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Title 26 Insurance Code

Wyoming · 26 · statute

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Contents: 1,241 provisions

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1,241 provisions

26-19-204. Violations; penalty.

Any person who violates any of the provisions of this article shall be subject to the penalties provided by W.S. 26-1-107.

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26-19-301. Short title.

This act shall be known and may be cited as the "Small Employer Health Insurance Availability Act."

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26-19-302. Definitions.

(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 26-19-310.

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26-19-303. Applicability and scope.

(a) This act shall apply to any health benefit plan which provides coverage to two (2) or more employees of a small employer in this state if: (i) Any portion of the premium or benefits is paid by a small employer or if an eligible employee or dependent is reimbursed, whether through wage adjustments or otherwise, by a small employer for any portion of the premium; or (ii) The health benefit plan is treated by the employer or any of the eligible employees or dependents as part of a plan or program for the purposes of section 162, section 125 or section 106 existing as of the effective date of this act or similar sections subsequently enacted of the United States Internal Revenue Code. (b) Notwithstanding subsection (a) of this section, W.S. 26-19-305(a) and (c) and 26-19-304(a) shall not apply to individual health benefit policies sold to small employers which are subject to approval for policy form by the commissioner. (c) A Taft-Hartley trust, or a carrier with the written authorization of a Taft-Hartley trust may make a written request to the commissioner for a waiver from the application of any of the provisions of W.S. 26-19-304(a) with respect to a health benefit plan provided to the trust. The commissioner may grant the waiver if he finds that application of W.S. 26-19-304(a) with respect to the trust would have a substantial adverse effect on the participants and beneficiaries of the trust, and would require significant modifications to one (1) or more collectively bargained arrangement for which the trust is established or maintained. A waiver granted under this subsection shall not apply to an individual if the person participates in the trust as an associate member of an employee organization. (d) This act shall apply to multiple employer welfare arrangements, consistent with W.S. 26-19-115.

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26-19-304. Restrictions relating to premium rates.

(a) Premium rates for health benefit plans subject to this act shall be subject to the following provisions: (i) The index rate for a rating period for any class of business shall not exceed the index rate for any other class of business by more than twenty percent (20%); (ii) For a class of business, the premium rates charged during a rating period to small employers with similar case characteristics for the same or similar coverage, or the rates which could be charged to employers under the rating system for that class of business shall not vary from the index rate by more than thirty-five percent (35%) of the index rate; (iii) The percentage increase in the premium rate charged to a small employer for a new rating period shall not exceed the sum of the following: (A) The percentage change in the new business premium rate measured from the first day of the prior rating period to the first day of the new rating period. In the case of a health benefit plan into which a small employer carrier is no longer enrolling new small employers, the carrier shall use the percentage change in the base premium rate, provided that the change does not exceed, on a percentage basis, the change in the new business premium rate for the most similar health benefit plan into which the carrier is actively enrolling new small employers; (B) Any adjustment, not to exceed fifteen percent (15%) annually and adjusted pro rata for rating periods of less than one (1) year, due to the claim experience, health status or duration of coverage of the employees or dependents of the small employer as determined from the small employer carrier's rate manual for the class of business; and (C) Any adjustment due to change in coverage or change in the case characteristics of the small employer as determined from the small employer carrier's rate manual for the class of business. (iv) Adjustments in rates for claims experience, health status and duration from issue shall not be charged to individual employees or dependents. Any such adjustment shall be applied uniformly to the rates charged for all employees and dependents of the small employer; (v) Any adjustment in rates charged by a small employer carrier caused by reinsurance is subject to the rating limitations set forth in this section; (vi) Premium rates for health benefit plans shall comply with the requirements of this section notwithstanding any assessments paid or payable by small employer carriers under this act; (vii) In any case where a small employer carrier utilizes industry as a case characteristic in establishing premium rates, the rate factor associated with any industry classification shall not vary from the arithmetic average of the rate factors associated with all industry classifications by greater than fifteen percent (15%) of such coverage; (viii) In the case of health benefit plans issued prior to the effective date of this act, a premium rate for a rating period may exceed the ranges set forth in paragraphs (i) and (ii) of subsection (a) of this section for a period of three (3) years following the effective date of this act. In such case, the percentage increase in the premium rate charged to a small employer in such a class of business for a new rating period may not exceed the sum of the following: (A) The percentage change in the new business premium rate measured from the first day of the prior rating period to the first day of the new rating period. In the case of a health benefit plan into which a small employer carrier is no longer enrolling new small employers, the carrier shall use the percentage change in the base premium rate, provided that the change does not exceed, on a percentage basis, the change in the new business premium rate for the most similar health benefit plan into which the carrier is actively enrolling new small employers; and (B) Any adjustment due to change in coverage or change in the case characteristics of the small employer as determined from the carrier's rate manual for the class of business. (ix) Small employer carriers shall apply rating factors, including case characteristics, consistently with respect to all small employers in a class of business; (x) For the purposes of this subsection, a health benefit plan that utilizes a provider network shall not be considered similar coverage to a health benefit plan that does not utilize such a network, provided that utilization of the network results in substantial differences in claims costs; (xi) The small employer carrier shall not use case characteristics, other than age, gender, industry, geographic area, family composition and group size without prior approval of the commissioner; (xii) The commissioner shall adopt regulations to implement the provisions of this section and to assure that rating practices used by small employer carriers are consistent with the purposes of this act, including regulations that: (A) Assure that differences in rates charged for health benefit plans by small employer carriers are reasonable and reflect objective differences in plan design; (B) Prescribe the manner in which case characteristics may be used by small employer carriers. (b) A small employer carrier shall not transfer a small employer involuntarily into or out of a class of business. A small employer carrier shall not offer to transfer a small employer into or out of a class of business unless the offer is made to transfer all small employers in the class of business without regard to case characteristics, claim experience, health status or duration of coverage since issue. (c) The commissioner may suspend for a specified period the application of paragraph (a)(i) of this section as to the premium rates applicable to one (1) or more small employers included within a class of business of a small employer carrier for one (1) or more rating periods upon a filing by the small employer carrier and a finding by the commissioner either that the suspension is reasonable in light of financial condition of the small employer carrier or that the suspension would enhance the efficiency and fairness of the marketplace for small employer health insurance. (d) In connection with the offering for sale of any health benefit plan to a small employer, the small employer carrier shall make a reasonable disclosure, as part of its solicitation and sales materials, of the following: (i) The extent to which premium rates for a specified small employer are established or adjusted in part based upon the actual or expected variation in claims costs or actual or expected variation in health condition of the employees and dependents of the small employer; (ii) The provisions concerning the small employer carrier's right to change premium rates and the factors other than claim experience which affect changes in premium rates; (iii) The provisions relating to renewability of policies and contracts; and (iv) The provisions relating to any preexisting condition provision. (e) Each small employer carrier shall: (i) Maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles; (ii) File with the commissioner annually on or before March 15 an actuarial certification certifying that the carrier is in compliance with this act and that the rating methods of the small employer carrier are actuarially sound. A copy of the certification shall be retained by the small employer carrier at its principal place of business; (iii) Make the information and documentation described in paragraph (i) of this subsection available to the commissioner upon request. Except in cases of violations of this act, the information shall be considered proprietary and trade secret information and shall not be subject to disclosure by the commissioner to persons outside of the department except as agreed to by the small employer carrier or as ordered by a court of competent jurisdiction.

