State Codes and Statutes

Statutes > Wyoming > Title26 > Chapter22

CHAPTER 22 - HOSPITAL OR MEDICAL SERVICE INSURANCE AND PREPAIDHEALTH SERVICE PLANS

 

ARTICLE 1 - REIMBURSEMENT UNDER MEDICAL SERVICE CONTRACT ORDISABILITY INSURANCE POLICY

 

26-22-101. Reimbursement for health services provided by licensedpractitioner or registered dietitian not to be denied.

 

 

(a) Notwithstanding any provision of any medical servicecontract or policy of disability insurance or certificate to the contrary if amedical service contract or insurance policy or certificate provides forreimbursement to the insured or subscriber for health services, reimbursementin amounts provided under the contract or insurance policy shall not be deniedif the services are rendered to the insured or subscriber by a person licensedunder the laws of this state to treat the illness or disability or perform thehealth services covered by the contract or policy. Nothing in this sectionprevents the insured from contracting with the insurer for direct payment ofpolicy proceeds to the provider of health services.

 

(b) For purposes of reimbursements provided by subsection (a)of this section for dietary services, a dietitian registered with thecommission on dietetic registration of the American dietetic association shallbe deemed a "person licensed" within the meaning of subsection (a)and benefits otherwise provided by the contract shall be provided. Nothing inthis section shall require a disability insurer to pay for services provided bya dietitian or a registered dietitian unless otherwise provided as a benefit inthe contract or policy.

 

26-22-102. Requirements of accident and sickness insurance to taxsupported institutions.

 

(a) No individual or group policy of accident and sicknessinsurance delivered or issued for delivery to any person in this state whichprovides coverage for mental illness or intellectual disability or both shallexclude benefits for the care or treatment of the mental illness orintellectual disability provided by a tax supported institution of the state,provided:

 

(i) The institution establishes and actively utilizesappropriate professional standard review organizations according to W.S.35-17-101, or comparable peer review programs;

 

(ii) The operation of the institution is subject to reviewaccording to federal and state law; and

 

(iii) Charges are made for the services.

 

26-22-103. Applicability; compliance by use of endorsements or riders.

 

W.S.26-22-102 and this section apply to all accident and sickness policies issuedand delivered in the state or issued for delivery in the state after January 1,1976, but do not apply to any policies issued and delivered in the state orissued for delivery in the state prior to that date. With respect to any policyforms approved by the insurance commission prior to January 1, 1976, an insureris authorized to achieve compliance by the use of endorsements or riders if theendorsements or riders are approved by the insurance commission as being incompliance with W.S. 26-22-102.

 

26-22-104. Reimbursement for health care; includes health care bypsychologists.

 

Notwithstandingany provisions in policies or contracts or certificates issued as evidencethereof which might be construed to the contrary, from and after July 1, 1985,all individual and group or blanket policies of accident and sickness insuranceor individual or group service or indemnity contracts issued by a corporationincluding corporations which provide health care to its employees as a benefitof employment which are issued, delivered, issued for delivery, amended orrenewed in this state or which cover any risk resident, located or to beperformed in this state and which provide coverage for diagnostic and therapeuticservices which are within the lawful scope of practice of a psychologist dulylicensed to practice, shall be deemed to provide that any person covered underthe policies or contracts is entitled to receive reimbursement for the servicesunder the policies or contracts if they are rendered by a duly licensed doctorof medicine or a duly licensed psychologist.

 

ARTICLE 2 - GROUP HEALTH INSURANCE CONVERSION

 

26-22-201. Group health insurance conversion.

 

Agroup policy or certificate delivered or issued for delivery in this statewhich provides hospital, surgical or major medical expense insurance, or anycombination of these coverages, on an expense incurred basis, but not a policywhich provides benefits for specific diseases or for accidental injuries only,shall provide that an employee or member whose insurance under the group policyhas been terminated for any reason and who has been continuously insured underthe group policy, and under any group policy providing similar benefits whichit replaces, for at least three (3) months immediately prior to termination, isentitled to have the insurer issue to him a policy of health insurance,referred to in this article as the converted policy. An employee or member isnot entitled to have a converted policy issued to him if termination of hisinsurance under the group policy occurred because he failed to pay any requiredcontribution, or any discontinued group coverage was replaced by similar groupcoverage within thirty-one (31) days from the date of discontinuation.

 

26-22-202. Issuance of a converted policy; conditions.

 

 

(a) Issuance of a converted policy is subject to the followingconditions:

 

(i) Written application for the converted policy shall be madeand the first premium paid to the insurer not later than thirty-one (31) daysafter termination of the insured's coverage by the group policy and terminationof the subsequent continuation rights offered by the group policy;

 

(ii) The effective date of the converted policy is the dayfollowing the termination of the insured's coverage under the group policy andtermination of the subsequent continuation rights offered by the group policy;

 

(iii) The converted policy shall:

 

(A) Cover the employee or member and his dependents who werecovered by the group policy on the date of termination of insurance, and at theinsurer's option, a separate converted policy may be issued to cover anydependent;

 

(B) Be issued without evidence of insurability;

 

(C) Not exclude a preexisting condition not excluded by thegroup policy.

 

(iv) The insurer is not required to issue a converted policy:

 

(A) Covering any person if the person is or could be covered byMedicare (Title XVIII of the United States Social Security Act as added by theSocial Security Amendments of 1965 or as later amended or superseded);

 

(B) Covering any person if:

 

(I) The person is covered for similar benefits by anotherhospital, surgical, medical or major medical expense insurance policy orhospital or medical service subscriber contract or medical practice or otherprepayment plan or by any other plan or program; or

 

(II) The person is eligible for similar benefits, whether or notcovered therefor, under any arrangement of coverage for individuals in a group,whether on an insured or uninsured basis; or

 

(III) Similar benefits are provided for or available to theperson, pursuant to or in accordance with the requirements of any state orfederal law; and

 

(IV) The benefits provided under the sources referred to insubdivision (B)(I) of this paragraph for the person or benefits provided oravailable under the sources referred to in subdivisions (B)(II) and (III) ofthis paragraph for the person, together with the benefits provided by theconverted policy, would result in overinsurance according to the insurer'sstandards. The insurer's standards must bear some reasonable relationship toactual health care costs in the area in which the insured lives at the time ofconversion and must be filed with the commissioner prior to their use indenying coverage;

 

(V) Which provides benefits in excess of those provided underthe group policy from which conversion is made.

 

(v) A converted policy may:

 

(A) Include a provision whereby the insurer may requestinformation in advance of any premium due date of the policy of any personcovered thereunder as to whether:

 

(I) He is covered for similar benefits by another hospital,surgical, medical or major medical expense insurance policy or hospital ormedical service subscriber contract or medical practice or other prepaymentplan or by any other plan or program;

 

(II) He is covered for similar benefits under any arrangement ofcoverage for individuals in a group, whether on an insured or uninsured basis;or

 

(III) Similar benefits are provided for or available to theperson, pursuant to or in accordance with the requirements of any state orfederal law.

 

(B) Provide that the insurer may refuse to renew the policy orthe coverage of any person insured thereunder for the following reasons only:

 

(I) Either the benefits provided under the sources referred toin subdivisions (A)(I) and (II) of this paragraph for the person or benefitsprovided or available under the sources referred to in subdivision (A)(III) ofthis paragraph for the person, together with the benefits provided by theconverted policy, would result in overinsurance according to the insurer'sstandards on file with the commissioner, or the converted policyholder fails toprovide the requested information;

 

(II) Fraud or material misrepresentation in applying for anybenefits under the converted policy;

 

(III) Eligibility of the insured person for coverage underMedicare (Title XVIII of the United States Social Security Act as added by theSocial Security Amendments of 1965 or as later amended or superseded) or underany other state or federal law providing for benefits similar to those providedby the converted policy;

 

(IV) Other reasons the commissioner approves.

