26-32-101. Supervision and audit of funds; approval of
investment; promulgation of rules and regulations; licenses.
(a) The department shall supervise and audit the funds derived by any person either residing in or doing business within the state, from prepaid or prearranged funeral contracts providing for the sale of caskets, burial vaults, monuments or memorials or any burial supplies and equipment and funeral services, if the sale is made, either outright or on the installment basis, prior to the demise of the person purchasing them or for whom they are purchased, with the merchandise or service, or both, to be delivered at a future date at time of need. All funds received from these contracts or arrangements by any person either residing in or doing business within this state shall be received, invested and withdrawn according to requirements the department approves. Investment in a bank, trust company or federal savings and loan association in Wyoming is an approved investment. The deposit of funds received from the sale of these contracts or arrangements in irrevocable pre-need funeral trusts, the funds of which are invested in compliance with W.S. 4-10-901 and 4-10-902, is an approved investment. Earnings, including interest, income and dividends, from any investment of an irrevocable pre-need funeral trust may inure to the benefit of the seller of the prepaid or prearranged funeral contract, but shall be withdrawn from the irrevocable trust only upon the occurrence of an event that requires withdrawal of the corpus of the trust. Neither the person purchasing a prepaid or prearranged funeral contract nor any person for whom the contract is purchased shall be entitled to terminate or cancel the contract or make demand for the funds paid for the contract after the funds are deposited into an irrevocable pre-need funeral trust.
(b) The commissioner shall promulgate rules and regulations for the purposes specified in subsection (a) of this section to include regulation of contract provisions and funds thereunder. The rules shall require notice to buyers of prepaid or prearranged funeral contracts of the types of investments into which funds derived from the sale of these contracts may be deposited and the risks associated with those investments. The rules shall require notice to buyers of the ability to cancel or terminate a contract or make demand for any amounts paid for the contract. Rules promulgated by the commissioner shall not require any additional surety bond amount for those monies deposited in an irrevocable pre-need funeral trust and invested in compliance with W.S 4-10-902 beyond the minimum surety bond required of all persons deriving funds from prepaid or prearranged funeral contracts.
(c) A person shall not sell prepaid or prearranged funeral contracts in this state unless the person is licensed by the department in accordance with W.S. 26-9-203.
26-32-102. Exemption from attachment or garnishment.
In the absence of fraud no interest of any participant in such fund, contract or investment is liable to attachment, garnishment, or other processes, or shall be seized, taken, appropriated or applied by any legal or equitable process or operation of law to pay any debt or liability of the participant, or any other person who may have a right thereunder. Any funds received and invested as stipulated in this chapter shall be as a trust and are not liable to attachment, garnishment or other processes, nor shall they be seized, taken or appropriated or applied by any legal or equitable processes or operation of law to pay any debt or liability of the person issuing the prepaid or prearranged funeral contract, or both.
Any person who violates any provision of this chapter is guilty of a misdemeanor, and upon conviction thereof, shall be punished by a fine of not more than five hundred dollars ($500.00) or by imprisonment for not more than six (6) months, or both.
26-32-201. Life insurers contracts for funeral services; rules.
(a) A life insurer may contract or agree with any person, funeral director, mortuary or undertaker for the sole purpose of the funeral director, mortuary or undertaker conducting the funeral of any insured of the insurer.
(b) The commissioner shall by rule regulate contracts authorized under this section.
(a) As used in this chapter:
(i) "Account" means the medical liability compensation account;
(ii) "Board" means the board of directors of the medical liability compensation account;
(iii) "Health care" means any act or treatment performed or furnished, or which should have been performed or furnished, by any physician for, to, or on behalf of a patient during the patient's medical care, treatment or confinement;
(iv) "Insurer" means an authority or an insurance company engaged in writing malpractice liability insurance in this state in accordance with this code;
(v) "Malpractice" means the rendering of or failure to render professional medical services as a result of which the patient has a cause of action against a licensed physician for monetary damages;
(vi) "Physician" means a person licensed by the state board of medicine to provide health care or professional services as a physician.