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26-19-305. Renewability of coverage.

(a) A health benefit plan subject to this act shall be renewable with respect to all eligible employees or dependents at the option of the employer except in the following cases: (i) Nonpayment of the required premiums; (ii) Fraud or misrepresentation of the employer or, with respect to coverage of individual insureds, the insureds or their representatives; (iii) Noncompliance with the carrier's minimum participation requirements; (iv) Noncompliance with the carrier's employer contribution requirements; (v) Repeated misuse of a provider network provision; (vi) The carrier elects not to renew all of its health benefit plans issued to small employers in this state. In such a case, the carrier shall: (A) Provide advanced notice of its decision under this paragraph to the commissioner in each state in which it is licensed; and (B) Provide notice of the decision not to renew coverage to all affected health benefit plans and to the commissioner in each state in which an affected insured individual is known to reside at least one hundred eighty (180) days prior to the nonrenewal of any health benefit plans by the carrier. Notice to the commissioner under this subparagraph shall be provided at least three (3) working days prior to the notice to the affected health plans. (vii) The commissioner finds that the continuation of the coverage would: (A) Not be in the best interests of the policyholders or certificate holders; or (B) Impair the carrier's ability to meet its contractual obligations. (b) If the commissioner finds that the carrier may elect not to renew coverage under paragraph (vii) of subsection (a) of this section he shall assist affected small employers in finding replacement coverage. (c) A carrier that elects not to renew a health benefit plan under paragraph (vi) of subsection (a) of this section shall be prohibited from writing new business in the small employer market for a period of five (5) years from the date of notice to the commissioner. (d) In the case of a health maintenance organization doing business in the small employer market in one (1) established geographic service area of the state, the provisions set forth in this section shall apply to the health maintenance organization's operations in that service area.

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26-19-306. Availability of coverage.

(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.

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26-19-307. Small employer carrier reinsurance program.