 

(C) Provide that any hospital, surgical or medical benefitspayable thereunder may be reduced by the amount of any such benefits payableunder the group policy after the termination of the individual's insuranceunder the group policy;

 

(D) Provide that during the first policy year the benefits payableunder the converted policy, together with the benefits payable under the grouppolicy, shall not exceed those that would have been payable had theindividual's insurance under the group policy remained in force and effect;

 

(E) Provide for reduction of coverage on any person upon hiseligibility for coverage under Medicare (Title XVIII of the United StatesSocial Security Act as added by the Social Security Amendments of 1965 or aslater amended or superseded) or under any other state or federal law providingfor benefits similar to those provided by the converted policy.

 

(vi) Subject to the provisions and conditions of this section:

 

(A) If the group insurance policy from which conversion is madeinsures the employee or member for:

 

(I) Basic hospital or surgical expense insurance, the employeeor member is entitled to obtain a converted policy providing, at his option,coverage on an expense incurred basis under any one (1) of the plans meetingthe following requirements:

 

(1) Plan A:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount approximating the average semiprivate rate charged inmetropolitan areas of this state, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital expense benefits of a maximum amountof ten (10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit ofeight hundred dollars ($800.00); or

 

(2) Plan B:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount equal to seventy-five percent (75%) of the maximum dollar amountdetermined for Plan A, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital expense benefits of a maximum amountof ten (10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit of sixhundred dollars ($600.00); or

 

(3) Plan C:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount equal to fifty percent (50%) of the maximum dollar amountdetermined for Plan A, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital benefits of a maximum amount of ten(10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit of fourhundred dollars ($400.00);

 

d. The maximum dollar amounts in Plan A shall be determined bythe commissioner and may be redetermined by him from time to time as toconverted policies issued subsequent to the redetermination, except that noredetermination shall be made more often than once in three (3) years and themaximum dollar amounts in Plans A, B and C shall be rounded to the nearestmultiple of ten dollars ($10.00).

 

(II) Major medical expense insurance, the employee or member isentitled to obtain a converted policy providing catastrophic or major medicalcoverage under a plan meeting the following requirements:

 

(1) A maximum benefit at least equal to either, at theinsurer's option, subdivisions (1) or (2) of this subdivision:

 

a. The smaller of the following amounts:

 

i. The maximum benefit provided under the group policy;

 

ii. A maximum payment of two hundred fifty thousand dollars($250,000.00) per covered person for all covered medical expenses incurredduring the covered person's lifetime.

 

b. The smaller of the following amounts:

 

i. The maximum benefit provided under the group policy;

 

ii. A maximum payment of two hundred fifty thousand dollars($250,000.00) for each unrelated injury or sickness.

 

(2) Payment of benefits at the rate of eighty percent (80%) ofcovered medical expenses which are in excess of the deductible, until twentypercent (20%) of those expenses in a benefit period reaches one thousanddollars ($1,000.00), after which benefits will be paid at the rate of onehundred percent (100%) during the remainder of the benefit period, except thatpayment of benefits for outpatient treatment of mental illness, if provided inthe converted policy, may be at a lesser rate but not less than fifty percent(50%);

 

(3) A deductible for each benefit period which, at theinsurer's option, shall be either the sum of the benefits deductible and onehundred dollars ($100.00), or the corresponding deductible in the group policy.

 

(B) The conversion privilege shall also be available to:

 

(I) The surviving spouse, if any, at the death of the employeeor member, with respect to the spouse and the children whose coverage under thegroup policy terminates by reason of the death, otherwise to each survivingchild whose coverage under the group policy terminates by reason of the death,or if the group policy provides for continuation of dependent's coveragefollowing the employee's or member's death, at the end of the continuation;

 

(II) The spouse of the employee or member upon termination ofcoverage of the spouse, while the employee or member remains insured under thegroup policy, by reason of ceasing to be a qualified family member under thegroup policy, with respect to the spouse and the children whose coverage under thegroup policy terminates at the same time; or

 

(III) A child solely with respect to himself upon termination ofhis coverage by reason of ceasing to be a qualified member under the grouppolicy, if a conversion privilege is not otherwise provided in this sectionwith respect to the termination.

 

(vii) If the maximum benefit is determined by subdivision(A)(II)(1)b. of this paragraph, the insurer may require that the deductible besatisfied during a period of not less than three (3) months if the deductibleis one hundred dollars ($100.00) or less, and not less than six (6) months ifthe deductible exceeds one hundred dollars ($100.00);

 

(viii) The benefit period shall be each calendar year when themaximum benefit is determined by subdivision (A)(II)(1) of this paragraph ortwenty-four (24) months when the maximum benefit is determined by subdivision(A)(II)(1)b. of this paragraph;

 

(ix) Any surgical schedule shall be consistent with thosecustomarily offered by the insurer under group or individual health insurancepolicies and shall provide at least a one thousand two hundred dollar($1,200.00) maximum benefit;

 

(x) As used in paragraph (vi) of this subsection:

 

(A) "Benefits deductible" means the value of anybenefits provided on an expense incurred basis which are provided with respectto covered medical expenses by any other hospital, surgical or medicalinsurance policy or hospital or medical service subscriber contract or medicalpractice or other prepayment plan, or any other plan or program whether on aninsured or uninsured basis, or in accordance with the requirements of any stateor federal law and, if pursuant to paragraph (viii) of this subsection, theconverted policy provides both basic hospital or surgical coverage and majormedical coverage, the value of the basic benefits;

 

(B) "Covered medical expenses" includes, at least, inthe case of hospital room and board charges, the lesser of the dollar amount inPlan A and the average semiprivate room and board rate for the hospital inwhich the individual is confined and twice that amount for charges in anintensive care unit.

 

(xi) The conversion privilege required by this section shall, ifthe group insurance policy insures the employee or member for basic hospital orsurgical expense insurance as well as major medical expense insurance, makeavailable the plans of benefits set forth in paragraph (vi) of this subsection;

 

(xii) An insurer may:

 

(A) Provide the plans of benefits specified in paragraph (vi)of this subsection under one (1) policy;

 

(B) Instead of the plans of benefits set forth in paragraph(vi) of this subsection, provide a policy of comprehensive medical expensebenefits without first dollar coverage, which policy shall conform to therequirements of subparagraph (vi)(B) of this subsection, except that an insurerelecting to provide such a policy shall make available a low deductible option,not to exceed one hundred dollars ($100.00), a high deductible option betweenfive hundred dollars ($500.00) and one thousand dollars ($1,000.00) and a thirddeductible option midway between the high and low deductible options;

 

(C) Offer alternative plans for group health conversion inaddition to those required by this section;

 

(D) Provide group insurance coverage instead of issuing aconverted individual policy.

 

(xiii) If coverage would be continued under the group policy on anemployee following his retirement prior to the time he is or could be coveredby Medicare, he may elect instead of continuation of group insurance, to havethe same conversion rights as would apply if his insurance terminated atretirement by reason of termination of employment or membership;

 

(xiv) If the benefit levels required in paragraph (vi) of thissubsection exceed the benefit levels provided under the group policy, theconversion policy may offer benefits which are substantially similar to thoseprovided under the group policy instead of those required in paragraph (vi) ofthis subsection;

 

(xv) Maternity benefits may be included at the insured's optionand may be subject to the preexisting conditions limitations as discussed underparagraph (v) of this subsection;

 

(xvi) A notification of the conversion privilege shall beincluded in each certificate of coverage;

 

(xvii) A converted policy which is delivered outside this statemust be on a form which could be delivered in the other jurisdiction as aconverted policy had the group policy been issued in that jurisdiction.

