICLE 2 - DIABETES COVERAGE

 

26-20-201. Diabetes coverage required.

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, individual and group serviceor indemnity type contracts issued by any insurer including any nonprofitcorporation and individual and group service contracts issued by a healthmaintenance organization, which provide coverage shall also provide coveragefor the equipment, supplies and outpatient self-management training andeducation, including medical nutrition therapy for the treatment ofinsulin-dependent diabetes, insulin-using diabetes, gestational diabetes andnoninsulin using diabetes if prescribed by a health care professional legallyauthorized to prescribe such items under law. Covered diabetes outpatientself-management training and education shall be provided by a certified,registered or licensed health care professional with expertise in diabetes. Forpurposes of this section, required covered outpatient self-management trainingand education shall be limited to:

 

(i) A one-time evaluation and training program when medicallynecessary, within one (1) year of diagnosis;

 

(ii) Additional medically necessary self-management trainingshall be provided upon a significant change in symptoms, condition or treatment.This additional training shall be limited to three (3) hours per year.

 

(b) The benefits provided under this section shall be subjectto the same annual deductibles or coinsurance established for all other coveredbenefits within a given policy. Private third-party payors may not reduce oreliminate coverage due to the requirements of this section. Enforcement of thissection shall be performed by the commissioner or his designee.

 

(c) This section shall apply to a private health benefit planas defined under W.S. 26-1-102(a)(xxxiii) delivered or issued on or after July1, 2001.

 

ARTICLE 3 - CLINICAL TRIALS COVERAGE

 

26-20-301. Clinical trials and studies coverage required.

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, individual and group serviceor indemnity type contracts issued by any insurer including any nonprofitcorporation and individual and group service contracts or certificates issuedby a health maintenance organization which provide coverage for treatment ofcancer shall also provide coverage for routine patient care costs which apolicyholder or certificate holder, or his covered dependent, receives as partof a clinical trial or study if:

 

(i) The medical treatment is provided in a phase II, phase IIIor phase IV study or clinical trial for the treatment of cancer;

 

(ii) The clinical trial or study is approved by:

 

(A) An agency of the national institutes of health as set forthin 42 U.S.C. 281(b) or a research entity that meets the NIH granting criteria;

 

(B) The United States food and drug administration as anapplication for a new investigational drug;

 

(C) The United States department of veterans affairs; or

 

(D) The United States department of defense.

 

(iii) The medical treatment is provided by a licensed health careprovider practicing within the scope of the provider's license and the facilityand personnel providing the treatment have the experience and training toprovide the treatment in a competent manner; and

 

(iv) The participant in the clinical trial or study, beforecommencing participation, has signed a statement of consent indicating that theparticipant has been informed of:

 

(A) The procedure to be undertaken;

 

(B) Alternative methods of treatment; and

 

(C) The general nature and extent of risks associated withparticipation in the clinical trial or study.

 

(b) Coverage for medical treatment required by this sectionshall be limited to routine patient care costs.

 

(c) The coverage required by this section does not include:

 

(i) Any portion of the clinical trial or study that iscustomarily paid for by a government or a biotechnical, pharmaceutical ormedical industry;

 

(ii) Coverage for any drug or device that is paid for by themanufacturer, distributor or provider of the drug or device;

 

(iii) Health care services that are customarily provided by thesponsors of the clinical trial or study free of charge to the participants inthe trial or study;

 

(iv) Extraneous expenses related to participation in theclinical trial or study including, without limitation, travel, housing andother expenses that a participant or person accompanying a participant mayincur;

 

(v) Any item or service that is provided solely to satisfy aneed or desire for data collection or analysis that is not directly related tothe clinical management of the patient;

 

(vi) Any costs for the management of research relating to theclinical trial or study.

