Wyoming's mandated health care law is codified in the Wyoming Statutes Annotated at Title 26, Chapters 19, 20 and 22. Coordination of benefits provisions are located in the Code of Wyoming Rules at Section 04-000-010 (State Insurance Department Chapter 10).

DEFINITIONS

A "small employer" is any person, firm, corporation, partnership, or association that is actively engaged in business that on at least half (50 percent) of its working days during the preceding calendar quarter employed at least two but no more than 50 eligible employees, the majority of whom are employed in Wyoming. Companies that are affiliated companies or eligible to file a combined tax return for the state are considered one employer (Sec. 26-19-302, as amended by Ch. 120, L. 1997).

WHAT THE EMPLOYER MUST DO

Wyoming does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.

Mental health coverage: Facilities. --No individual or group policy of accident and sickness insurance delivered or issued for delivery to any person in Wyoming that provides coverage for mental illness or mental retardation or both must exclude benefits for the care or treatment of the mental illness or mental retardation provided by a tax supported institution of the state, provided (Sec. 26-22-102):

(1) the institution establishes and actively utilizes appropriate professional standard review organizations or comparable peer review programs;

(2) the operation of the institution is subject to review according to federal and state law; and

(3) charges are made for the services.

Dependent care coverage. --All individual and group health insurance policies providing coverage on an expense-incurred basis, and individual and group service or indemnity type contracts issued by any insurer, including any nonprofit corporation, that provide coverage for a family member of the insured or subscriber, must also provide, as to the family members' coverage, that the health insurance benefits applicable for children are automatically payable with respect to (Sec. 26-20-101):

(1) a newly born child of the insured or subscriber from the moment of birth; and

(2) an adopted child from the earlier of the date the petition for adoption is filed or entry of the child in the adoptive home, except that when the child is in the custody of the state, coverage begins at the date of entry of a final decree of adoption. Coverage for an adopted child continues unless the petition is denied.

The coverage for newly born children must consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities (Sec. 26-20-102).

Disabilities. --Any individual or group hospital or medical expense insurance policy or hospital service plan contract or medical service plan contract, delivered or issued for delivery in Wyoming which provides that coverage of a dependent child of a policyholder or subscriber, or of an employee or other member of the covered group, as the case may be, terminates upon attainment of the limiting age for dependent children specified in the policy or contract, must also provide in substance that attainment of the limiting age does not terminate the child's coverage while the child is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical disability and chiefly dependent upon the policyholder or subscriber, or the employee or other member of the covered group, as the case may be, for support and maintenance (Sec. 26-22-401).

Coordination of benefits. --An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.

The following types of plans must specify how benefits will be coordinated: group, blanket, or franchise insurance coverage; service plan contracts, group practice, individual practice, and other prepayment coverage; coverage under labor-management trusteed plans, union welfare plans, employer organization plans, or employee benefit organization plans; and any coverage under government programs or required by statute, such as Medicare. A plan does not include: family policies, school accident-type coverage, or group or group-type indemnity benefits written on a non-expense basis (Code of Wyoming Rules, Sec. 04-000-010 (State Insurance Department Chapter 10), as authorized by Wyoming Statutes Secs. 26-2-110 and 26-15-111).

Order of benefits. --The following priority applies when coordinating health benefit payments (Code of Wyoming Rules Sec. 04-000-010):

(1) Employee/Dependent: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;

(2) Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one plan specifies the birthday rule and the other plan specifies priority based on the gender of the parent, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;

(3) Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent;

(4) Active/Inactive Employee: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard does not apply; and

(5) Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time.

Providers: Dietitians. --If a medical service contract or insurance policy or certificate provides for reimbursement to the insured or subscriber for health services, reimbursement in amounts provided under the contract or insurance policy may not be denied if the services are rendered to the insured or subscriber by a person licensed under the laws of Wyoming to treat the illness or disability or perform the health services covered by the contract or policy. This includes dietary services rendered by a registered dietitian (Sec. 26-22-101).