 

ARTICLE 3 - PREPAID HOSPITAL, MEDICAL-SURGICAL OR OTHER HEALTHSERVICE PLANS

 

26-22-301. Prepaid hospital, medical-surgical or other health serviceplans subject to provisions of code; exceptions.

 

 

(a) Any corporation which establishes, maintains or operatesprepaid hospital, medical-surgical or other health service plans, orcombination thereof, in which hospital, medical-surgical or other healthservice may be provided to its members or subscribers by hospitals orphysicians with which the corporation has contracted for that purpose, istransacting insurance and subject to regulation and taxation as an insurerunder this code.

 

(b) This section does not apply to company-operated oremployee-operated organizations, not covered by hospital or sickness insurance,but formed and operated for the purpose of providing hospital or medicalservices supported or financed by dues paid to the associations by or on behalfof those who are employees or pensioners of the company.

 

ARTICLE 4 - INSURANCE FOR MENTALLY RETARDED OR PHYSICALLYHANDICAPPED

 

26-22-401. Required provision of individual or group policy orcontract.

 

(a) Any individual or group hospital or medical expenseinsurance policy or hospital service plan contract or medical service plancontract, delivered or issued for delivery in this state which provides thatcoverage of a dependent child of a policyholder or subscriber, or of anemployee or other member of the covered group, as the case may be, terminatesupon attainment of the limiting age for dependent children specified in thepolicy or contract, shall also provide in substance that attainment of thelimiting age does not terminate the child's coverage while the child is andcontinues to be both:

 

(i) Incapable of self-sustaining employment by reason ofintellectual disability or physical disability; and

 

(ii) Chiefly dependent upon the policyholder or subscriber, orthe employee or other member of the covered group, as the case may be, forsupport and maintenance, provided proof of the incapacity and dependency isfurnished to the insurer or hospital service plan corporation or medicalservice plan corporation by the policyholder or subscriber, or employee orother member of the covered group, as the case may be, within thirty-one (31)days of the child's attainment of the limiting age and subsequently as theinsurer or corporation requires but not more frequently than annually after thetwo (2) year period following the child's attainment of the limiting age.

 

ARTICLE 5 - HEALTH CARE REIMBURSEMENT REFORM

 

26-22-501. Short title.

 

Thisarticle is known and may be cited as the "Health Care Reimbursement ReformAct of 1985".

 

26-22-502. Definitions.

 

 

(a) As used in this article:

 

(i) "Group" means any individual, partnership orcorporation employing individuals in any occupation, or any labor union orother association representing such individuals if those individuals wouldqualify as an eligible group under W.S. 26-19-102(a)(i), (ii), (iii) or (viii)or any other number of individuals organized or united for a common purposeincluding any purpose specified in this article;

 

(ii) "Health care services" means health care servicesor products rendered or sold by a provider within the scope of the provider'slicense or legal authorization and includes, but is not limited to, hospital,medical, surgical, dental, vision and pharmaceutical services or products;

 

(iii) "Insured" means an individual entitled toreimbursement for expenses of health care services under an agreement between agroup and a provider or under a policy or subscriber contract issued oradministered by an insurer;

 

(iv) "Insurer" means an insurance company or a healthservice corporation authorized in this state to issue policies or subscribercontracts which reimburse for expenses of health care services;

 

(v) "Provider" means an individual or entity licensedor legally authorized to provide health care services.

 

26-22-503. Policies with incentives or limits on reimbursementauthorized; conditions.

 

 

(a) Notwithstanding any other provision of law to the contrary:

 

(i) Any provider may enter into a written agreement with anygroup or insurer relating to health care services which may be rendered toinsureds, including amounts to be charged the insured for services rendered;

 

(ii) Any group or insured may contract with insurers to issuepolicies which:

 

(A) Include incentives for the insured;

 

(B) Limit reimbursement for health care services.

 

(iii) Before entering into any written agreement under paragraph(a)(i) of this section, the group or insurer shall establish terms andconditions to be required of any provider interested in entering into theagreement. In no event shall the established terms and conditions discriminateagainst any Wyoming provider nor shall any Wyoming provider willing to meet theestablished terms and conditions be denied the right to enter into any writtenagreement;

 

(iv) This section shall not be construed to expand the scope ofcoverage as defined by any agreement.

 

(b) In no event may an insurer deny or limit reimbursement toan insured under this article on the grounds that the insured was not referredto the provider by a person acting on behalf of or under an agreement with theinsurer.

 

(c) Any group may contract with an insurer, preferred providerorganization or health maintenance organization for provision of medicalservices outside of Wyoming for the insureds of that group, provided theinsureds are not restricted from utilizing any Wyoming provider who providesthe same health care services.

 

26-22-504. Refusal to contract or compensate for covered services.

 

An insurer shall not refuse to contract with or compensatefor covered services an otherwise eligible health care provider solely becausethat provider has in good faith communicated with one (1) or more of hiscurrent, former or prospective patients regarding the provisions, terms orrequirements of the insurer's products as they related to the needs of thatprovider's patients.

 

State Codes and Statutes

Statutes > Wyoming > Title26 > Chapter22

CHAPTER 22 - HOSPITAL OR MEDICAL SERVICE INSURANCE AND PREPAIDHEALTH SERVICE PLANS

 

ARTICLE 1 - REIMBURSEMENT UNDER MEDICAL SERVICE CONTRACT ORDISABILITY INSURANCE POLICY

 

26-22-101. Reimbursement for health services provided by licensedpractitioner or registered dietitian not to be denied.

 

 

(a) Notwithstanding any provision of any medical servicecontract or policy of disability insurance or certificate to the contrary if amedical service contract or insurance policy or certificate provides forreimbursement to the insured or subscriber for health services, reimbursementin amounts provided under the contract or insurance policy shall not be deniedif the services are rendered to the insured or subscriber by a person licensedunder the laws of this state to treat the illness or disability or perform thehealth services covered by the contract or policy. Nothing in this sectionprevents the insured from contracting with the insurer for direct payment ofpolicy proceeds to the provider of health services.

 

(b) For purposes of reimbursements provided by subsection (a)of this section for dietary services, a dietitian registered with thecommission on dietetic registration of the American dietetic association shallbe deemed a "person licensed" within the meaning of subsection (a)and benefits otherwise provided by the contract shall be provided. Nothing inthis section shall require a disability insurer to pay for services provided bya dietitian or a registered dietitian unless otherwise provided as a benefit inthe contract or policy.

 

26-22-102. Requirements of accident and sickness insurance to taxsupported institutions.

 

(a) No individual or group policy of accident and sicknessinsurance delivered or issued for delivery to any person in this state whichprovides coverage for mental illness or intellectual disability or both shallexclude benefits for the care or treatment of the mental illness orintellectual disability provided by a tax supported institution of the state,provided:

 

(i) The institution establishes and actively utilizesappropriate professional standard review organizations according to W.S.35-17-101, or comparable peer review programs;

 

(ii) The operation of the institution is subject to reviewaccording to federal and state law; and

 

(iii) Charges are made for the services.

 

26-22-103. Applicability; compliance by use of endorsements or riders.

 

W.S.26-22-102 and this section apply to all accident and sickness policies issuedand delivered in the state or issued for delivery in the state after January 1,1976, but do not apply to any policies issued and delivered in the state orissued for delivery in the state prior to that date. With respect to any policyforms approved by the insurance commission prior to January 1, 1976, an insureris authorized to achieve compliance by the use of endorsements or riders if theendorsements or riders are approved by the insurance commission as being incompliance with W.S. 26-22-102.

 

26-22-104. Reimbursement for health care; includes health care bypsychologists.

