Wyo. Code R. 044-0002-41
Chapter 41: Scope of Pool Cov. & Sched. of Bens. Offered by Wyo. Hlth. Ins. Pool
Effective Date: 03/07/1991 to 12/31/1996
Rule Type: Superceded Rules & Regulations
Reference Number: 044.0002.41.03071991
Program GENERAL General Agency, Board or Commission Rules
Chapter Name Scope of Pool Cov. & Sched. of Bens. Offered by Wyo. Hlth. Ins. Poolhapter No.41 lhapter No.41
Date Filed 03/07/91 Expr Date
Supr Date
Repeal Date
Document Type RULES
Chapter XLI
WYOMING HEALTH INSURANCE POOL
Effective March 7, 1991
(Section) 1 Authority 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.
(Section) 2 Purpose
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.
(Section) 3 Eligibility
(a) Except as provided in subsection (b) of this section any individual person who is a resident of this state is eligible for pool coverage if evidence of the following is provided:
(i) Rejection of or refusal to issue health insurance for health reasons by one insurer;
(ii) Refusal to issue health insurance except at a rate exceeding the pool rate; or
(iii) Refusal to issue health insurance except with a reduction or exclusion of coverage for a preexisting health condition which reduction or exclusion is more restrictive than the reduction or exclusion provided by pool coverage.
(b) The following persons are not eligible for pool coverage:
(i) Persons who have coverage under health insurance or insurance arrangement on the issue date of pool coverage;
(ii) Any person who is at the time of pool application eligible for Medicaid healthcare benefits or Medicare;
(iii) Any person who terminated coverage in the pool unless twelve (12) months have elapsed from the termination date;
(iv) Any person on whose behalf the pool has paid $250,000 in benefits;
(v) Inmates of public institutions.
(c) 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.
Any person on whose behalf the pool has paid $250,000 in benefits over his lifetime is no longer eligible for pool coverage. The yearly out-of-pocket expense maximum shall be $3,000 per individual and $9,000 per family of three or more persons.
The policy offered by the Wyoming Health Insurance Pool includes one or more cost containment features which affects the level of benefits which will be paid. Cost containment features utilized by the pool includes the following:
(a) Mandatory preadmission review;
(b) Concurrent inpatient review;
(c) Medical necessity;
(d) Accounts specific reporting;
(e) Usual, customary and reasonable fee determinations;
(f) Other cost containment measures as may from time to time be established by the board.
(a) 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.
(b) Pool coverage shall not include medical costs associated with:
(i) Organ transplant;
(ii) Cosmetic surgery;
(iii) Other procedures as determined by the Board and not covered under Appendix A or excluded by the subscriber agreement.
(a) Pool coverage shall exclude charges or expenses incurred during a minimum of the first six (6) months following the effective date of coverage as to any condition which during a minimum of the six (6) month period immediately preceding the effective date of coverage manifested itself in such a manner as would cause an ordinary prudent person to seek diagnosis, care or treatment, or for which medical advice, care or treatment was recommended or received as to the condition.
(b) Preexisting condition exclusions may be waived to the extent to which similar exclusions, if any, have been satisfied under any prior health insurance coverage which was involuntarily terminated and coverage in the pool is effective from the date on which the prior coverage was terminated if application for pool coverage is made not later than thirty-one (31) days following the involuntary termination.
(a) All benefits otherwise payable under pool coverage are reduced by:
(i) All amounts paid or payable through any other health insurance or insurance arrangement;
(ii) All hospital and medical expense benefits paid or payable under any workman's compensation coverage or automobile medical payment or liability insurance whether provided on the basis of fault or no-fault; and
(iii) Any hospital or medical benefits paid or payable under or provided pursuant to any state or federal law or program except for Medicaid.
(b) The administrator or the board has a cause of action against any eligible person for the recovery of the amount of benefits paid which are not for covered expenses. Benefits due from the pool may be reduced or refused as a set-off against any amount recoverable under this section.
(Section) 9 Separability 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.
(Section) 10 Effective Date This regulation shall become effective upon filing with the
Secretary of State. APPENDIX A
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This is intended as a brief overview of benefits for the Wyoming Health Insurance Pool.
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