§ 26-19-306 — Availability of coverage

Wyoming § 26-19-306

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

Text

(a) Within one hundred eighty (180) days after the
commissioner's approval of the basic health benefit plan and the
standard health benefit plan developed pursuant to W.S.
26-19-308, but in no case prior to March 31, 1993, every small
employer carrier shall, as a condition of transacting business
in this state with small employers, actively offer to small
employers all health benefit plans which it actively markets to
small employers in this state, including at least two (2) health
benefit plans. One (1) plan to be offered by each small
employer carrier shall be a basic health benefit plan and one
(1) plan shall be a standard health benefit plan. Except as
provided in this section, all small employer carriers shall
issue any health benefit plan to any eligible small employer
that applies for the plan and agrees to make the required
premium payments and to satisfy the other reasonable provisions
of the plan. Carriers or multiple employer welfare associations
whose bylaws or charters do not permit them to issue coverage on
a marketwide basis shall only be required to guarantee issue to
those small employers which meet the requirements of the bylaws
or charters. Charter or bylaw provisions which prohibit
issuance to specific populations based on health status or
health risk shall not be considered as exceptions to the
requirements of this subsection.
(b) A small employer carrier shall file with the
commissioner, in a format and manner prescribed by the
commissioner, the basic health benefit plan and the standard
health benefit plan to be used by the carrier. A plan filed
pursuant to this section may be used by a small employer carrier
beginning forty-five (45) days after it is filed unless the
commissioner disapproves its use. The commissioner at any time
may, after providing notice and an opportunity for a hearing to
the small employer carrier, disapprove the continued use by a
small employer carrier of a basic or standard health benefit
plan on the grounds that the plan does not meet the requirements
of this section.
(c) All health benefit plans covering small employers
shall comply with the following provisions:
(i) Preexisting condition provisions shall not
exclude coverage for a period beyond twelve (12) months
following the individual's effective date of coverage and shall
only relate to conditions for which medical advice, diagnosis,
care or treatment was recommended or received during the six (6)
months immediately preceding the effective date of coverage.
Pregnancy shall not be treated as a preexisting condition.
Genetic information shall not be treated as a preexisting
condition in the absence of a diagnosis of a condition related
to such information;
(ii) In determining whether a preexisting condition
provision applies to an eligible employee or dependent, all
health benefit plans shall credit the time the person was
previously covered by public or private health insurance or
other health benefit arrangement if the previous coverage was
continuous to a date not more than ninety (90) days prior to the
effective date of the new coverage, exclusive of any applicable
waiting period under such plan;
(iii) Late enrollees may be excluded from coverage
for the greater of eighteen (18) months or an eighteen (18)
month preexisting condition exclusion, provided that if both a
period of exclusion from coverage and a preexisting condition
exclusion are applicable to a late enrollee, the combined period
shall not exceed eighteen (18) months;
(iv) Any requirement used by a small employer carrier
in determining whether to provide coverage to a small employer
group, including requirements for minimum participation of
eligible employees and minimum employer contributions, shall be
applied uniformly among all small employer groups with the same
number of eligible employees applying for coverage or receiving
coverage from the small employer carrier. A small employer
carrier may vary application of minimum participation
requirements and minimum employer contribution requirements only
by the size of the small employer group;
(v) In applying minimum participation requirements
with respect to a small employer, a small employer carrier shall
not consider employees or dependents who are otherwise covered
by a public or an employment based health benefit plan in
determining whether the applicable percentage of participation
is met;
(vi) If a small employer carrier offers coverage to a
small employer, it shall offer coverage to all of the small
employer's eligible employees and may offer coverage to their
dependents. A small employer carrier shall not offer coverage
to only certain persons in a group or to only part of a group,
except in the case of late enrollees as provided in paragraph
(iii) of this subsection. Except as permitted under paragraphs
(i) and (iii) of this subsection, a small employer carrier shall
not modify a health benefit plan with respect to a small
employer or any eligible employee or dependent, through riders,
endorsements or otherwise, to restrict or exclude coverage or
benefits for specified diseases, medical conditions or services
otherwise covered by the plan;
(vii) In the case of a group health plan that offers
medical care through health insurance coverage offered by a
health maintenance organization, the plan may provide for an
affiliation period with respect to coverage through the health
maintenance organization only if:
(A) No preexisting condition exclusion is
imposed with respect to such coverage;
(B) The affiliation period is applied uniformly
without regard to any health status related factors; and
(C) The affiliation period does not exceed two
(2) months, or three (3) months in the case of a late enrollee.
(d) No small employer carrier shall be required to offer
coverage or accept applications pursuant to subsection (a) of
this section in the case of the following:
(i) To a small employer, where the small employer is
not physically located in the small employer carrier's
established geographic service area;
(ii) To an employer whose employees do not work or
reside within the small employer carrier's established
geographic service area; or
(iii) Within an area where the small employer carrier
reasonably anticipates, and demonstrates to the satisfaction of
the commissioner, that it will not have the capacity within its
established geographic service area to deliver service
adequately to the members of such groups because of its
obligations to existing group contract holders and enrollees.
(e) A small employer carrier that cannot offer coverage
pursuant to paragraph (d)(iii) of this section shall not offer
coverage in the applicable area to new cases of employer groups
with more than fifty (50) eligible employees or small employer
groups until the later of one hundred eighty (180) days
following each such refusal or the date on which the carrier
notifies the commissioner that it has regained capacity to
deliver services to small employer groups.
(f) If any carrier has insured a disproportionate number
of small employer groups with employees requiring reinsurance,
the carrier may petition the commissioner to temporarily suspend
the requirement to accept every small employer applying for
coverage. The suspension may be granted only if the
commissioner finds:
(i) The carrier is reasonably reinsuring lives at a
rate of at least one hundred thirty percent (130%) of the
statewide average for reinsurance; and
(ii) The rate of reinsurance is having a significant
disproportional adverse effect on the carrier that is impairing
its ability to offer policies at competitive rates in the small
group market.
(g) A small employer carrier shall not be required to
offer coverage or accept applications pursuant to subsection (a)
of this section for so long as the commissioner finds that the
acceptance of an application or applications would place the
small employer carrier in a financially impaired condition.
(h) The requirements of subsections (a) and (b) of this
section shall not apply to any carrier which maintains existing
health benefit plans covering eligible employees of one (1) or
more small employers but is no longer enrolling new small
employers.
(j) In addition to the prohibition on the use of genetic
testing information provided in paragraph (c)(i) of this
section, all health benefit plans covering small employers shall
not, based on the genetic testing information of an individual
or a family member of an individual:
(i) Establish rules of eligibility to enroll in the
plan;
(ii) Deny eligibility;
(iii) Adjust premium rates;
(iv) Adjust contribution rates;
(v) Request or require predictive genetic testing
information concerning an individual or a family member of the
individual, except the health benefit plan may only request, but
not require, predictive genetic testing information if needed
for diagnosis, treatment or payment. As part of a request under
this paragraph, the plan or issuer shall provide a description
of the procedures in place to safeguard confidentiality of the
information.