 

Notwithstandingany provisions in policies or contracts or certificates issued as evidencethereof which might be construed to the contrary, from and after July 1, 1985,all individual and group or blanket policies of accident and sickness insuranceor individual or group service or indemnity contracts issued by a corporationincluding corporations which provide health care to its employees as a benefitof employment which are issued, delivered, issued for delivery, amended orrenewed in this state or which cover any risk resident, located or to beperformed in this state and which provide coverage for diagnostic and therapeuticservices which are within the lawful scope of practice of a psychologist dulylicensed to practice, shall be deemed to provide that any person covered underthe policies or contracts is entitled to receive reimbursement for the servicesunder the policies or contracts if they are rendered by a duly licensed doctorof medicine or a duly licensed psychologist.

 

ARTICLE 2 - GROUP HEALTH INSURANCE CONVERSION

 

26-22-201. Group health insurance conversion.

 

Agroup policy or certificate delivered or issued for delivery in this statewhich provides hospital, surgical or major medical expense insurance, or anycombination of these coverages, on an expense incurred basis, but not a policywhich provides benefits for specific diseases or for accidental injuries only,shall provide that an employee or member whose insurance under the group policyhas been terminated for any reason and who has been continuously insured underthe group policy, and under any group policy providing similar benefits whichit replaces, for at least three (3) months immediately prior to termination, isentitled to have the insurer issue to him a policy of health insurance,referred to in this article as the converted policy. An employee or member isnot entitled to have a converted policy issued to him if termination of hisinsurance under the group policy occurred because he failed to pay any requiredcontribution, or any discontinued group coverage was replaced by similar groupcoverage within thirty-one (31) days from the date of discontinuation.

 

26-22-202. Issuance of a converted policy; conditions.

 

 

(a) Issuance of a converted policy is subject to the followingconditions:

 

(i) Written application for the converted policy shall be madeand the first premium paid to the insurer not later than thirty-one (31) daysafter termination of the insured's coverage by the group policy and terminationof the subsequent continuation rights offered by the group policy;

 

(ii) The effective date of the converted policy is the dayfollowing the termination of the insured's coverage under the group policy andtermination of the subsequent continuation rights offered by the group policy;

 

(iii) The converted policy shall:

 

(A) Cover the employee or member and his dependents who werecovered by the group policy on the date of termination of insurance, and at theinsurer's option, a separate converted policy may be issued to cover anydependent;

 

(B) Be issued without evidence of insurability;

 

(C) Not exclude a preexisting condition not excluded by thegroup policy.

 

(iv) The insurer is not required to issue a converted policy:

 

(A) Covering any person if the person is or could be covered byMedicare (Title XVIII of the United States Social Security Act as added by theSocial Security Amendments of 1965 or as later amended or superseded);

 

(B) Covering any person if:

 

(I) The person is covered for similar benefits by anotherhospital, surgical, medical or major medical expense insurance policy orhospital or medical service subscriber contract or medical practice or otherprepayment plan or by any other plan or program; or

 

(II) The person is eligible for similar benefits, whether or notcovered therefor, under any arrangement of coverage for individuals in a group,whether on an insured or uninsured basis; or

 

(III) Similar benefits are provided for or available to theperson, pursuant to or in accordance with the requirements of any state orfederal law; and

 

(IV) The benefits provided under the sources referred to insubdivision (B)(I) of this paragraph for the person or benefits provided oravailable under the sources referred to in subdivisions (B)(II) and (III) ofthis paragraph for the person, together with the benefits provided by theconverted policy, would result in overinsurance according to the insurer'sstandards. The insurer's standards must bear some reasonable relationship toactual health care costs in the area in which the insured lives at the time ofconversion and must be filed with the commissioner prior to their use indenying coverage;

 

(V) Which provides benefits in excess of those provided underthe group policy from which conversion is made.

 

(v) A converted policy may:

 

(A) Include a provision whereby the insurer may requestinformation in advance of any premium due date of the policy of any personcovered thereunder as to whether:

 

(I) He is covered for similar benefits by another hospital,surgical, medical or major medical expense insurance policy or hospital ormedical service subscriber contract or medical practice or other prepaymentplan or by any other plan or program;

 

(II) He is covered for similar benefits under any arrangement ofcoverage for individuals in a group, whether on an insured or uninsured basis;or

 

(III) Similar benefits are provided for or available to theperson, pursuant to or in accordance with the requirements of any state orfederal law.

 

(B) Provide that the insurer may refuse to renew the policy orthe coverage of any person insured thereunder for the following reasons only:

 

(I) Either the benefits provided under the sources referred toin subdivisions (A)(I) and (II) of this paragraph for the person or benefitsprovided or available under the sources referred to in subdivision (A)(III) ofthis paragraph for the person, together with the benefits provided by theconverted policy, would result in overinsurance according to the insurer'sstandards on file with the commissioner, or the converted policyholder fails toprovide the requested information;

 

(II) Fraud or material misrepresentation in applying for anybenefits under the converted policy;

 

(III) Eligibility of the insured person for coverage underMedicare (Title XVIII of the United States Social Security Act as added by theSocial Security Amendments of 1965 or as later amended or superseded) or underany other state or federal law providing for benefits similar to those providedby the converted policy;

 

(IV) Other reasons the commissioner approves.

 

(C) Provide that any hospital, surgical or medical benefitspayable thereunder may be reduced by the amount of any such benefits payableunder the group policy after the termination of the individual's insuranceunder the group policy;

 

(D) Provide that during the first policy year the benefits payableunder the converted policy, together with the benefits payable under the grouppolicy, shall not exceed those that would have been payable had theindividual's insurance under the group policy remained in force and effect;

 

(E) Provide for reduction of coverage on any person upon hiseligibility for coverage under Medicare (Title XVIII of the United StatesSocial Security Act as added by the Social Security Amendments of 1965 or aslater amended or superseded) or under any other state or federal law providingfor benefits similar to those provided by the converted policy.

 

(vi) Subject to the provisions and conditions of this section:

 

(A) If the group insurance policy from which conversion is madeinsures the employee or member for:

 

(I) Basic hospital or surgical expense insurance, the employeeor member is entitled to obtain a converted policy providing, at his option,coverage on an expense incurred basis under any one (1) of the plans meetingthe following requirements:

 

(1) Plan A:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount approximating the average semiprivate rate charged inmetropolitan areas of this state, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital expense benefits of a maximum amountof ten (10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit ofeight hundred dollars ($800.00); or

 

(2) Plan B:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount equal to seventy-five percent (75%) of the maximum dollar amountdetermined for Plan A, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital expense benefits of a maximum amountof ten (10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit of sixhundred dollars ($600.00); or

 

(3) Plan C:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount equal to fifty percent (50%) of the maximum dollar amountdetermined for Plan A, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital benefits of a maximum amount of ten(10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit of fourhundred dollars ($400.00);

 

d. The maximum dollar amounts in Plan A shall be determined bythe commissioner and may be redetermined by him from time to time as toconverted policies issued subsequent to the redetermination, except that noredetermination shall be made more often than once in three (3) years and themaximum dollar amounts in Plans A, B and C shall be rounded to the nearestmultiple of ten dollars ($10.00).

 

(II) Major medical expense insurance, the employee or member isentitled to obtain a converted policy providing catastrophic or major medicalcoverage under a plan meeting the following requirements:

 

(1) A maximum benefit at least equal to either, at theinsurer's option, subdivisions (1) or (2) of this subdivision:

 

a. The smaller of the following amounts:

 

i. The maximum benefit provided under the group policy;

 

ii. A maximum payment of two hundred fifty thousand dollars($250,000.00) per covered person for all covered medical expenses incurredduring the covered person's lifetime.