(a) To be qualified under this chapter, a physician shall annually purchase health care professional liability insurance coverage of not less than fifty thousand dollars ($50,000.00) per occurrence for any act, error or omission relating to medical care rendered during the policy year and pay the surcharge pursuant to W.S. 26-33-105(c).
(b) A physician failing to qualify under this section is not covered by this chapter.
A qualified physician shall be insured in a minimum amount of fifty thousand dollars ($50,000.00) against a claim for malpractice. Any award or settlement adjudicated or allowed on a malpractice claim in excess of fifty thousand dollars ($50,000.00) or limits of other underlying coverage if greater occurring during any year in which the physician is qualified under this chapter shall be paid from the account subject to the limitation that obligations from the account shall not exceed one million dollars ($1,000,000.00) in any calendar year for one (1) or more awards or settlements against an individual physician.
Any advance payment a defendant physician or his insurer makes to or for the plaintiff, or any other person, is not an admission of liability for injuries or damages the plaintiff or anyone else suffers as to a claim for malpractice. Evidence of an advance payment is not admissible in a court proceeding concerning malpractice until there is final determination in the plaintiff's favor, in which case the final amount payable shall be reduced by any advance payments.
26-33-105. Medical liability compensation account.
(a) There is created a medical liability compensation account, the monies of which shall be collected by the commissioner for exclusive use for the purposes stated in this chapter. The account and any investment income from it shall be held in trust and invested and reinvested by the state treasurer pursuant to W.S. 9-4-715(a), (d) and (e).
(b) The commissioner may use account monies to purchase insurance for the account and its obligations. The commissioner shall be notified of a suit within thirty (30) days from the date the suit is filed. The commissioner may participate in a physician's defense if any claim is sufficient to be a potential liability against the account. Reasonable legal expenses the board approves and the commissioner incurs in defense against any malpractice claim are payable out of the account.
(c) To create the account, all physicians qualified under W.S. 26-33-102, practicing in Wyoming and who elect to participate, shall pay an annual surcharge. The commissioner shall determine the surcharge based upon sound actuarial principles using data obtained from Wyoming experience. The surcharge shall not exceed one hundred fifty percent (150%) of the cost to each physician for a basic fifty thousand dollar ($50,000.00) malpractice insurance premium and shall be collected on the same basis as premiums by each insurer from the physician.
(d) The surcharge is due and payable within thirty (30) days after the insurer receives the premiums for malpractice liability insurance from the practicing physician in Wyoming. The commissioner shall send to each insurer a statement explaining the provisions of this section together with any other information necessary for their compliance with this section.
(e) If the insurer collects the annual premium surcharge but does not pay it to the state within the stated time limit, the commissioner may suspend the insurer's certificate of authority until the annual premium surcharge is paid.
(f) All expenses of collecting, protecting and administering the account or related to the purchase of insurance for the account shall be paid from the account. The commissioner may employ financial, administrative or legal consultants to assist in the account management.
(g) If the account balance exceeds four million dollars ($4,000,000.00) at the end of any calendar year after payment of all claims and expenses, the commissioner shall reduce the surcharge to maintain the account at an approximate level of four million dollars ($4,000,000.00).
(h) The commissioner shall purchase reinsurance, if needed, to protect the account from depletion due to judgment against it. The reinsurance so purchased shall cover each qualified physician from two hundred fifty thousand dollars ($250,000.00) to one million dollars ($1,000,000.00) per year. Cost of reinsurance shall be paid from the monies of the account.
(a) There is created a medical liability compensation account board which shall consist of six (6) members. The governor shall appoint four (4) members with the advice and consent of the senate. The state treasurer and the commissioner are the other voting members. The governor may remove any member he appoints as provided in W.S. 9-1-202.
