§ 26-34-109 — Requirements for group contract, individual contract, evidence of coverage and premiums for health care services

(a) Every group and individual contract holder is entitled
to a group or individual contract. The contract shall not
contain provisions or statements which are unjust, unfair,
inequitable, misleading, deceptive, or which encourage
misrepresentation as defined by W.S. 26-34-117(a). The contract
shall contain a clear statement of the following:
(i) Name and address of the health maintenance
organization;
(ii) Eligibility requirements;
(iii) Benefits and services within the service area;
(iv) Emergency care benefits and services;
(v) Out of area benefits and services, if any;
(vi) Copayments, coinsurance, deductibles or other
out-of-pocket expenses;
(vii) Limitations and exclusions, including an
explanation of any prescription drug benefits not provided for
under a specified health plan;
(viii) Enrollee termination;
(ix) Enrollee reinstatement, if any;
(x) Claims procedures;
(xi) Enrollee complaint procedures;
(xii) Continuation of coverage;
(xiii) Conversion;
(xiv) Extension of benefits, if any;
(xv) Coordination of benefits, if applicable;
(xvi) Subrogation, if any;
(xvii) Description of the service area;
(xviii) Entire contract provision;
(xix) Term of coverage;
(xx) Cancellation of group or individual contract
holder;
(xxi) Renewal;
(xxii) Reinstatement of group or individual contract
holder, if any;
(xxiii) Grace period as provided in W.S. 26-18-107;
(xxiv) Conformity with state law; and
(xxv) Any withholding agreement pertaining to health
care delivery services which requires reimbursement to the
provider at a later date dependent upon decisions regarding
coverage. The agreement shall specify the requirements in
detail. If the existence of a withholding agreement has been
disclosed in the contract, the health maintenance organization
may alter the terms of the agreement without being deemed to
alter the terms of the contract provided the contract holder is
notified in detail of the new terms of the agreement at his next
renewal.
(b) In addition to those provisions required in subsection
(a) of this section, an individual contract shall provide for a
ten (10) day period to examine and return the contract and have
the premium refunded. If services were received during the ten
(10) day period, and the person returns the contract to receive
a refund of the premium paid, he shall pay for the services.
(c) Each enrollee residing in this state shall receive an
evidence of coverage from the group contract holder or the
health maintenance organization. The evidence of coverage shall
not contain provisions or statements which are unfair, unjust,
inequitable, misleading, deceptive or which encourage
misrepresentation as defined by W.S. 26-34-117(a). The evidence
of coverage shall contain:
(i) A clear statement of the provisions required in
paragraphs (a)(i) through (xvii) of this section; and
(ii) A provision that any subsequent material change
shall be evidenced in a separate document issued to the
enrollee.
(d) No group or individual contract, evidence of coverage,
or amendment thereto, shall be issued or delivered to any person
in this state:
(i) Until a copy of the form of the contract,
evidence of coverage, or amendment thereto, has been filed with
and approved by the commissioner.
(e) Every form required by this section shall be filed
with the commissioner not less than forty-five (45) days prior
to delivery or issue for delivery in this state. At any time
during the initial forty-five (45) day period, the commissioner
may extend the period for review for an additional forty-five
(45) days. Notice of an extension shall be in writing. At the
end of the review period, the form is deemed approved if the
commissioner has taken no action. The filer shall notify the
commissioner in writing prior to using a form that is deemed
approved.
(f) At any time, after thirty (30) days notice and for
cause shown, the commissioner may withdraw approval of any form,
effective at the end of thirty (30) days.
(g) When a filing is disapproved or approval of a form is
withdrawn, the commissioner shall give the health maintenance
organization written notice of the reasons for disapproval and
in the notice shall inform the health maintenance organization
that within thirty (30) days of receipt of the notice the health
maintenance organization may request a hearing. A hearing shall
be conducted within thirty (30) days after the commissioner has
received the request for hearing.
(h) The commissioner may adopt regulations establishing
readability standards for individual contract, group contract,
and evidence of coverage forms.
(j) No schedule of premiums or methodology for determining
a schedule of premiums for enrollee coverage for health care
services, or amendment thereto, may be used until a copy of that
schedule, or amendment thereto, has been filed with and approved
by the commissioner.
(k) Premiums or methodology for determining a schedule of
premiums shall be established in accordance with actuarial
principles for various categories of enrollees, provided that
premiums applicable to an enrollee may not be individually
determined based on the status of his health. However, the
premiums shall not be excessive, inadequate or unfairly
discriminatory. A certification, by a qualified actuary or
other qualified person acceptable to the commissioner, to the
appropriateness of the use of the methodology, based on
reasonable assumptions, shall accompany the filing along with
adequate supporting information.
(m) The commissioner, within a reasonable period, shall
approve any form if the requirements of subsections (a) through
(g) of this section are met and any schedule of premiums if the
requirements of subsections (j) and (k) of this section are met.
It is unlawful to issue a form or to use the schedule of
premiums until approved or deemed approved.
(n) The commissioner may require the submission of
whatever relevant information he deems necessary in determining
whether to approve or disapprove a filing made pursuant to this
section.