§ 26-34-102 — Definitions

(a) As used in this chapter:
(i) "Administrator" means the director of the
department of health;
(ii) "Basic health care services" means emergency
care, inpatient hospital and physician care, and outpatient
medical services, but does not include mental health services or
services for alcohol or drug abuse;
(iii) "Capitated basis" means fixed per member per
month payment or percentage of premium payment wherein the
provider assumes the full risk for the cost of contracted
services without regard to the type, value or frequency of
services provided. For purposes of this definition, "capitated
basis" includes the cost associated with operating staff model
facilities;
(iv) "Carrier" means a health maintenance
organization, an insurer, a hospital and medical service
corporation or other entity responsible for the payment of
benefits or the provision of services under a group contract;
(v) "Commissioner" means the insurance commissioner
of this state;
(vi) "Coinsurance" means a percentage of eligible
charges payable by an enrollee directly to a provider for
covered services rendered;
(vii) "Copayment" means an amount an enrollee must
pay in order to receive a specific service which is not fully
prepaid;
(viii) "Deductible" means the amount an enrollee is
responsible to pay out-of-pocket before the health maintenance
organization begins to pay the costs associated with treatment;
(ix) "Discontinuance" means the termination of the
contract between the group contract holder and a health
maintenance organization due to the insolvency of the health
maintenance organization, and does not refer to the termination
of any agreement between any individual enrollee and the health
maintenance organization;
(x) "Enrollee" means an individual who is enrolled in
a health maintenance organization;
(xi) "Evidence of coverage" means any certificate,
agreement or contract issued to an enrollee setting out the
coverage to which the enrollee is entitled;
(xii) "Extension of benefits" means the continuation
of coverage under a particular benefit provided under a contract
following termination with respect to an enrollee who is totally
disabled on the date of termination;
(xiii) "Group contract" means a contract for health
care services which by its terms limits eligibility to members
of a specified group. The group contract may include coverage
for dependents;
(xiv) "Group contract holder" means the person to
which a group contract has been issued;
(xv) "Health care services" means any services
included in the furnishing to any individual of medical or
dental care, vision care or hospitalization or incident to the
furnishing of that care or hospitalization, as well as the
furnishing to any person of any other services for the purpose
of preventing, alleviating, curing or healing human illness,
injury or physical disability;
(xvi) "Health maintenance organization" means any
person, except a person offering a dental only or vision only
plan, who undertakes to provide or arrange for basic health care
services to enrollees on a prepaid basis, except for enrollee
responsibility for copayments, coinsurance or deductibles, and
may include providing or arranging for:
(A) Physician services directly through
physician employees or under arrangements with individual
physicians or groups of physicians;
(B) Other health care services on a prepayment
or other financial basis.
(xvii) "Health maintenance organization producer"
means a person who solicits, negotiates, effects, procures,
delivers, renews or continues a policy or contract for health
maintenance organization membership, or who takes or transmits a
membership fee or premium for such a policy or contract, other
than for himself, or a person who advertises or otherwise holds
himself out to the public as undertaking any of the activities
of a health maintenance organization producer;
(xviii) "Individual contract" means a contract for
health care services issued to and covering an individual. The
individual contract may include dependents of the subscriber;
(xix) "Insolvent" or "insolvency" means that the
organization has been declared insolvent and placed under an
order of liquidation by a court of competent jurisdiction;
(xx) "Managed hospital payment basis" means
agreements under which the financial risk is primarily related
to the degree of utilization rather than to the cost of
services;
(xxi) "Net worth" means the excess of total admitted
assets over total liabilities, but the liabilities shall not
include fully subordinated debt;
(xxii) "Participating provider" means a provider as
defined in paragraph (xxiv) of this subsection who, under an
express or implied contract with the health maintenance
organization or with its contractor or subcontractor, has agreed
to provide health care services to enrollees with an expectation
of receiving payment, other than copayment, coinsurance or
deductible, directly or indirectly from the health maintenance
organization;
(xxiii) "Person" means as defined by W.S.
26-1-102(a)(xx);
(xxiv) "Provider" means any physician, hospital or
other person which is licensed or otherwise authorized to
furnish health care services in the state in which the services
are rendered;
(xxv) "Replacement coverage" means the benefits
provided by a succeeding carrier;
(xxvi) "Subscriber" means an individual whose
employment or other status, except family dependency, is the
basis for eligibility for enrollment in the health maintenance
organization, or in the case of an individual contract, the
person in whose name the contract is issued;
(xxvii) "Uncovered expenditures" means the costs to
the health maintenance organization for health care services
that are the obligation of the health maintenance organization,
for which an enrollee may also be liable in the event of the
health maintenance organization's insolvency and for which no
alternative arrangements have been made that are acceptable to
the commissioner;
(xxviii) "This code" means title 26 of the Wyoming
statutes;
(xxix) "This act" means W.S. 26-34-101 through