(b) Of the members the governor appoints:
(i) One (1) shall be a physician licensed to practice in Wyoming by the state board of medicine;
(ii) One (1) shall be a practicing attorney licensed to practice in Wyoming by the Wyoming state bar;
(iii) One (1) shall be a health care consumer; and
(iv) One (1) shall be a licensed insurance agent in Wyoming.
(c) Two (2) members shall serve for terms ending two (2) years from January 1 immediately following their appointment and two (2) members shall serve for a term of four (4) years from that date. Their successors shall serve for terms of three (3) years each. Effective July 1, 1979, appointments and terms shall be in accordance with W.S. 28-12-101 through 28-12-103.
(d) The board shall administer and govern the account and shall file rules and regulations therefor with the secretary of state.
Any settlement of a claim against a physician exceeding fifty thousand dollars ($50,000.00) or limits of other underlying coverage if greater shall be carried out through agreement jointly by the claimant, the insurance carrier and the commissioner. If the claimant settles with the insurance carrier, without including the commissioner in the settlement agreement, the claimant waives any claim for damages exceeding fifty thousand dollars ($50,000.00) or limits of other underlying coverage if greater arising from the incident for which the claim is made.
The state auditor, at the direction of the commissioner, shall issue a warrant in satisfaction of each claim submitted to him against the account after receipt of a certified copy of a final judgment from a court having jurisdiction, or a settlement agreement signed by a claimant, a qualified representative of the insurance carrier and the commissioner, with original signatures. The warrant shall be for the amount exceeding fifty thousand dollars ($50,000.00) or limits of other underlying coverage, if greater, set forth in the judgment or settlement, subject to the limitation that the amounts paid from the account shall not exceed one million dollars ($1,000,000.00) in any calendar year for one (1) or more awards or settlements against an individual physician.
Any policy issued under this chapter is presumed to comply with this chapter. The insurer assumes all obligations to pay an award imposed against its insured under this chapter and no policy termination by cancellation is effective unless at least ninety (90) days before the effective date of the cancellation both the insured and the commissioner receive at their offices, a written notice giving the date upon which termination is effective.
(a) If a professional liability insurer, in the regular course of business, fails to pay its portion of any judgment rendered against any physician or any other person insured under this chapter, the commissioner shall suspend that insurer's certificate of authority until the portion of the judgment allocable to the insurer is paid in full, provided the insurer has the right to a hearing in accordance with W.S. 26-3-115(b).
(b) This section does not apply:
(i) If the insurer has asserted against the physician any policy defense based upon misrepresentation, fraud, noncooperation or any other matter which constitutes an avoidance of the policy;
(ii) If the time for filing any petition for review, new trial, appeal or rehearing, or all of them has not expired; or
(iii) Until such time as all review or appellate decisions are final.
(a) As used in this chapter:
(i) "Administrator" means the director of the department of health;
(ii) "Basic health care services" means emergency care, inpatient hospital and physician care, and outpatient medical services, but does not include mental health services or services for alcohol or drug abuse;
(iii) "Capitated basis" means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided. For purposes of this definition, "capitated basis" includes the cost associated with operating staff model facilities;
(iv) "Carrier" means a health maintenance organization, an insurer, a hospital and medical service corporation or other entity responsible for the payment of benefits or the provision of services under a group contract;
(v) "Commissioner" means the insurance commissioner of this state;
(vi) "Coinsurance" means a percentage of eligible charges payable by an enrollee directly to a provider for covered services rendered;
(vii) "Copayment" means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid;
(viii) "Deductible" means the amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment;
(ix) "Discontinuance" means the termination of the contract between the group contract holder and a health maintenance organization due to the insolvency of the health maintenance organization, and does not refer to the termination of any agreement between any individual enrollee and the health maintenance organization;
(x) "Enrollee" means an individual who is enrolled in a health maintenance organization;
(xi) "Evidence of coverage" means any certificate, agreement or contract issued to an enrollee setting out the coverage to which the enrollee is entitled;
(xii) "Extension of benefits" means the continuation of coverage under a particular benefit provided under a contract following termination with respect to an enrollee who is totally disabled on the date of termination;
(xiii) "Group contract" means a contract for health care services which by its terms limits eligibility to members of a specified group. The group contract may include coverage for dependents;
(xiv) "Group contract holder" means the person to which a group contract has been issued;
(xv) "Health care services" means any services included in the furnishing to any individual of medical or dental care, vision care or hospitalization or incident to the furnishing of that care or hospitalization, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing or healing human illness, injury or physical disability;
(xvi) "Health maintenance organization" means any person, except a person offering a dental only or vision only plan, who undertakes to provide or arrange for basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments, coinsurance or deductibles, and may include providing or arranging for:
(A) Physician services directly through physician employees or under arrangements with individual physicians or groups of physicians;
(B) Other health care services on a prepayment or other financial basis.