 

b. The smaller of the following amounts:

 

i. The maximum benefit provided under the group policy;

 

ii. A maximum payment of two hundred fifty thousand dollars($250,000.00) for each unrelated injury or sickness.

 

(2) Payment of benefits at the rate of eighty percent (80%) ofcovered medical expenses which are in excess of the deductible, until twentypercent (20%) of those expenses in a benefit period reaches one thousanddollars ($1,000.00), after which benefits will be paid at the rate of onehundred percent (100%) during the remainder of the benefit period, except thatpayment of benefits for outpatient treatment of mental illness, if provided inthe converted policy, may be at a lesser rate but not less than fifty percent(50%);

 

(3) A deductible for each benefit period which, at theinsurer's option, shall be either the sum of the benefits deductible and onehundred dollars ($100.00), or the corresponding deductible in the group policy.

 

(B) The conversion privilege shall also be available to:

 

(I) The surviving spouse, if any, at the death of the employeeor member, with respect to the spouse and the children whose coverage under thegroup policy terminates by reason of the death, otherwise to each survivingchild whose coverage under the group policy terminates by reason of the death,or if the group policy provides for continuation of dependent's coveragefollowing the employee's or member's death, at the end of the continuation;

 

(II) The spouse of the employee or member upon termination ofcoverage of the spouse, while the employee or member remains insured under thegroup policy, by reason of ceasing to be a qualified family member under thegroup policy, with respect to the spouse and the children whose coverage under thegroup policy terminates at the same time; or

 

(III) A child solely with respect to himself upon termination ofhis coverage by reason of ceasing to be a qualified member under the grouppolicy, if a conversion privilege is not otherwise provided in this sectionwith respect to the termination.

 

(vii) If the maximum benefit is determined by subdivision(A)(II)(1)b. of this paragraph, the insurer may require that the deductible besatisfied during a period of not less than three (3) months if the deductibleis one hundred dollars ($100.00) or less, and not less than six (6) months ifthe deductible exceeds one hundred dollars ($100.00);

 

(viii) The benefit period shall be each calendar year when themaximum benefit is determined by subdivision (A)(II)(1) of this paragraph ortwenty-four (24) months when the maximum benefit is determined by subdivision(A)(II)(1)b. of this paragraph;

 

(ix) Any surgical schedule shall be consistent with thosecustomarily offered by the insurer under group or individual health insurancepolicies and shall provide at least a one thousand two hundred dollar($1,200.00) maximum benefit;

 

(x) As used in paragraph (vi) of this subsection:

 

(A) "Benefits deductible" means the value of anybenefits provided on an expense incurred basis which are provided with respectto covered medical expenses by any other hospital, surgical or medicalinsurance policy or hospital or medical service subscriber contract or medicalpractice or other prepayment plan, or any other plan or program whether on aninsured or uninsured basis, or in accordance with the requirements of any stateor federal law and, if pursuant to paragraph (viii) of this subsection, theconverted policy provides both basic hospital or surgical coverage and majormedical coverage, the value of the basic benefits;

 

(B) "Covered medical expenses" includes, at least, inthe case of hospital room and board charges, the lesser of the dollar amount inPlan A and the average semiprivate room and board rate for the hospital inwhich the individual is confined and twice that amount for charges in anintensive care unit.

 

(xi) The conversion privilege required by this section shall, ifthe group insurance policy insures the employee or member for basic hospital orsurgical expense insurance as well as major medical expense insurance, makeavailable the plans of benefits set forth in paragraph (vi) of this subsection;

 

(xii) An insurer may:

 

(A) Provide the plans of benefits specified in paragraph (vi)of this subsection under one (1) policy;

 

(B) Instead of the plans of benefits set forth in paragraph(vi) of this subsection, provide a policy of comprehensive medical expensebenefits without first dollar coverage, which policy shall conform to therequirements of subparagraph (vi)(B) of this subsection, except that an insurerelecting to provide such a policy shall make available a low deductible option,not to exceed one hundred dollars ($100.00), a high deductible option betweenfive hundred dollars ($500.00) and one thousand dollars ($1,000.00) and a thirddeductible option midway between the high and low deductible options;

 

(C) Offer alternative plans for group health conversion inaddition to those required by this section;

 

(D) Provide group insurance coverage instead of issuing aconverted individual policy.

 

(xiii) If coverage would be continued under the group policy on anemployee following his retirement prior to the time he is or could be coveredby Medicare, he may elect instead of continuation of group insurance, to havethe same conversion rights as would apply if his insurance terminated atretirement by reason of termination of employment or membership;

 

(xiv) If the benefit levels required in paragraph (vi) of thissubsection exceed the benefit levels provided under the group policy, theconversion policy may offer benefits which are substantially similar to thoseprovided under the group policy instead of those required in paragraph (vi) ofthis subsection;

 

(xv) Maternity benefits may be included at the insured's optionand may be subject to the preexisting conditions limitations as discussed underparagraph (v) of this subsection;

 

(xvi) A notification of the conversion privilege shall beincluded in each certificate of coverage;

 

(xvii) A converted policy which is delivered outside this statemust be on a form which could be delivered in the other jurisdiction as aconverted policy had the group policy been issued in that jurisdiction.

 

ARTICLE 3 - PREPAID HOSPITAL, MEDICAL-SURGICAL OR OTHER HEALTHSERVICE PLANS

 

26-22-301. Prepaid hospital, medical-surgical or other health serviceplans subject to provisions of code; exceptions.

 

 

(a) Any corporation which establishes, maintains or operatesprepaid hospital, medical-surgical or other health service plans, orcombination thereof, in which hospital, medical-surgical or other healthservice may be provided to its members or subscribers by hospitals orphysicians with which the corporation has contracted for that purpose, istransacting insurance and subject to regulation and taxation as an insurerunder this code.

 

(b) This section does not apply to company-operated oremployee-operated organizations, not covered by hospital or sickness insurance,but formed and operated for the purpose of providing hospital or medicalservices supported or financed by dues paid to the associations by or on behalfof those who are employees or pensioners of the company.

 

ARTICLE 4 - INSURANCE FOR MENTALLY RETARDED OR PHYSICALLYHANDICAPPED

 

26-22-401. Required provision of individual or group policy orcontract.

 

(a) Any individual or group hospital or medical expenseinsurance policy or hospital service plan contract or medical service plancontract, delivered or issued for delivery in this state which provides thatcoverage of a dependent child of a policyholder or subscriber, or of anemployee or other member of the covered group, as the case may be, terminatesupon attainment of the limiting age for dependent children specified in thepolicy or contract, shall also provide in substance that attainment of thelimiting age does not terminate the child's coverage while the child is andcontinues to be both:

 

(i) Incapable of self-sustaining employment by reason ofintellectual disability or physical disability; and

 

(ii) Chiefly dependent upon the policyholder or subscriber, orthe employee or other member of the covered group, as the case may be, forsupport and maintenance, provided proof of the incapacity and dependency isfurnished to the insurer or hospital service plan corporation or medicalservice plan corporation by the policyholder or subscriber, or employee orother member of the covered group, as the case may be, within thirty-one (31)days of the child's attainment of the limiting age and subsequently as theinsurer or corporation requires but not more frequently than annually after thetwo (2) year period following the child's attainment of the limiting age.

 

ARTICLE 5 - HEALTH CARE REIMBURSEMENT REFORM

 

26-22-501. Short title.

 

Thisarticle is known and may be cited as the "Health Care Reimbursement ReformAct of 1985".

 

26-22-502. Definitions.