(a) There is hereby created a nonprofit entity to be known as the "Wyoming small employer health reinsurance program" or "WySEHRP." (b) Within sixty (60) days of a written request by the commissioner, each small employer carrier shall make a filing with the commissioner containing the carrier's net health insurance premium derived from health benefit plans delivered to small employers in this state in the previous calendar year. (c) Participating carriers shall nominate board members which shall be subject to approval by the commissioner. The board shall consist of at least three (3) and not more than seven (7) representatives who shall serve three (3) year staggered terms. To the extent possible, the board shall include representation from carriers whose principal health insurance business is in the small employer market, health maintenance organizations and nonprofit health, hospital or medical service corporations. Members of the board shall be reimbursed from the assets of the program for expenses incurred by them as members of the board but shall not otherwise be compensated by the program for their services. The commissioner or the commissioner's designee shall be an ex officio voting member of the board. In approving the selection of the board, the commissioner shall assure that all participating carriers are fairly represented. (d) If at any time there is no board, the commissioner may appoint an initial board. (e) Within one hundred eighty (180) days after the selection or appointment of an initial board pursuant to subsection (d) of this section, the board shall submit to the commissioner a plan of operation and thereafter any amendments necessary or suitable, to assure the fair, reasonable and equitable administration of the program. The plan of operation shall be effective upon approval in writing by the commissioner consistent with the date on which the coverage under this section is available. Any plan of operation or amendments thereto, submitted to the commissioner by the board pursuant to this subsection shall be deemed approved by the commissioner if not expressly disapproved in writing by the commissioner within ninety (90) days of its receipt by the commissioner. (f) Repealed by Laws 2017, ch. 58, § 2. (g) The plan of operation shall: (i) Establish procedures for handling and accounting of program assets and monies and for an annual fiscal reporting to the commissioner; (ii) Establish terms of office and procedures for filling vacancies on the board, subject to the approval of the commissioner; (iii) Establish procedures for selecting an administering carrier and setting forth the powers and duties of the administering carrier; (iv) Establish procedures for reinsuring risks in accordance with the provisions of this act; (v) Establish procedures for collecting assessments from participating carriers to provide for claims reinsured by the program and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made; (vi) Provide for any additional matters at the discretion of the board. (h) The program shall have the general powers and authority granted under the laws of this state to insurance companies and health maintenance organizations licensed to transact business, except the power to issue health benefit plans directly to either groups or individuals. The program shall also have the specific authority to: (i) Enter into contracts necessary or proper to carry out the provisions and purposes of this act, including the authority, with the approval of the commissioner, to enter into contracts with similar programs of other states for the joint performance of common functions or with persons or other organizations for the performance of administrative functions; (ii) Sue or be sued, including taking any legal actions necessary or proper for recovering any assessments and penalties for, on behalf of, or against the program or any participating carriers; (iii) Take any legal action necessary to avoid the payment of improper claims against the program; (iv) Define the array of health coverage products for which reinsurance will be provided, and to issue reinsurance policies, in accordance with the requirements of this act; (v) Establish rules, conditions and procedures pertaining to the reinsurance of participating carrier's risks by the program; (vi) Establish actuarial functions as appropriate for the operation of the program; (vii) Assess participating carriers in accordance with the provisions of subsection (g) of this section, and to make advance interim assessments as may be reasonable and necessary for organizational and interim operating expenses. Any interim assessments shall be credited as offsets against any regular assessments due following the close of the fiscal year; (viii) Appoint appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the program, policy and other contract design, and any other function within the authority of the program; (ix) Borrow money to effect the purposes of the program. Any notes or other indebtedness of the program not in default shall be legal investments for carriers and may be carried as admitted assets; (x) Adjust the five thousand dollar ($5,000.00) deductible reinsurance requirement contained in paragraph (j)(v) of this section to reflect the effects of inflation. The board annually shall adjust the deductible reinsurance requirement to reflect increases in costs and utilization within the standard market for health benefit plans within the state. The adjustment shall not be less than the annual change in the medical component of the "Consumer Price Index for all Urban Consumers" of the department of labor, bureau of labor statistics, unless the board proposes and the commissioner approves a lower adjustment factor. Also, with the approval of the commissioner the board may increase or decrease the amount set forth in paragraph (j)(v) of this section and paragraphs (k)(i) and (ii) of this section if it is necessary to effectuate the purposes of this act and does not require participating carriers to retain an unreasonable level of risk. (j) A participating carrier may reinsure with the program as provided for in this subsection: (i) With respect to a basic health benefit plan or a standard health benefit plan, the program shall reinsure the level of coverage provided and, with respect to other plans, the program shall reinsure up to the level of coverage provided in a basic or standard health benefit plan; (ii) Except in the case of a late enrollee, a participating carrier may reinsure an eligible employee or dependent within sixty (60) days of the commencement of the coverage of the small employer. A newly eligible employee or dependent may be reinsured within sixty (60) days of the commencement of his coverage; (iii) A participating carrier may reinsure an entire employer group within sixty (60) days of the commencement of the group's coverage under the plan. The carrier may choose to reinsure newly eligible employees and dependents of a reinsured group pursuant to paragraph (ii) of this subsection; (iv) Any eligible small employer group business in force before a program's plan of operation becomes effective shall be reinsured by the program only if the board determines that sufficient funding sources are available. The board shall adopt rules and regulations providing conditions under which reinsurance will be issued on employers, employees, or dependents who were subject to riders, endorsements or other contract provisions which restricted or excluded coverage or benefits for specified diseases, medical conditions or services otherwise covered by the plans if the provisions were in force prior to the effective date of the program's plan of operation. The reinsurance may be limited to coverage for the specified diseases, medical conditions or services that had previously been restricted or excluded by the riders, endorsements or other provisions; (v) The program shall not reimburse a participating carrier with respect to the claims of a reinsured employee or dependent until the carrier has paid a deductible of five thousand dollars ($5,000.00) in a calendar year for benefits covered by the program. A participating carrier's liability under this paragraph shall not exceed a maximum limit of five thousand dollars ($5,000.00), in any one (1) calendar year with respect to any one (1) person reinsured. The amounts stated in this paragraph shall be increased in accordance with inflation adjustments made by the board under paragraph (h)(x) of this section; (vi) A participating carrier may terminate reinsurance for all of the reinsured employees or dependents of a small employer on any plan anniversary; (vii) Premium rates charged for reinsurance by the program to a health maintenance organization which is federally qualified under 42 U.S.C. § 300 e(c)(2)(A) or a similar section subsequently enacted, and as such is subject to requirements that limit the amount of risk that may be ceded to the program that is more restrictive than paragraph (v) of this subsection, shall be reduced to reflect that portion of the risk above the amount set forth in paragraph (v) of this subsection that shall not be ceded to the program, if any; (viii) The board may consider adjustments to the premium rates charged for reinsurance by the program for carriers using effective cost containment, including high-cost case management, as defined by the board; (ix) A participating carrier shall apply its case management and claims handling techniques, including but not limited to utilization review, individual case management, preferred provider provisions, other managed care provisions or methods of operation, consistently with both reinsured and nonreinsured business. (k) The board, as part of the plan of operation, shall establish a methodology for determining premium rates to be charged by the program for reinsuring small employers and individuals pursuant to this section. The methodology shall include a system for classification of small employers that reflects the types of case characteristics commonly used by small employer carriers in the state. The methodology shall provide for the development of base reinsurance premium rates, which shall be multiplied by the factors set forth in paragraphs (i) and (ii) of this subsection to determine the premium rates for the program. The base reinsurance premium rates and number and type of insured groupings shall be established by the board, subject to the approval of the commissioner, and shall be set at levels which reasonably approximate gross premiums charged to small employers by small employer carriers. The board periodically shall review the methodology established under this subsection, including the system of classification and any rating factors, to assure that it reasonably reflects the claims experience of the program. The board may propose changes to the methodology which shall be subject to the approval of the commissioner. The board shall take steps to expand the usage of the reinsurance program and to reduce the impacts of high risk individuals on any particular group. Premiums for the program shall be as follows: (i) An entire small employer group may be reinsured for a rate that is between one and one-tenth (1.1) and one and one-half (1.5) times the base reinsurance premium rate for the group established pursuant to this subsection; (ii) An eligible employee or dependent may be reinsured for a rate that is between one and one-half (1.5) and five (5) times the base reinsurance premium rate for the individual established pursuant to this subsection; (iii) The premiums shall be kept as close as practical to the lower limits provided by this subsection except to the extent needed to keep the assessments needed within the forty percent (40%) of premium tax limit pursuant to W.S. 26-19-312(b). (m) In any case where a health benefit plan for a small employer is entirely or partially reinsured with the program, the premium charged to the small employer for any rating period for the coverage issued shall be consistent with the requirements relating to premium rates set forth in W.S. 26-19-304(a). (n) Assessments and other fees required by the program shall be made in accordance with this subsection: (i) Repealed By Laws 2006, Chapter 120, § 3. (ii) Repealed By Laws 2006, Chapter 120, § 3. (iii) Repealed By Laws 2006, Chapter 120, § 3. (iv) Repealed By Laws 2006, Chapter 120, § 3. (v) Provisions shall be made in the plan of operation for the imposition of an interest penalty for late payment of assessments; (vi) A participating carrier may seek from the commissioner a deferment in whole or in part, from any assessment issued by the board. The commissioner may defer, in whole or in part, the assessment of a participating carrier if, in the opinion of the commissioner, the payment of the assessment would place the participating carrier in a financially impaired condition. In the event an assessment against a participating carrier is deferred in whole or in part, the amount by which the assessment is deferred may be assessed against the other participating carriers in a manner consistent with the basis for the assessment set forth in this section. The participating carrier receiving a deferment shall remain liable to the program for the amount deferred. (o) Neither the participation in the program, the establishment of procedures, nor any other joint or collective action required by this act shall be the basis of any legal action, criminal or civil liability, or penalty against the program or any participating carriers either jointly or separately. (p) The program shall be exempt from any and all taxes.