 

(d) Nothing in this section shall:

 

(i) Preclude an insurer from excluding coverage for any claimarising from the practice of medicine or other health care by a person withoutan applicable physician or health care provider license;

 

(ii) Preclude an insurer from asserting the right to subrogatefor expenses arising from complications caused by a drug or device that issubsequently approved for usage upon completion of the clinical trial;

 

(iii) Provide a private cause of action against any healthinsurer described in subsection (a) of this section for damages arising as aresult of compliance with this section.

 

(e) For purposes of this section:

 

(i) "Clinical trial" means any experiment in which adrug is administered to, dispensed to or used by one (1) or more humansubjects. For purposes of this paragraph, an experiment is any use of a drugexcept for the use of a marketed drug in the course of medical practice;

 

(ii) "Routine patient care cost" means:

 

(A) A medical service or treatment that is a benefit under ahealth plan that would be covered if the patient were receiving standard cancertreatment; or

 

(B) A drug provided to a patient during a cancer clinicaltrial, other than the drug that is the subject of the clinical trial, if thedrug has been approved by the federal food and drug administration for use intreating the patient's particular condition.

 


State Codes and Statutes

State Codes and Statutes

Statutes > Wyoming > Title26 > Chapter20

CHAPTER 20 - MANDATED COVERAGE

 

ARTICLE 1 - NEWBORN AND ADOPTED CHILDREN COVERAGE

 

26-20-101. Newly born and adopted child coverage required.

 

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, and individual and groupservice or indemnity type contracts issued by any insurer including anynonprofit corporation which provide coverage for a family member of the insuredor subscriber, shall also provide, as to the family members' coverage, that thehealth insurance benefits applicable for children are automatically payablewith respect to:

 

(i) A newly born child of the insured or subscriber from themoment of birth; and

 

(ii) An adopted child from the earlier of the date the petitionfor adoption is filed or entry of the child in the adoptive home, except thatwhen the child is in the custody of the state, coverage shall begin at the dateof entry of a final decree of adoption. Coverage for an adopted child shallcontinue unless the petition is denied.

 

26-20-102. Specific coverage.

 

Thecoverage for newly born children shall consist of coverage of injury orsickness including the necessary care and treatment of medically diagnosedcongenital defects and birth abnormalities. The coverage for adopted childrenshall consist of coverage of injury or sickness including the necessary careand treatment of medical conditions existing prior to the date of placement.

 

26-20-103. Premiums.

 

Ifpayment of a specific premium or subscription fee is required to providecoverage for a child, the policy or contract may require that notification ofbirth of a child or the placement for adoption of a child and payment of therequired premium or fees shall be furnished to the insurer or nonprofit serviceor indemnity corporation within thirty-one (31) days after the date of birth orafter the date coverage of a child placed for adoption begins in order to havethe coverage continue beyond the thirty-one (31) day period.

 

26-20-104. Applicability of article.

 

Therequirements of this article regarding newly born children apply to allinsurance policies and subscriber contracts delivered or issued for delivery inthis state more than one hundred twenty (120) days after May 30, 1975. Therequirements of this article regarding adopted children apply to all insurancepolicies and subscriber contracts delivered or issued for delivery in thisstate after June 8, 1989.

 

ARTICLE 2 - DIABETES COVERAGE

 

26-20-201. Diabetes coverage required.

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, individual and group serviceor indemnity type contracts issued by any insurer including any nonprofitcorporation and individual and group service contracts issued by a healthmaintenance organization, which provide coverage shall also provide coveragefor the equipment, supplies and outpatient self-management training andeducation, including medical nutrition therapy for the treatment ofinsulin-dependent diabetes, insulin-using diabetes, gestational diabetes andnoninsulin using diabetes if prescribed by a health care professional legallyauthorized to prescribe such items under law. Covered diabetes outpatientself-management training and education shall be provided by a certified,registered or licensed health care professional with expertise in diabetes. Forpurposes of this section, required covered outpatient self-management trainingand education shall be limited to:

 

(i) A one-time evaluation and training program when medicallynecessary, within one (1) year of diagnosis;

 

(ii) Additional medically necessary self-management trainingshall be provided upon a significant change in symptoms, condition or treatment.This additional training shall be limited to three (3) hours per year.