 

 

(a) As used in this article:

 

(i) "Group" means any individual, partnership orcorporation employing individuals in any occupation, or any labor union orother association representing such individuals if those individuals wouldqualify as an eligible group under W.S. 26-19-102(a)(i), (ii), (iii) or (viii)or any other number of individuals organized or united for a common purposeincluding any purpose specified in this article;

 

(ii) "Health care services" means health care servicesor products rendered or sold by a provider within the scope of the provider'slicense or legal authorization and includes, but is not limited to, hospital,medical, surgical, dental, vision and pharmaceutical services or products;

 

(iii) "Insured" means an individual entitled toreimbursement for expenses of health care services under an agreement between agroup and a provider or under a policy or subscriber contract issued oradministered by an insurer;

 

(iv) "Insurer" means an insurance company or a healthservice corporation authorized in this state to issue policies or subscribercontracts which reimburse for expenses of health care services;

 

(v) "Provider" means an individual or entity licensedor legally authorized to provide health care services.

 

26-22-503. Policies with incentives or limits on reimbursementauthorized; conditions.

 

 

(a) Notwithstanding any other provision of law to the contrary:

 

(i) Any provider may enter into a written agreement with anygroup or insurer relating to health care services which may be rendered toinsureds, including amounts to be charged the insured for services rendered;

 

(ii) Any group or insured may contract with insurers to issuepolicies which:

 

(A) Include incentives for the insured;

 

(B) Limit reimbursement for health care services.

 

(iii) Before entering into any written agreement under paragraph(a)(i) of this section, the group or insurer shall establish terms andconditions to be required of any provider interested in entering into theagreement. In no event shall the established terms and conditions discriminateagainst any Wyoming provider nor shall any Wyoming provider willing to meet theestablished terms and conditions be denied the right to enter into any writtenagreement;

 

(iv) This section shall not be construed to expand the scope ofcoverage as defined by any agreement.

 

(b) In no event may an insurer deny or limit reimbursement toan insured under this article on the grounds that the insured was not referredto the provider by a person acting on behalf of or under an agreement with theinsurer.

 

(c) Any group may contract with an insurer, preferred providerorganization or health maintenance organization for provision of medicalservices outside of Wyoming for the insureds of that group, provided theinsureds are not restricted from utilizing any Wyoming provider who providesthe same health care services.

 

26-22-504. Refusal to contract or compensate for covered services.

 

An insurer shall not refuse to contract with or compensatefor covered services an otherwise eligible health care provider solely becausethat provider has in good faith communicated with one (1) or more of hiscurrent, former or prospective patients regarding the provisions, terms orrequirements of the insurer's products as they related to the needs of thatprovider's patients.

 


State Codes and Statutes

State Codes and Statutes

Statutes > Wyoming > Title26 > Chapter22

CHAPTER 22 - HOSPITAL OR MEDICAL SERVICE INSURANCE AND PREPAIDHEALTH SERVICE PLANS

 

ARTICLE 1 - REIMBURSEMENT UNDER MEDICAL SERVICE CONTRACT ORDISABILITY INSURANCE POLICY

 

26-22-101. Reimbursement for health services provided by licensedpractitioner or registered dietitian not to be denied.

 

 

(a) Notwithstanding any provision of any medical servicecontract or policy of disability insurance or certificate to the contrary if amedical service contract or insurance policy or certificate provides forreimbursement to the insured or subscriber for health services, reimbursementin amounts provided under the contract or insurance policy shall not be deniedif the services are rendered to the insured or subscriber by a person licensedunder the laws of this state to treat the illness or disability or perform thehealth services covered by the contract or policy. Nothing in this sectionprevents the insured from contracting with the insurer for direct payment ofpolicy proceeds to the provider of health services.

 

(b) For purposes of reimbursements provided by subsection (a)of this section for dietary services, a dietitian registered with thecommission on dietetic registration of the American dietetic association shallbe deemed a "person licensed" within the meaning of subsection (a)and benefits otherwise provided by the contract shall be provided. Nothing inthis section shall require a disability insurer to pay for services provided bya dietitian or a registered dietitian unless otherwise provided as a benefit inthe contract or policy.

 

26-22-102. Requirements of accident and sickness insurance to taxsupported institutions.

 

(a) No individual or group policy of accident and sicknessinsurance delivered or issued for delivery to any person in this state whichprovides coverage for mental illness or intellectual disability or both shallexclude benefits for the care or treatment of the mental illness orintellectual disability provided by a tax supported institution of the state,provided:

 

(i) The institution establishes and actively utilizesappropriate professional standard review organizations according to W.S.35-17-101, or comparable peer review programs;

 

(ii) The operation of the institution is subject to reviewaccording to federal and state law; and

 

(iii) Charges are made for the services.

 

26-22-103. Applicability; compliance by use of endorsements or riders.

 

W.S.26-22-102 and this section apply to all accident and sickness policies issuedand delivered in the state or issued for delivery in the state after January 1,1976, but do not apply to any policies issued and delivered in the state orissued for delivery in the state prior to that date. With respect to any policyforms approved by the insurance commission prior to January 1, 1976, an insureris authorized to achieve compliance by the use of endorsements or riders if theendorsements or riders are approved by the insurance commission as being incompliance with W.S. 26-22-102.

 

26-22-104. Reimbursement for health care; includes health care bypsychologists.

 

Notwithstandingany provisions in policies or contracts or certificates issued as evidencethereof which might be construed to the contrary, from and after July 1, 1985,all individual and group or blanket policies of accident and sickness insuranceor individual or group service or indemnity contracts issued by a corporationincluding corporations which provide health care to its employees as a benefitof employment which are issued, delivered, issued for delivery, amended orrenewed in this state or which cover any risk resident, located or to beperformed in this state and which provide coverage for diagnostic and therapeuticservices which are within the lawful scope of practice of a psychologist dulylicensed to practice, shall be deemed to provide that any person covered underthe policies or contracts is entitled to receive reimbursement for the servicesunder the policies or contracts if they are rendered by a duly licensed doctorof medicine or a duly licensed psychologist.

 

ARTICLE 2 - GROUP HEALTH INSURANCE CONVERSION

 

26-22-201. Group health insurance conversion.

 

Agroup policy or certificate delivered or issued for delivery in this statewhich provides hospital, surgical or major medical expense insurance, or anycombination of these coverages, on an expense incurred basis, but not a policywhich provides benefits for specific diseases or for accidental injuries only,shall provide that an employee or member whose insurance under the group policyhas been terminated for any reason and who has been continuously insured underthe group policy, and under any group policy providing similar benefits whichit replaces, for at least three (3) months immediately prior to termination, isentitled to have the insurer issue to him a policy of health insurance,referred to in this article as the converted policy. An employee or member isnot entitled to have a converted policy issued to him if termination of hisinsurance under the group policy occurred because he failed to pay any requiredcontribution, or any discontinued group coverage was replaced by similar groupcoverage within thirty-one (31) days from the date of discontinuation.

 

26-22-202. Issuance of a converted policy; conditions.

 

 

(a) Issuance of a converted policy is subject to the followingconditions:

 

(i) Written application for the converted policy shall be madeand the first premium paid to the insurer not later than thirty-one (31) daysafter termination of the insured's coverage by the group policy and terminationof the subsequent continuation rights offered by the group policy;

 

(ii) The effective date of the converted policy is the dayfollowing the termination of the insured's coverage under the group policy andtermination of the subsequent continuation rights offered by the group policy;

 

(iii) The converted policy shall:

 

(A) Cover the employee or member and his dependents who werecovered by the group policy on the date of termination of insurance, and at theinsurer's option, a separate converted policy may be issued to cover anydependent;

 

(B) Be issued without evidence of insurability;

 

(C) Not exclude a preexisting condition not excluded by thegroup policy.