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26-19-308. Health benefit plan committee.

(a) The commissioner shall appoint a health benefit plan committee. The committee shall be composed of seven (7) members, which shall include: (i) The commissioner; (ii) Three (3) representatives of participating carriers; and (iii) One (1) representative each of a small employer, an employee of a small employer and a health care provider. (b) The committee shall recommend the form and level of coverages to be made available by small employer carriers pursuant to W.S. 26-19-306. (c) The committee shall recommend benefit levels, cost sharing factors, exclusions and limitations for the basic health benefit plan and the standard health benefit plan. One (1) basic health benefit plan and one (1) standard health care plan shall contain benefit and cost sharing levels that are consistent with the basic method of operation and the benefit plans of health maintenance organizations, including any restrictions imposed by federal law: (i) The plans recommended by the committee may include cost containment features such as, but not limited to: (A) Utilization review of health care services, including review of medical necessity of hospital and physician services; (B) Case management benefit alternatives; (C) Reasonable benefit differentials applicable to participating and nonparticipating providers; and (D) Other managed care provisions. (ii) The committee shall submit the plans to the commissioner for approval within one hundred eighty (180) days after the appointment of the committee pursuant to this section. If the commissioner disapproves of the plans in whole or in part he shall submit alternative interim plans to the committee for its approval. (d) Members of the committee shall be reimbursed from the assets of the program for expenses incurred by them as members of the committee but shall not otherwise be compensated by the program for their services.

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26-19-309. Periodic market evaluation.

The board shall study and report at least every three (3) years to the commissioner on the effectiveness of this act. The report shall analyze the effectiveness of this act in promoting rate stability, product availability and affordability of coverage and may contain recommendations for actions to improve the overall effectiveness, efficiency and fairness of the small group health insurance marketplace. The report also shall address whether carriers and producers are fairly and actively marketing or issuing health benefit plans to small employers in fulfillment of the purposes of this act and may contain recommendations for market conduct or other regulatory standards or action.

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26-19-310. Administrative procedures.

The commissioner may issue regulations in accordance with W.S. 26-2-110 for the implementation and administration of the Small Employer Health Insurance Availability Act.

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26-19-311. Small employer carrier reinsurance account created.

There is created an account in which all money received or collected to support the small employer carrier reinsurance program created pursuant to this act shall be credited and continuously appropriated for the purposes of this act. All claims, insurer reimbursements, cost of administration and other necessary expenses incurred pursuant to this act shall be paid from the account. All money in the account not immediately necessary for the purposes of this act, which amount is certified by the board to the state treasurer, shall be invested and any interest earned shall be credited to the account.

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26-19-312. Small employer carrier reinsurance program assessments; premium tax credit.

(a) After each calendar year, the board shall determine the amount of assessment needed to support the small carrier reinsurance program considering all payments made, costs incurred, premiums received and other income received. (b) All authorized insurers liable for premium tax shall be assessed as necessary to meet the requirements determined under subsection (a) of this section. The assessment shall be in proportion to the gross premium tax owed and shall be expressed as a percentage of the gross premium tax owed. The gross premium tax is the premium tax owed before any deduction for any assessments. The assessment pursuant to this subsection for any individual insurer shall not exceed forty percent (40%) of the gross premium tax owed. (c) On or before June 1 of each year, the board shall determine each insurer's assessment for the calendar year. Any deficit incurred by the program shall be recouped by assessment apportioned as provided by this section. Notification of assessments shall be mailed by the board not later than June 1 of each year. (d) The total amount of assessment paid by any insurer pursuant to this section plus an amount equal to five percent (5%) of that total assessment shall be allowed as a credit against any premium or retaliatory tax owed by the member under this code for the year for which the assessment is payable. If assessments including the additional credit authorized exceed the premium or retaliatory tax owed considering all assessments pursuant to this act and other acts, the credits may be carried forward to other tax years until used. (e) If assessments exceed actual losses and administrative expenses of the program, the excess shall be paid to the state treasurer, credited to the account created by W.S. 26-19-311 and used by the administrator to offset future losses or to reduce program premiums. As used in this subsection, "future losses" includes reserves for incurred but unreported claims. (f) The board may require initial calendar year 2006 and interim assessments as reasonably necessary for the organizational, administrative and interim operating expenses of the program and to pay claims in excess of premiums collected. Any initial or interim assessments shall be credited as offsets against any regular assessment due following the close of the calendar year. (g) Assessments collected pursuant to the small employer carrier reinsurance program shall be paid to the state treasurer and credited to the account created by W.S. 26-19-311.