 

(b) The benefits provided under this section shall be subjectto the same annual deductibles or coinsurance established for all other coveredbenefits within a given policy. Private third-party payors may not reduce oreliminate coverage due to the requirements of this section. Enforcement of thissection shall be performed by the commissioner or his designee.

 

(c) This section shall apply to a private health benefit planas defined under W.S. 26-1-102(a)(xxxiii) delivered or issued on or after July1, 2001.

 

ARTICLE 3 - CLINICAL TRIALS COVERAGE

 

26-20-301. Clinical trials and studies coverage required.

 

(a) All individual and group health insurance policiesproviding coverage on an expense incurred basis, individual and group serviceor indemnity type contracts issued by any insurer including any nonprofitcorporation and individual and group service contracts or certificates issuedby a health maintenance organization which provide coverage for treatment ofcancer shall also provide coverage for routine patient care costs which apolicyholder or certificate holder, or his covered dependent, receives as partof a clinical trial or study if:

 

(i) The medical treatment is provided in a phase II, phase IIIor phase IV study or clinical trial for the treatment of cancer;

 

(ii) The clinical trial or study is approved by:

 

(A) An agency of the national institutes of health as set forthin 42 U.S.C. 281(b) or a research entity that meets the NIH granting criteria;

 

(B) The United States food and drug administration as anapplication for a new investigational drug;

 

(C) The United States department of veterans affairs; or

 

(D) The United States department of defense.

 

(iii) The medical treatment is provided by a licensed health careprovider practicing within the scope of the provider's license and the facilityand personnel providing the treatment have the experience and training toprovide the treatment in a competent manner; and

 

(iv) The participant in the clinical trial or study, beforecommencing participation, has signed a statement of consent indicating that theparticipant has been informed of:

 

(A) The procedure to be undertaken;

 

(B) Alternative methods of treatment; and

 

(C) The general nature and extent of risks associated withparticipation in the clinical trial or study.

 

(b) Coverage for medical treatment required by this sectionshall be limited to routine patient care costs.

 

(c) The coverage required by this section does not include:

 

(i) Any portion of the clinical trial or study that iscustomarily paid for by a government or a biotechnical, pharmaceutical ormedical industry;

 

(ii) Coverage for any drug or device that is paid for by themanufacturer, distributor or provider of the drug or device;

 

(iii) Health care services that are customarily provided by thesponsors of the clinical trial or study free of charge to the participants inthe trial or study;

 

(iv) Extraneous expenses related to participation in theclinical trial or study including, without limitation, travel, housing andother expenses that a participant or person accompanying a participant mayincur;

 

(v) Any item or service that is provided solely to satisfy aneed or desire for data collection or analysis that is not directly related tothe clinical management of the patient;

 

(vi) Any costs for the management of research relating to theclinical trial or study.

 

(d) Nothing in this section shall:

 

(i) Preclude an insurer from excluding coverage for any claimarising from the practice of medicine or other health care by a person withoutan applicable physician or health care provider license;

 

(ii) Preclude an insurer from asserting the right to subrogatefor expenses arising from complications caused by a drug or device that issubsequently approved for usage upon completion of the clinical trial;

 

(iii) Provide a private cause of action against any healthinsurer described in subsection (a) of this section for damages arising as aresult of compliance with this section.

 

(e) For purposes of this section:

 

(i) "Clinical trial" means any experiment in which adrug is administered to, dispensed to or used by one (1) or more humansubjects. For purposes of this paragraph, an experiment is any use of a drugexcept for the use of a marketed drug in the course of medical practice;

 

(ii) "Routine patient care cost" means:

 

(A) A medical service or treatment that is a benefit under ahealth plan that would be covered if the patient were receiving standard cancertreatment; or

 

(B) A drug provided to a patient during a cancer clinicaltrial, other than the drug that is the subject of the clinical trial, if thedrug has been approved by the federal food and drug administration for use intreating the patient's particular condition.

 

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