 

(iv) The insurer is not required to issue a converted policy:

 

(A) Covering any person if the person is or could be covered byMedicare (Title XVIII of the United States Social Security Act as added by theSocial Security Amendments of 1965 or as later amended or superseded);

 

(B) Covering any person if:

 

(I) The person is covered for similar benefits by anotherhospital, surgical, medical or major medical expense insurance policy orhospital or medical service subscriber contract or medical practice or otherprepayment plan or by any other plan or program; or

 

(II) The person is eligible for similar benefits, whether or notcovered therefor, under any arrangement of coverage for individuals in a group,whether on an insured or uninsured basis; or

 

(III) Similar benefits are provided for or available to theperson, pursuant to or in accordance with the requirements of any state orfederal law; and

 

(IV) The benefits provided under the sources referred to insubdivision (B)(I) of this paragraph for the person or benefits provided oravailable under the sources referred to in subdivisions (B)(II) and (III) ofthis paragraph for the person, together with the benefits provided by theconverted policy, would result in overinsurance according to the insurer'sstandards. The insurer's standards must bear some reasonable relationship toactual health care costs in the area in which the insured lives at the time ofconversion and must be filed with the commissioner prior to their use indenying coverage;

 

(V) Which provides benefits in excess of those provided underthe group policy from which conversion is made.

 

(v) A converted policy may:

 

(A) Include a provision whereby the insurer may requestinformation in advance of any premium due date of the policy of any personcovered thereunder as to whether:

 

(I) He is covered for similar benefits by another hospital,surgical, medical or major medical expense insurance policy or hospital ormedical service subscriber contract or medical practice or other prepaymentplan or by any other plan or program;

 

(II) He is covered for similar benefits under any arrangement ofcoverage for individuals in a group, whether on an insured or uninsured basis;or

 

(III) Similar benefits are provided for or available to theperson, pursuant to or in accordance with the requirements of any state orfederal law.

 

(B) Provide that the insurer may refuse to renew the policy orthe coverage of any person insured thereunder for the following reasons only:

 

(I) Either the benefits provided under the sources referred toin subdivisions (A)(I) and (II) of this paragraph for the person or benefitsprovided or available under the sources referred to in subdivision (A)(III) ofthis paragraph for the person, together with the benefits provided by theconverted policy, would result in overinsurance according to the insurer'sstandards on file with the commissioner, or the converted policyholder fails toprovide the requested information;

 

(II) Fraud or material misrepresentation in applying for anybenefits under the converted policy;

 

(III) Eligibility of the insured person for coverage underMedicare (Title XVIII of the United States Social Security Act as added by theSocial Security Amendments of 1965 or as later amended or superseded) or underany other state or federal law providing for benefits similar to those providedby the converted policy;

 

(IV) Other reasons the commissioner approves.

 

(C) Provide that any hospital, surgical or medical benefitspayable thereunder may be reduced by the amount of any such benefits payableunder the group policy after the termination of the individual's insuranceunder the group policy;

 

(D) Provide that during the first policy year the benefits payableunder the converted policy, together with the benefits payable under the grouppolicy, shall not exceed those that would have been payable had theindividual's insurance under the group policy remained in force and effect;

 

(E) Provide for reduction of coverage on any person upon hiseligibility for coverage under Medicare (Title XVIII of the United StatesSocial Security Act as added by the Social Security Amendments of 1965 or aslater amended or superseded) or under any other state or federal law providingfor benefits similar to those provided by the converted policy.

 

(vi) Subject to the provisions and conditions of this section:

 

(A) If the group insurance policy from which conversion is madeinsures the employee or member for:

 

(I) Basic hospital or surgical expense insurance, the employeeor member is entitled to obtain a converted policy providing, at his option,coverage on an expense incurred basis under any one (1) of the plans meetingthe following requirements:

 

(1) Plan A:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount approximating the average semiprivate rate charged inmetropolitan areas of this state, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital expense benefits of a maximum amountof ten (10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit ofeight hundred dollars ($800.00); or

 

(2) Plan B:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount equal to seventy-five percent (75%) of the maximum dollar amountdetermined for Plan A, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital expense benefits of a maximum amountof ten (10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit of sixhundred dollars ($600.00); or

 

(3) Plan C:

 

a. Hospital room and board daily expense benefits in a maximumdollar amount equal to fifty percent (50%) of the maximum dollar amountdetermined for Plan A, for a maximum duration of seventy (70) days;

 

b. Miscellaneous hospital benefits of a maximum amount of ten(10) times the hospital room and board daily expense benefits; and

 

c. Surgical operation expense benefits according to a surgicalschedule consistent with those customarily offered by the insurer under groupor individual health insurance policies and providing a maximum benefit of fourhundred dollars ($400.00);

 

d. The maximum dollar amounts in Plan A shall be determined bythe commissioner and may be redetermined by him from time to time as toconverted policies issued subsequent to the redetermination, except that noredetermination shall be made more often than once in three (3) years and themaximum dollar amounts in Plans A, B and C shall be rounded to the nearestmultiple of ten dollars ($10.00).

 

(II) Major medical expense insurance, the employee or member isentitled to obtain a converted policy providing catastrophic or major medicalcoverage under a plan meeting the following requirements:

 

(1) A maximum benefit at least equal to either, at theinsurer's option, subdivisions (1) or (2) of this subdivision:

 

a. The smaller of the following amounts:

 

i. The maximum benefit provided under the group policy;

 

ii. A maximum payment of two hundred fifty thousand dollars($250,000.00) per covered person for all covered medical expenses incurredduring the covered person's lifetime.

 

b. The smaller of the following amounts:

 

i. The maximum benefit provided under the group policy;

 

ii. A maximum payment of two hundred fifty thousand dollars($250,000.00) for each unrelated injury or sickness.

 

(2) Payment of benefits at the rate of eighty percent (80%) ofcovered medical expenses which are in excess of the deductible, until twentypercent (20%) of those expenses in a benefit period reaches one thousanddollars ($1,000.00), after which benefits will be paid at the rate of onehundred percent (100%) during the remainder of the benefit period, except thatpayment of benefits for outpatient treatment of mental illness, if provided inthe converted policy, may be at a lesser rate but not less than fifty percent(50%);

 

(3) A deductible for each benefit period which, at theinsurer's option, shall be either the sum of the benefits deductible and onehundred dollars ($100.00), or the corresponding deductible in the group policy.

 

(B) The conversion privilege shall also be available to:

 

(I) The surviving spouse, if any, at the death of the employeeor member, with respect to the spouse and the children whose coverage under thegroup policy terminates by reason of the death, otherwise to each survivingchild whose coverage under the group policy terminates by reason of the death,or if the group policy provides for continuation of dependent's coveragefollowing the employee's or member's death, at the end of the continuation;

 

(II) The spouse of the employee or member upon termination ofcoverage of the spouse, while the employee or member remains insured under thegroup policy, by reason of ceasing to be a qualified family member under thegroup policy, with respect to the spouse and the children whose coverage under thegroup policy terminates at the same time; or

 

(III) A child solely with respect to himself upon termination ofhis coverage by reason of ceasing to be a qualified member under the grouppolicy, if a conversion privilege is not otherwise provided in this sectionwith respect to the termination.