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26-20-101. Newly born and adopted child coverage required.

(a) 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 which provide coverage for a family member of the insured or subscriber, shall also provide, as to the family members' coverage, that the health insurance benefits applicable for children are automatically payable with respect to: (i) A newly born child of the insured or subscriber from the moment of birth; and (ii) 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 shall begin at the date of entry of a final decree of adoption. Coverage for an adopted child shall continue unless the petition is denied.

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26-20-102. Specific coverage.

The coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. The coverage for adopted children shall consist of coverage of injury or sickness including the necessary care and treatment of medical conditions existing prior to the date of placement.

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26-20-103. Premiums.

If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a child or the placement for adoption of a child and payment of the required premium or fees shall be furnished to the insurer or nonprofit service or indemnity corporation within thirty-one (31) days after the date of birth or after the date coverage of a child placed for adoption begins in order to have the coverage continue beyond the thirty-one (31) day period.

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26-20-104. Applicability of article.

The requirements of this article regarding newly born children apply to all insurance policies and subscriber contracts delivered or issued for delivery in this state more than one hundred twenty (120) days after May 30, 1975. The requirements of this article regarding adopted children apply to all insurance policies and subscriber contracts delivered or issued for delivery in this state after June 8, 1989.

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26-20-201. Diabetes coverage required.

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26-20-301. Clinical trials and studies coverage required.

(a) All individual and group health insurance policies providing coverage on an expense incurred basis, individual and group service or indemnity type contracts issued by any insurer including any nonprofit corporation and individual and group service contracts or certificates issued by a health maintenance organization which provide coverage for treatment of cancer shall also provide coverage for routine patient care costs which a policyholder or certificate holder, or his covered dependent, receives as part of a clinical trial or study if: (i) The medical treatment is provided in a phase II, phase III or phase IV study or clinical trial for the treatment of cancer; (ii) The clinical trial or study is approved by: (A) An agency of the national institutes of health as set forth in 42 U.S.C. 281(b) or a research entity that meets the NIH granting criteria; (B) The United States food and drug administration as an application for a new investigational drug; (C) The United States department of veterans affairs; or (D) The United States department of defense. (iii) The medical treatment is provided by a licensed health care provider practicing within the scope of the provider's license and the facility and personnel providing the treatment have the experience and training to provide the treatment in a competent manner; and (iv) The participant in the clinical trial or study, before commencing participation, has signed a statement of consent indicating that the participant has been informed of: (A) The procedure to be undertaken; (B) Alternative methods of treatment; and (C) The general nature and extent of risks associated with participation in the clinical trial or study. (b) Coverage for medical treatment required by this section shall be limited to routine patient care costs. (c) The coverage required by this section does not include: (i) Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or medical industry; (ii) Coverage for any drug or device that is paid for by the manufacturer, distributor or provider of the drug or device; (iii) Health care services that are customarily provided by the sponsors of the clinical trial or study free of charge to the participants in the trial or study; (iv) Extraneous expenses related to participation in the clinical trial or study including, without limitation, travel, housing and other expenses that a participant or person accompanying a participant may incur; (v) Any item or service that is provided solely to satisfy a need or desire for data collection or analysis that is not directly related to the clinical management of the patient; (vi) Any costs for the management of research relating to the clinical trial or study. (d) Nothing in this section shall: (i) Preclude an insurer from excluding coverage for any claim arising from the practice of medicine or other health care by a person without an applicable physician or health care provider license; (ii) Preclude an insurer from asserting the right to subrogate for expenses arising from complications caused by a drug or device that is subsequently approved for usage upon completion of the clinical trial; (iii) Provide a private cause of action against any health insurer described in subsection (a) of this section for damages arising as a result of compliance with this section. (e) For purposes of this section: (i) "Clinical trial" means any experiment in which a drug is administered to, dispensed to or used by one (1) or more human subjects. For purposes of this paragraph, an experiment is any use of a drug except for the use of a marketed drug in the course of medical practice; (ii) "Routine patient care cost" means: (A) A medical service or treatment that is a benefit under a health plan that would be covered if the patient were receiving standard cancer treatment; or (B) A drug provided to a patient during a cancer clinical trial, other than the drug that is the subject of the clinical trial, if the drug has been approved by the federal food and drug administration for use in treating the patient's particular condition.

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26-20-401. Inherited enzymatic disorder coverage required.

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26-20-501. Prescription eye drop refill coverage required.

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26-20-601. Oral chemotherapy parity with injectable and intravenous.

(a) No individual or group health insurance policy providing coverage on an expense incurred basis, individual and group service or indemnity type contract issued by any insurer including any nonprofit corporation and individual and no group service contract issued by a health maintenance organization, shall require a higher copayment, deductible or coinsurance amount for oral chemotherapy than required for injected or intravenous chemotherapy, regardless of the formulation or benefit category determination by the policy or contract issuer. (b) No issuer of a health insurance policy or contract shall comply with subsection (a) of this section by increasing the copayment, deductible or coinsurance amount required for covered injected or intravenous chemotherapy or by reclassifying benefits with respect to cancer treatment medications. (c) This section shall apply to all policies and contracts, as described in subsection (a) of this section, issued or renewed after July 1, 2015. (d) For purposes of this section, "chemotherapy" means administration of drugs and biologics to kill, slow or prevent the growth of cancerous cells.

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26-20-701. Required parity for mental health and substance use disorder insurance.