Psychologists. --All individual and group or blanket policies of accident and sickness insurance or individual or group service or indemnity contracts issued by a corporation, including corporations that provide health care to their employees as a benefit of employment, and that are issued, delivered, issued for delivery, amended or renewed in Wyoming or that cover any risk resident, located or to be performed in Wyoming and that provide coverage for diagnostic and therapeutic services within the lawful scope of practice of a psychologist duly licensed to practice, must be deemed to provide that any person covered under the policies or contracts is entitled to receive reimbursement for the services if they are rendered by a duly licensed doctor of medicine or a duly licensed psychologist (Sec. 26-22-104).

Preexisting conditions. --Group and blanket disability insurance plans may deny health benefit coverage because of preexisting conditions only if medical advice, diagnosis, care or treatment was recommended or received within six months immediately before the effective date of coverage. Coverage will not be excluded due to preexisting conditions for longer than 12 months after the effective date. If the insured is covered within 90 days of having other qualifying coverage, the new policy will credit the time covered under the previous contract or policy toward an exclusion for preexisting conditions (Sec. 26-19-107(a), as amended by S. 29, L. 1998).

No policy of group or blanket disability insurance may treat the following as a preexisting condition (Sec. 26-19-107(f), as added by Ch. 120, L. 1997):

(1) pregnancy existing on the effective date of coverage;

(2) genetic information, in the absence of a diagnosis of a condition related to the genetic information.

Small employers. --Group and blanket disability insurance plans for small employers may deny health benefit coverage because of preexisting conditions for which medical advice, diagnosis, care or treatment was recommended or received within six months immediately before the effective date of coverage. Pregnancy may not be treated as a preexisting condition. Genetic information may not be treated as a preexisting condition in the absence of a diagnosis of a condition related to such information. Coverage will not be excluded due to preexisting conditions for longer than 12 months after the effective date (Sec. 26-19-306, as amended by Ch. 120, L. 1997).

Diabetes. --All group health insurance policies providing coverage on an expense-incurred basis, group service or indemnity-type contracts issued by any insurer including any nonprofit corporation and group service contracts issued by an HMO, which provide coverage must also provide coverage for the equipment, supplies and outpatient self-management training and education, including medical nutrition therapy for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes if prescribed by a health care professional legally authorized to prescribe such items (Sec. 26-20-201, as added by H. 185, L. 2001).

Cancer screenings. --All group and blanket disability insurance policies providing coverage on an expense-incurred basis, group service or indemnity-type contracts issued by a nonprofit corporation, group service contracts issued by an HMO, all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed on or after July 1, 2001, and providing coverage to any resident of Wyoming must provide benefits or coverage for (Sec. 26-19-107(j), as added by H. 26, L. 2001):

(1) a pelvic examination and pap smear for any covered nonsymptomatic women;

(2) a colorectal cancer exam and lab tests for cancer for any nonsymptomatic person covered;

(3) a prostate exam and lab tests for cancer for any covered nonsymptomatic man; and

(4) a breast cancer exam, including a screening mammogram and clinical breast exam, for any covered nonsymptomatic person.

Wellness benefits. --If issued or delivered on or after January 1, 1999, group disability and blanket disability insurance policies must provide a notice on the face of the policy as to the extent to which the policy includes comprehensive adult wellness benefits, which benefits must at a minimum provide for testing procedures and for the examination of adult policyholders and their spouses for breast cancer, prostate cancer, cervical cancer and diabetes (Sec. 26-19-107, as amended by H. 26, L. 2001).

Genetic information. --An insurer offering a policy of group or blanket disability insurance shall not, based on the genetic testing information of an individual or a family member of an individual (Sec. 26-19-107(m), as added by H. 24, L. 2003):

(1) deny eligibility;

(2) adjust premium rates;

(3) adjust contribution rates;

(4) request or require predictive genetic testing information concerning an individual or a family member of the individual, except the insurer may 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.

WHO TO CONTACT

Contact the Insurance Commissioner at Herschler Bldg., 3rd Fl. East, 122 W. 25th Street, Cheyenne, WY 82002-0440. Telephone: (307) 777-7401. Fax: (307) 777-5895.

DOC, STATE-SUMMARIES Health Insurance Benefit Coverage Law Summaries Health Insurance Benefit Coverage Law Summaries 52-4000 Health Insurance Benefit Coverage Law Summaries Wyoming's mandated health care law is codified in the Wyoming Statutes Annotated at Title 26, Chapters 19, 20 and 22. Coordin