 

(vii) If the maximum benefit is determined by subdivision(A)(II)(1)b. of this paragraph, the insurer may require that the deductible besatisfied during a period of not less than three (3) months if the deductibleis one hundred dollars ($100.00) or less, and not less than six (6) months ifthe deductible exceeds one hundred dollars ($100.00);

 

(viii) The benefit period shall be each calendar year when themaximum benefit is determined by subdivision (A)(II)(1) of this paragraph ortwenty-four (24) months when the maximum benefit is determined by subdivision(A)(II)(1)b. of this paragraph;

 

(ix) Any surgical schedule shall be consistent with thosecustomarily offered by the insurer under group or individual health insurancepolicies and shall provide at least a one thousand two hundred dollar($1,200.00) maximum benefit;

 

(x) As used in paragraph (vi) of this subsection:

 

(A) "Benefits deductible" means the value of anybenefits provided on an expense incurred basis which are provided with respectto covered medical expenses by any other hospital, surgical or medicalinsurance policy or hospital or medical service subscriber contract or medicalpractice or other prepayment plan, or any other plan or program whether on aninsured or uninsured basis, or in accordance with the requirements of any stateor federal law and, if pursuant to paragraph (viii) of this subsection, theconverted policy provides both basic hospital or surgical coverage and majormedical coverage, the value of the basic benefits;

 

(B) "Covered medical expenses" includes, at least, inthe case of hospital room and board charges, the lesser of the dollar amount inPlan A and the average semiprivate room and board rate for the hospital inwhich the individual is confined and twice that amount for charges in anintensive care unit.

 

(xi) The conversion privilege required by this section shall, ifthe group insurance policy insures the employee or member for basic hospital orsurgical expense insurance as well as major medical expense insurance, makeavailable the plans of benefits set forth in paragraph (vi) of this subsection;

 

(xii) An insurer may:

 

(A) Provide the plans of benefits specified in paragraph (vi)of this subsection under one (1) policy;

 

(B) Instead of the plans of benefits set forth in paragraph(vi) of this subsection, provide a policy of comprehensive medical expensebenefits without first dollar coverage, which policy shall conform to therequirements of subparagraph (vi)(B) of this subsection, except that an insurerelecting to provide such a policy shall make available a low deductible option,not to exceed one hundred dollars ($100.00), a high deductible option betweenfive hundred dollars ($500.00) and one thousand dollars ($1,000.00) and a thirddeductible option midway between the high and low deductible options;

 

(C) Offer alternative plans for group health conversion inaddition to those required by this section;

 

(D) Provide group insurance coverage instead of issuing aconverted individual policy.

 

(xiii) If coverage would be continued under the group policy on anemployee following his retirement prior to the time he is or could be coveredby Medicare, he may elect instead of continuation of group insurance, to havethe same conversion rights as would apply if his insurance terminated atretirement by reason of termination of employment or membership;

 

(xiv) If the benefit levels required in paragraph (vi) of thissubsection exceed the benefit levels provided under the group policy, theconversion policy may offer benefits which are substantially similar to thoseprovided under the group policy instead of those required in paragraph (vi) ofthis subsection;

 

(xv) Maternity benefits may be included at the insured's optionand may be subject to the preexisting conditions limitations as discussed underparagraph (v) of this subsection;

 

(xvi) A notification of the conversion privilege shall beincluded in each certificate of coverage;

 

(xvii) A converted policy which is delivered outside this statemust be on a form which could be delivered in the other jurisdiction as aconverted policy had the group policy been issued in that jurisdiction.

 

ARTICLE 3 - PREPAID HOSPITAL, MEDICAL-SURGICAL OR OTHER HEALTHSERVICE PLANS

 

26-22-301. Prepaid hospital, medical-surgical or other health serviceplans subject to provisions of code; exceptions.

 

 

(a) Any corporation which establishes, maintains or operatesprepaid hospital, medical-surgical or other health service plans, orcombination thereof, in which hospital, medical-surgical or other healthservice may be provided to its members or subscribers by hospitals orphysicians with which the corporation has contracted for that purpose, istransacting insurance and subject to regulation and taxation as an insurerunder this code.

 

(b) This section does not apply to company-operated oremployee-operated organizations, not covered by hospital or sickness insurance,but formed and operated for the purpose of providing hospital or medicalservices supported or financed by dues paid to the associations by or on behalfof those who are employees or pensioners of the company.

 

ARTICLE 4 - INSURANCE FOR MENTALLY RETARDED OR PHYSICALLYHANDICAPPED

 

26-22-401. Required provision of individual or group policy orcontract.

 

(a) Any individual or group hospital or medical expenseinsurance policy or hospital service plan contract or medical service plancontract, delivered or issued for delivery in this state which provides thatcoverage of a dependent child of a policyholder or subscriber, or of anemployee or other member of the covered group, as the case may be, terminatesupon attainment of the limiting age for dependent children specified in thepolicy or contract, shall also provide in substance that attainment of thelimiting age does not terminate the child's coverage while the child is andcontinues to be both:

 

(i) Incapable of self-sustaining employment by reason ofintellectual disability or physical disability; and

 

(ii) Chiefly dependent upon the policyholder or subscriber, orthe employee or other member of the covered group, as the case may be, forsupport and maintenance, provided proof of the incapacity and dependency isfurnished to the insurer or hospital service plan corporation or medicalservice plan corporation by the policyholder or subscriber, or employee orother member of the covered group, as the case may be, within thirty-one (31)days of the child's attainment of the limiting age and subsequently as theinsurer or corporation requires but not more frequently than annually after thetwo (2) year period following the child's attainment of the limiting age.

 

ARTICLE 5 - HEALTH CARE REIMBURSEMENT REFORM

 

26-22-501. Short title.

 

Thisarticle is known and may be cited as the "Health Care Reimbursement ReformAct of 1985".

 

26-22-502. Definitions.

 

 

(a) As used in this article:

 

(i) "Group" means any individual, partnership orcorporation employing individuals in any occupation, or any labor union orother association representing such individuals if those individuals wouldqualify as an eligible group under W.S. 26-19-102(a)(i), (ii), (iii) or (viii)or any other number of individuals organized or united for a common purposeincluding any purpose specified in this article;

 

(ii) "Health care services" means health care servicesor products rendered or sold by a provider within the scope of the provider'slicense or legal authorization and includes, but is not limited to, hospital,medical, surgical, dental, vision and pharmaceutical services or products;

 

(iii) "Insured" means an individual entitled toreimbursement for expenses of health care services under an agreement between agroup and a provider or under a policy or subscriber contract issued oradministered by an insurer;

 

(iv) "Insurer" means an insurance company or a healthservice corporation authorized in this state to issue policies or subscribercontracts which reimburse for expenses of health care services;

 

(v) "Provider" means an individual or entity licensedor legally authorized to provide health care services.

 

26-22-503. Policies with incentives or limits on reimbursementauthorized; conditions.

 

 

(a) Notwithstanding any other provision of law to the contrary:

 

(i) Any provider may enter into a written agreement with anygroup or insurer relating to health care services which may be rendered toinsureds, including amounts to be charged the insured for services rendered;

 

(ii) Any group or insured may contract with insurers to issuepolicies which:

 

(A) Include incentives for the insured;

 

(B) Limit reimbursement for health care services.

 

(iii) Before entering into any written agreement under paragraph(a)(i) of this section, the group or insurer shall establish terms andconditions to be required of any provider interested in entering into theagreement. In no event shall the established terms and conditions discriminateagainst any Wyoming provider nor shall any Wyoming provider willing to meet theestablished terms and conditions be denied the right to enter into any writtenagreement;

 

(iv) This section shall not be construed to expand the scope ofcoverage as defined by any agreement.

 

(b) In no event may an insurer deny or limit reimbursement toan insured under this article on the grounds that the insured was not referredto the provider by a person acting on behalf of or under an agreement with theinsurer.

 

(c) Any group may contract with an insurer, preferred providerorganization or health maintenance organization for provision of medicalservices outside of Wyoming for the insureds of that group, provided theinsureds are not restricted from utilizing any Wyoming provider who providesthe same health care services.

 

26-22-504. Refusal to contract or compensate for covered services.

 

An insurer shall not refuse to contract with or compensatefor covered services an otherwise eligible health care provider solely becausethat provider has in good faith communicated with one (1) or more of hiscurrent, former or prospective patients regarding the provisions, terms orrequirements of the insurer's products as they related to the needs of thatprovider's patients.

 

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