Wyo. Code R. 044-0002-41
Chapter 41: Scope of Pool Coverage & Schedule of Benefits by WY Health Insurance Pool
Effective Date: 12/31/1996 to 12/09/2016
Rule Type: Superceded Rules & Regulations
Reference Number: 044.0002.41.12311996
SCOPE OF POOL COVERAGE AND SCHEDULE OF BENEFITS OFFERED BY WYOMING HEALTH INSURANCE POOL
This regulation is issued pursuant to the authority vested in the Wyoming Insurance Commissioner under W.S. 26-2-110 and W.S. 26-43-106 of the Wyoming Insurance Code and W.S. 16-3-101, et seq., of the Wyoming Administrative Procedure Act.
The purpose of this regulation is to set forth the scope of pool coverage and schedule of benefits offered by the Wyoming Health Insurance Pool.
(a) A 'resident' of the state for purposes of eligibility for pool coverage shall mean:
(i) Any individual person who occupies a dwelling in this state and has a present intent to make this state his home.
(ii) The pool administrator shall consider the following factors as indicating intent to remain in this state:
(A) Whether the applicant (or his custodial parent in the case of a minor) is registered to vote in this state;
(B) Whether the applicant (or his custodial parent in the case of a minor) has applied for or received a Wyoming driver's license;
(C) Whether the minor children of the applicant are enrolled to attend school in this state;
(D) If the applicant is of school age, then whether the applicant is enrolled to attend school in this state; and
(E) Whether the applicant (or his custodial parent in the case of a minor) has applied for or currently receives service in his name from any public utility at a dwelling within this state.
(iii) Any applicant currently occupying a dwelling in this state and meeting any two or more of the above-listed criteria shall be considered a resident eligible for pool coverage.
(iv) Any applicant denied pool coverage due to the administrator's determination of resident status shall have a right to appeal the administrator's determination in the manner set forth in the Plan of Operation for the pool.
The Wyoming Health Insurance pool provides coverage on all policies issued by the pool after January 1, 1991. The general benefit features for an insured of the pool are set forth in Appendix A.
Any section or provision of this regulation held by a court to be invalid or unconstitutional shall not affect the validity of any other section or provision of this regulation.
This regulation shall become effective upon filing with the Secretary of State.
SUMMARY OF BENEFIT FEATURES
Lifetime Maximum of: $[250,000]*
Out-of-Pocket Maximum of: $[3,000] per individual $[9,000] per family of 3 or more
Type A (reimbursed at [80]% of R&C after deductibles have been met)
| Inpatient Surgical | $[500] deductible per admission |
|---|---|
| Inpatient Medical | $[500] deductible per admission |
| Outpatient Surgery | $[500] deductible |
| Inpatient Physician | [No deductible] |
| Outpatient Physician Surgery | [No deductible] |
| Office Surgery | $[100] deductible per surgery |
| Ambulance | [No deductible]/subject to contract limitations |
Type B (reimbursed at [70%] of R&C after $[2,000] deductible has been met)
Type C (reimbursed at [100]% of R&C after $[4,000] deductible has been met)
This is intended as a brief overview of benefits for the Wyoming Health Insurance Pool.
*Hereinafter, every amount that appears in brackets is subject to change by the Wyoming Health Insurance Pool Board. Current amounts may be obtained from the Wyoming Insurance Department.
BENEFIT STRUCTURE
$[250,000] lifetime maximum*
Total out-of-pocket cost -- $[3,000] per individual. $[9,000] per family of 3 or more
| Benefits | Deductible | Reimbursement | Program Features |
|---|---|---|---|
| Hospital Services | $[500] per admission | [80%] of R&C after deductible | ·Semi-private room & board ·Intensive Care ·Ancillary Services ·Outpatient Emergency room surgery |
| Inpatient Medical | $[500] per admission | [80%] of R&C after Deductible | ·In-hospital visits ·Consultations |
| Physician Services (Inpatient & Outpatient Surgery) | [No deductible] | [80%] of R&C | ·Surgical Services ·Surgeon ·Assistant Surgeon ·Anesthesiologist |
| Ambulance Services | [No deductible] | [80%] of covered charges up to Contract maximum | ·Ambulance services are covered up to $[150] per ground trip and $[2000] per air trip |
| Office Surgery | $[100] deductible | [80%] of R&C after Deductible | ·Surgery ·Preoperative visits ·Local administration of anesthesia ·Follow-up care ·Recasting |
*Hereinafter, every amount that appears in brackets is subject to change by the Wyoming Health Insurance Pool Board. Current amount may be obtained from the Wyoming Insurance Department.
| Benefits Covered Services | Deductible $[2000] total on all Type B Benefits | Reimbursement [70%] of R&C after deductible | Program Features ·Office calls ·Outpatient drugs ·Outpatient diagnostic, x-ray and laboratory ·Outpatient psycho therapeutic (limited to 20 visits per calendar year and up to $30 per visit) ·Physical therapy (limited to 20 visits per calendar year) ·Chiropractic services (limited to $500 per calendar year) ·Rehabilitation therapy (limited to a lifetime maximum of $20,000) ·Outpatient emergency room medical care |
|---|---|---|---|
| Nervous/Mental | [same as above] | [70%] of R&C after deductible | ·Inpatient treatment for nervous and mental or psychotherapeutic services is limited to $5000 per 12 month period |
| Substance Abuse | [same as above] | [70%] or R&C after deductible | ·Alcohol or drug abuse payable to a lifetime maximum of $5000 |
| Benefits | Deductible | Reimbursement | Program Features |
|---|---|---|---|
| Maternity Service | $[4000] deductible | [100%] of R&C after deductible | ·Pre-natal care ·Delivery ·Post-natal care ·Routine newborn care |