§ 26-19-302 — Definitions

Wyoming § 26-19-302

• Jurisdiction: Wyoming
• Title 26: Insurance Code
• Ch. 19: GROUP AND BLANKET DISABILITY INSURANCE

Text

(a) As used in this act:
(i) "Actuarial certification" means a written
statement by a member of the American Academy of Actuaries or
other individual acceptable to the commissioner that a small
employer carrier is in compliance with the provisions of W.S.
26-19-304, based upon the person's examination, including a
review of the appropriate records and of the actuarial
assumptions and methods used by the small employer carrier in
establishing premium rates for applicable health benefit plans;
(ii) "Base premium rate" means, for each class of
business as to a rating period, the lowest premium rate charged
or that could have been charged under a rating system for that
class of business, by the small employer carrier to small
employers with similar case characteristics for health benefit
plans with the same or similar coverage;
(iii) "Basic health benefit plan" means a low cost
health benefit plan developed pursuant to W.S. 26-19-308;
(iv) "Board" means the board of directors of the
program;
(v) "Carrier" means any person who provides any
health benefit plan in this state subject to state insurance
regulation and includes, but is not limited to, an insurance
company, a fraternal benefit society, a prepaid hospital or
medical care plan, a health maintenance organization and a
multiple employer welfare arrangement. For purposes of this act,
companies that are affiliated companies or that are eligible to
file a consolidated tax return shall be treated as one (1)
carrier except that any insurance company, health service
corporation, hospital service corporation or medical service
corporation that is an affiliate of a health maintenance
organization located in this state, or any health maintenance
organization located in this state which is an affiliate of an
insurance company, health service corporation, hospital service
corporation or medical service corporation may treat the health
maintenance organization as a separate carrier and each health
maintenance organization that operates only one (1) health
maintenance organization in an established geographic service
area of this state may be considered a separate carrier;
(vi) "Case characteristics" means demographic or
other objective characteristics of a small employer, as
determined by a small employer carrier, that are considered by
the small employer carrier in the determination of premium rates
for the small employer, provided, however, that claim
experience, health status and duration of coverage since issue
are not case characteristics for the purposes of this act;
(vii) "Class of business" means all of a distinct
grouping of small employers as shown on the records of the small
employer carrier, and provided:
(A) A distinct grouping may only be established
by the small employer carrier on the basis that the applicable
health benefit plans:
(I) Are marketed and sold through
individuals and organizations which are not participating in the
marketing or sale of other distinct groupings of small employers
for such small employer carrier;
(II) Have been acquired from another small
employer carrier as a distinct grouping of plans; or
(III) Are provided through an association
with membership of not less than two (2) small employers.
(B) A small employer carrier may establish no
more than two (2) additional groupings under each subdivision
(I) through (III) of subparagraph (A) of this paragraph on the
basis of underwriting criteria which are expected to produce
substantial variation in the health care costs;
(C) The commissioner may approve the
establishment of additional distinct groupings upon application
to the commissioner and a finding by the commissioner that such
action would enhance the efficiency and fairness of the small
employer marketplace.
(viii) Repealed by Laws 1995, ch. 94, § 3.
(ix) "Dependent" means:
(A) A spouse or unmarried child under the age of
nineteen (19) years;
(B) An unmarried child who is a full-time
student under the age of twenty-three (23);
(C) A child of any age who is disabled and
dependent upon the parent;
(D) Any other individual defined to be a
dependent in the health benefit plan covering the employee.
(x) "Eligible employee" means an employee who works
on a full-time basis, with a normal work week of thirty (30) or
more hours and has met any applicable waiting period
requirements. The term includes a sole proprietor, a partner of
a partnership or an independent contractor, if the sole
proprietor, partner or independent contractor is included as an
employee under a health benefit plan of a small employer, but
does not include employees who work on a part-time, temporary,
seasonal or substitute basis;
(xi) "Established geographic service area" means a
geographical area approved by the commissioner in conjunction
with the carrier's certificate of authority to transact
insurance in this state, within which the carrier is authorized
to provide coverage;
(xii) "Health benefit plan" means any hospital or
medical policy or certificate, major medical expense insurance,
hospital or medical service plan contract or health maintenance
organization subscriber contract. "Health benefit plan" does not
include accident-only, credit, dental, vision, Medicare
supplement, long-term care or disability income insurance,
coverage issued as a supplement to liability insurance, worker's