(a) All individual or group health insurance policies providing coverage on an expense incurred basis, individual and group service or indemnity type health insurance contracts issued by any insurer, including any nonprofit corporation and individual and group service contracts issued by a health maintenance organization, shall meet the requirements of, and the commissioner may enforce subject to the provisions of this section, the Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. § 300gg-26, as amended, and the regulations promulgated pursuant thereto as of January 1, 2018. Persons exempt from complying with the Mental Health Parity and Addiction Equity Act shall not be exempted from complying with the requirements of this section if this section otherwise applies to the person. The commissioner may promulgate reasonable rules which establish exemptions from the application of this section. (b) No policy or contract providing mental health or substance use coverage to which subsection (a) of this section applies shall: (i) Deny coverage for mental health or substance use services delivered using remote audio or audio-visual delivery systems to a person not physically present with the delivering health care provider if coverage would be provided for the same services when delivered in person; (ii) Charge a copayment, deductible or coinsurance amount to a person receiving mental health or substance use services through remote audio or audio-visual delivery systems that is higher than the copayment, deductible or coinsurance amount charged for the same services when delivered in person; (iii) Reduce any payment or reimbursement provided to a health care provider using remote audio or audio-visual delivery systems for the provision of mental health or substance use services to an amount that is less than the payment or reimbursement that would be made to a health care provider rendering those services in person.

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26-20-702. Reimbursement for mental health and substance use disorder benefits.

(a) As used in this section "mental health and substance use disorder benefits" means benefits for the treatment of any condition or disorder that involves a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental disorders section of the most recent edition of the International Classification of Disease or that is listed in the mental disorders section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. (b) All individual or group health insurance policies providing coverage on an expense incurred basis, individual and group service or indemnity type health insurance contracts issued by any insurer, including any nonprofit corporation and individual and group service contracts issued by a health maintenance organization and individual and group service contracts that provide mental health and substance use disorder benefits shall provide reimbursement for benefits that are delivered through the psychiatric Collaborative Care Model as defined by the American Medical Association's most recent procedural terminology codes and where a licensed and credentialed primary care team consists of a primary care provider, a care manager and a psychiatric consultant. (c) The benefit and reimbursement requirements of subsection (b) of this section shall not apply to any policy, contract or service that would require the state to defray the cost as specified in 42 U.S.C. 18031(d)(3)(B)(ii). (d) Nothing in this section shall restrict the health insurer's ability to apply appropriate medical management for the services rendered.

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26-20-801. Definitions.

(a) As used in this article: (i) "Covered person" means a policyholder, subscriber, enrollee, member or individual covered by any policy, contract or certificate listed in W.S. 26-20-802(a) or by any life insurance or long-term care insurance policy; (ii) "Health insurance issuer" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including through a policy, contract or certificate listed in W.S. 26-20-802(a), and shall include a sickness and accident insurance company, a nonprofit corporation, a health maintenance organization, a preferred provider organization, or any similar entity, or any other entity providing a plan of health insurance or health benefits; (iii) "Living organ donor" means a person who is not deceased and who has donated all or part of one (1) or more of the person's own organs or tissues to another person for transplant; (iv) "Organ transplant recipient" means a person who receives an organ transplant as defined by W.S. 35-5-301(a)(v). (b) The definitions in W.S. 35-5-301 shall apply to this article.

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26-20-802. Discrimination prohibited.

(a) No individual or group health insurance policy providing coverage on an expense incurred basis, individual or group service or indemnity type health insurance contract or certificate issued by any health insurance issuer that provides coverage for anatomical gifts, organ transplants or related treatment and services shall: (i) Deny coverage of an anatomical gift, organ transplant or related treatment or service to a covered person solely on the basis of the person's disability; (ii) Deny to a covered person eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy, contract or certificate, solely for the purpose of avoiding the requirements of this section or W.S. 35-5-301 through 35-5-303; (iii) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide monetary or nonmonetary incentives to an attending provider, to induce the provider to provide care to a covered person in a manner inconsistent with this section or W.S. 35-5-301 through 35-5-303; or (iv) Reduce or limit coverage benefits to a covered person for the medical services or other services related to organ transplantation performed pursuant to this section and W.S. 35-5-301 through 35-5-303 as determined in consultation with the attending physician and covered person. (b) In the case of any policy, contract or certificate listed in subsection (a) of this section that is maintained pursuant to one (1) or more collective bargaining agreements between employee representatives and one (1) or more employers, any policy, contract or certificate amendment made pursuant to a collective bargaining agreement relating to the policy and made solely to conform to any requirement under this section shall not be treated as a termination of the collective bargaining agreement. (c) Nothing in this section shall require a health insurance issuer to provide coverage for a medically inappropriate organ transplant.

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26-20-803. Living organ donor and organ transplant recipient coverage.

(a) No individual or group life insurance policy or long-term care insurance policy shall: (i) Deny or cancel coverage to a covered person solely on the basis of the person's status as a living organ donor or as an organ transplant recipient without any unique and material actuarial risks in accordance with sound actuarial principles and without any actual and reasonably anticipated and expected experience of a person on the basis of their status as a living organ donor or as an organ transplant recipient; (ii) Deny a covered person eligibility or continued eligibility to enroll or to renew coverage under the terms of a policy, contract or certificate, solely on the basis of the person's status as a living organ donor or as an organ transplant recipient without any unique and material actuarial risks in accordance with sound actuarial principles and without any actual and reasonably anticipated and expected experience of a person on the basis of their status as a living organ donor or as an organ transplant recipient; (iii) Reduce or limit coverage or benefits, increase the premiums or otherwise adversely affect the coverage or cost for a covered person's policy, contract or certificate solely on the basis of the person's status as a living organ donor or as an organ transplant recipient without any additional separate actuarial risk involved; (iv) Preclude a covered person from donating all or part of an organ or tissues as a condition of receiving or continuing to receive coverage under a policy, contract or certificate; (v) Preclude a covered person from receiving all or part of an organ or tissue through transplantation or transfusion as a condition of receiving or continuing to receive coverage under a policy, contract or certificate; (vi) Preclude a covered person from receiving medical services or other services related to organ transplantation, including diagnostic services, evaluation, surgery, counseling or post-operative treatment or services.

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26-21-101. Scope and applicability of chapter.

(a) All life insurance and all disability insurance in connection with loans or other credit transactions is subject to this chapter, except that insurance is not subject to this chapter if: (i) It is in connection with a loan or other credit transaction of more than ten (10) years; or (ii) The issuance of that insurance is an isolated transaction by the insurer not related to an agreement or a plan or regular course of conduct for insuring debtors of the creditor.

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26-21-102. Definitions.

(a) For the purpose of this chapter: (i) "Credit life insurance" means insurance on the life of a debtor pursuant to or in connection with a specific loan or other credit transaction; (ii) "Credit disability insurance" means insurance on a debtor to provide indemnity for payments becoming due on a specific loan or other credit transaction while the debtor is disabled as defined in the policy; (iii) "Creditor" means the lender of money or vendor of goods, services or property, including a lessor under a lease intended as a security, rights or privileges, for which payment is arranged through a credit transaction, or any successor to the right, title or interest of any such lender or vendor, and an affiliate, associate or subsidiary of any of them or any director, officer or employee of any of them or any other person in any way associated with any of them; (iv) "Debtor" means a borrower of money or a purchaser or lessee of goods, services, property, rights or privileges for which payment is arranged through a credit transaction; (v) "Indebtedness" means the total amount payable by a debtor to a creditor in connection with a loan or other credit transaction.

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26-21-103. Forms of credit life and credit disability insurance.

(a) Credit life insurance and credit disability insurance shall be issued only in the following forms: (i) Individual policies of life insurance issued to debtors on the term plan; (ii) Individual policies of disability insurance issued to debtors on a term plan, or disability benefit provisions in individual policies of credit life insurance; (iii) Group policies of life insurance issued to creditors providing insurance upon the lives of debtors on the term plan; (iv) Group policies of disability insurance issued to creditors on a term plan insuring debtors, or disability benefit provisions in group credit life insurance policies to provide disability coverage.

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26-21-104. Amount of credit life insurance.

(a) The initial amount of credit life insurance shall not exceed the total amount repayable under the contract of indebtedness. (b) If an indebtedness is repayable in substantially equal installments, the amount of insurance shall not exceed the scheduled or actual amount of unpaid indebtedness, whichever is greater. (c) Notwithstanding subsections (a) and (b) of this section, insurance on agricultural credit transactions not exceeding two (2) years in duration may be written up to the amount of the loan commitment on a nondecreasing or level term plan. (d) Notwithstanding any other provision of law, insurance on educational credit transaction commitments may be written for the amount of the portion of that commitment that the creditor has not advanced.

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26-21-105. Credit disability insurance.

The total amount of indemnity payable by credit disability insurance in case of disability, as defined in the policy, shall not exceed the aggregate of the periodic scheduled unpaid installments of the indebtedness, and the amount of each periodic indemnity payment shall not exceed the original indebtedness divided by the number of periodic installments.

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26-21-106. Term of insurance.

(a) The term of any credit life insurance or credit disability insurance, subject to the insurer's acceptance, commences on the date when the debtor becomes obligated to the creditor, or the date when the debtor applies for the insurance, whichever is later, except that if a group policy provides coverage with respect to the existing obligations, the insurance on a debtor with respect to the indebtedness commences on the effective date of the policy. (b) If evidence of insurability is required and that evidence is furnished more than thirty (30) days after the date when the debtor becomes obligated to the creditor, the term of the insurance may commence on the date on which the insurer determines the evidence to be satisfactory, and in that case there shall be an appropriate refund or adjustment of any charge to the debtor for insurance. The term of the insurance shall not extend more than fifteen (15) days beyond the scheduled maturity date of the indebtedness except when extended without additional cost to the debtor. (c) If the indebtedness is discharged because of renewal or refinancing prior to the scheduled maturity date, the insurance in force shall be terminated before any new insurance may be issued in connection with the renewed or refinanced indebtedness. (d) In all cases of termination prior to scheduled maturity, a refund shall be paid or credited as provided in W.S. 26-21-109.

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26-21-107. Provisions of policies and certificates; disclosure to debtors.

(a) All credit life insurance and credit disability insurance shall be evidenced by an individual policy, or in the case of group insurance by a certificate of insurance, which individual policy or group certificate shall be delivered to the debtor. (b) Each individual policy or group certificate of credit life insurance or credit disability insurance, or both, in addition to other requirements of law, shall: (i) Set forth: (A) The insurer's name and home office address; (B) The identity by name or otherwise of the persons insured; (C) The premium amount of payment, if any, by the debtor separately for credit life insurance and credit disability insurance; (D) A description of the amount, term and coverage including any exceptions, limitations and restrictions; and (ii) State that the benefits shall be paid to the creditor to reduce or extinguish the unpaid indebtedness and, if the amount of insurance exceeds the unpaid indebtedness, the excess is payable to a beneficiary, other than the creditor, named by the debtor or to his estate. (c) Except as otherwise provided in this section, the individual policy or group certificate of insurance shall be delivered to the insured debtor at the time the indebtedness is incurred. (d) If a debtor makes a separate payment for credit life or credit disability insurance and an individual policy or group certificate of insurance is not delivered to the debtor at the time the indebtedness is incurred, a copy of the application for the policy or a notice of proposed insurance shall be delivered at that time to the debtor. The copy of the application for, or notice of proposed insurance, shall: (i) Be signed by the debtor and shall set forth: (A) The identity by name or otherwise of the person or persons insured; (B) The premium or amount of payment by the debtor, if any, separately for credit life insurance and credit disability insurance; and (C) A statement that within thirty (30) days, if the insurer accepts the insurance, there shall be delivered to the debtor an individual policy or group certificate of insurance containing: (I) The insurer's name and home office address; (II) A description of the amount, term and coverage including any exceptions, limitations and restrictions. (ii) Refer exclusively to insurance coverage and shall be separate from the loan, sale or other credit statement of account, instrument or agreement, unless the information required by this subsection is prominently set forth in the copy of the application or the notice of proposed insurance. (e) Upon the insurer's acceptance of the insurance and within thirty (30) days from the date the indebtedness is incurred, the insurer shall cause the individual policy or group certificate of insurance to be delivered to the debtor. The application or notice of proposed insurance shall state that upon the insurer's acceptance, the insurance is effective as provided in W.S. 26-21-106. (f) If the named insurer does not accept the risk, the debtor shall receive a policy or certificate of insurance setting forth the name and home office address of the substituted insurer and the amount of the premium to be charged. If the amount of premium is less than that set forth in the notice of proposed insurance, an appropriate refund shall be made.