compensation or similar insurance or automobile medical-payment
insurance, nor does it include policies or certificates of
specified disease, hospital confinement indemnity or limited
benefit health insurance if the carrier offering the policies or
certificates certifies to the commissioner that policies or
certificates described in this paragraph are being offered and
marketed as supplemental health insurance and not as a
substitute for hospital or medical expense insurance or major
medical expense insurance;
(xiii) Repealed by Laws 1993, ch. 83, § 2.
(xiv) "Index rate" means, for each class of business
as to a rating period for small employers with similar case
characteristics, the arithmetic average of the applicable base
premium rate and the corresponding highest premium rate;
(xv) "Late enrollee" means an eligible employee or
dependent who requests enrollment in a health benefit plan of a
small employer following the initial enrollment period provided
under the terms of the health benefit plan, provided that the
initial enrollment period shall be a period of at least thirty
(30) days. An eligible employee or dependent shall not be
considered a late enrollee if:
(A) The individual:
(I) Was covered under a public or private
health insurance or other health benefit arrangement at the time
the individual was eligible to enroll;
(II) Has lost coverage under a public or
private health insurance or other health benefit arrangement as
a result of termination of employment or eligibility, the
termination of the other plan's coverage, death of a spouse,
divorce, legal separation or termination of employer
contribution; and
(III) Requests enrollment within thirty
(30) days after termination of coverage provided under a public
or private health insurance or other health benefit arrangement.
(B) The individual is employed by an employer
which offers multiple health benefit plans and the individual
elects a different plan during an open enrollment period; or
(C) A court has ordered coverage be provided for
a spouse or minor child under a covered employee's health
benefit plan and request for enrollment is made within thirty
(30) days after issuance of the court order.
(xvi) "New business premium rate" means, for each
class of business as to a rating period, the lowest premium rate
charged or offered, or which could have been charged or offered,
by the small employer carrier to small employers with similar
case characteristics for newly issued health benefit plans with
the same or similar coverage;
(xvii) "Participating carrier" means all small
employer carriers issuing health benefit plans in this state.
"Participating carrier" shall also include any carrier that
maintains an existing health benefit plan covering eligible
employees of one (1) or more small employers;
(xviii) "Plan of operation" means the plan of
operation of the program, including articles, bylaws and
operating rules adopted by the board pursuant to W.S. 26-19-307;
(xix) "Preexisting condition provision" means a
policy provision that excludes coverage for charges or expenses
incurred during a specified period following the insured's
effective date of coverage, as to a condition which, during a
specified period immediately preceding the effective date of
coverage, medical advice, diagnosis, care or treatment was
recommended or received;
(xx) "Program" means the Wyoming small employer
health reinsurance program created by W.S. 26-19-307;
(xxi) "Rating period" means the calendar period for
which premium rates established by a small employer carrier are
assumed to be in effect, as determined by the small employer
carrier;
(xxii) "Small employer" means any person, firm,
corporation, partnership or association who is actively engaged
in business who, on at least fifty percent (50%) of its working
days during the preceding calendar quarter, employed at least
two (2) but no more than fifty (50) eligible employees, the
majority of whom were employed within this state or were
residents of Wyoming. In determining the number of eligible
employees, companies which are affiliated companies, or which
are eligible to file a combined tax return for purposes of any
state taxation, shall be considered one (1) employer;
(xxiii) "Small employer carrier" means any carrier
that offers health benefit plans covering eligible employees of
one (1) or more small employers;
(xxiv) "Standard health benefit plan" means a health
benefit plan developed pursuant to W.S. 26-19-308;
(xxv) "Taft-Hartley trust" means a trust formed
pursuant to a collective bargaining agreement under the federal
Labor Management Relations Act of 1947;
(xxvi) "Affiliation period" means a period which,
under the terms of the health insurance coverage offered by a
health maintenance organization, must expire before the health
insurance coverage becomes effective. The health maintenance
organization is not required to provide health care services or
benefits during an affiliation period and no premiums shall be
charged to the participant or beneficiary for any coverage
during the period;
(xxvii) "Provider network" means health insurance
coverage offered by a health insurance issuer under which the
financing and delivery of medical care, including items and
services paid for as medical care, is provided in whole or in
part, through a defined set of providers under contract with the
issuer;
(xxviii) "This act" means W.S. 26-19-301 through