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26-21-108. Filing of policies with commissioner; approval or disapproval; withdrawal of approval.

(a) All policies, certificates of insurance, notices of proposed insurance, applications for insurance, endorsements and riders delivered or issued for delivery in this state and the schedule of premium rates pertaining thereto shall be filed with the commissioner. (b) The commissioner, within thirty (30) days after the filing of any such policies, certificates of insurance, notices of proposed insurance, applications for insurance, endorsements and riders, shall disapprove any such form if the premium rates charged or to be charged are excessive in relation to benefits, or if it contains provisions which are unjust, unfair, inequitable, misleading, deceptive or encourage misrepresentation of the coverage, or are contrary to any provision of this code or of any rule or regulation promulgated under this code. In determining whether to disapprove any form the commissioner shall consider past and prospective loss experience within and outside this state, underwriting practice and judgment to the extent appropriate and any other relevant factors within and outside this state. (c) If the commissioner notifies the insurer that the form is disapproved, it is unlawful for the insurer to issue or use that form. The commissioner shall specify in the notice the reason for his disapproval and state that a hearing will be granted within twenty (20) days after request in writing by the insurer. No policy, certificate of insurance, notice of proposed insurance, application, endorsement or rider shall be issued or used until the expiration of thirty (30) days after it is filed, unless the commissioner gives his prior written approval thereto. (d) The commissioner, at any time after a hearing held not less than twenty (20) days after written notice to the insurer, may withdraw his approval of any form on any ground set forth in subsection (b) of this section. The written notice of hearing shall state the reason for the proposed withdrawal. (e) The insurer shall not issue or use any form after the effective date of withdrawal. (f) If a group policy of credit life insurance or credit disability insurance is delivered in another state, the insurer shall file only the group certificate and notice of proposed insurance delivered or issued for delivery in this state as specified in W.S. 26-21-107(b) and (d). The commissioner shall approve the forms if they conform with the requirements specified in W.S. 26-21-107(b) and (d) and if the schedules of premium rates applicable to the insurance evidenced by the certificate or notice are not in excess of the insurer's schedules of premium rates filed with the commissioner.

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26-21-109. Schedules of premiums; refunds.

(a) Any insurer may revise its schedules of premium rates and shall file the revised schedules with the commissioner. No insurer shall issue any credit life insurance or credit disability insurance policy for which the premium rate exceeds that determined by the insurer's schedules then on file with the commissioner. (b) Each individual policy or group certificate shall provide that if the insurance is terminated prior to the scheduled maturity date of the indebtedness, any refund of an amount paid by the debtor for insurance shall be paid or credited promptly to the person entitled thereto. The commissioner shall prescribe a minimum refund and no refund less than the minimum need be made. The formula to be used in computing the refund shall be filed with and approved by the commissioner. (c) If a creditor requires a debtor to make any payment for credit life insurance or credit disability insurance and an individual policy or group certificate of insurance is not issued, the creditor shall immediately give written notice to the debtor and shall promptly make an appropriate credit to the account. (d) The amount charged to a debtor for any credit life or credit disability insurance shall not exceed the premiums charged by the insurer, as computed at the time the charge to the debtor is determined.

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26-21-110. Collection of premiums.

The insurance premium or other identifiable charge for credit life or credit disability insurance may be collected from the insured or included in the principal of any loan or other transaction at the time the transaction is completed. If included in the principal of the loan or other transaction, a statement that the premium is included in the principal and the amount of the premium shall be legible on the face of the policy or certificate in a size larger than the type used in the body of the policy or certificate.

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26-21-111. Premium not deemed interest; gains to creditor not violation.

The premium or cost of credit life or credit disability insurance when issued through any creditor is not deemed interest or charges, or consideration or an amount in excess of permitted charges in connection with the loan or other credit transaction. Any gain or advantage to the creditor arising out of the premium or commission or dividend from the issuance of the insurance is not a violation of any other law of this state.

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26-21-112. Issuance and delivery of policies.

All credit life insurance and credit disability insurance policies shall be delivered or issued for delivery in this state only by an insurer authorized to transact insurance in this state and shall be issued only through holders of licenses or authorizations issued by the commissioner.

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26-21-113. Claims.

(a) All claims shall be: (i) Promptly reported to the insurer or its designated claim representative, and the insurer shall maintain adequate claim files; (ii) Settled as soon as possible and in accordance with the terms of the insurance contract; (iii) Paid either by draft drawn upon the insurer or by check of the insurer to the order of the claimant to whom payment of the claim is due pursuant to the policy provisions, or upon direction of the claimant to one specified. (b) No plan or arrangement shall be used whereby any person other than the insurer or its designated claim representative is authorized to settle or adjust claims. The creditor shall not be designated as claim representative for the insurer in adjusting claims, except that a group policyholder, by arrangement with the group insurer, may draw drafts or checks in payment of claims due to the group policyholder subject to the insurer's audit and review.

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