(xvii) "Health maintenance organization producer" means a person who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for health maintenance organization membership, or who takes or transmits a membership fee or premium for such a policy or contract, other than for himself, or a person who advertises or otherwise holds himself out to the public as undertaking any of the activities of a health maintenance organization producer;
(xviii) "Individual contract" means a contract for health care services issued to and covering an individual. The individual contract may include dependents of the subscriber;
(xix) "Insolvent" or "insolvency" means that the organization has been declared insolvent and placed under an order of liquidation by a court of competent jurisdiction;
(xx) "Managed hospital payment basis" means agreements under which the financial risk is primarily related to the degree of utilization rather than to the cost of services;
(xxi) "Net worth" means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt;
(xxii) "Participating provider" means a provider as defined in paragraph (xxiv) of this subsection who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment, coinsurance or deductible, directly or indirectly from the health maintenance organization;
(xxiii) "Person" means as defined by W.S. 26-1-102(a)(xx);
(xxiv) "Provider" means any physician, hospital or other person which is licensed or otherwise authorized to furnish health care services in the state in which the services are rendered;
(xxv) "Replacement coverage" means the benefits provided by a succeeding carrier;
(xxvi) "Subscriber" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization, or in the case of an individual contract, the person in whose name the contract is issued;
(xxvii) "Uncovered expenditures" means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organization's insolvency and for which no alternative arrangements have been made that are acceptable to the commissioner;
(xxviii) "This code" means title 26 of the Wyoming statutes;
(xxix) "This act" means W.S. 26-34-101 through 26-34-134.
26-34-103. Establishment of health maintenance organizations.
(a) Notwithstanding any law of this state to the contrary, any person may apply to the commissioner for a certificate of authority to establish and operate a health maintenance organization in compliance with this chapter. No person shall establish or operate a health maintenance organization in this state, without obtaining a certificate of authority under this chapter.
(b) Any health maintenance organization in operation as of July 1, 1995, shall submit an application for a certificate of authority under this section not later than August 1, 1995. Each applicant may continue to operate until the commissioner acts upon the application. If an application is denied under W.S. 26-34-104, the applicant shall be treated as a health maintenance organization whose certificate of authority has been revoked.
(c) Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form the commissioner prescribes and shall set forth or be accompanied by the following:
(i) A copy of the applicant's organizational documents, such as the articles of incorporation, articles of association, partnership agreement, trust agreement or other applicable documents, and all amendments thereto;
(ii) A copy of the bylaws, rules and regulations or similar document, if any, regulating the conduct of the applicant's internal affairs;
(iii) A list of the names, addresses, biographical information and official positions of the persons who are to be responsible for the conduct of the applicant's affairs, including all members of the board of directors, board of trustees, executive committee or other governing board or committee, the principal officers in the case of a corporation, and the partners or members in the case of a partnership or association;
(iv) A copy of any contract made or to be made between any providers, third party administrators, marketing consultants or persons listed in paragraph (iii) of this subsection and the health maintenance organization;
(v) A copy of the form of evidence of coverage to be issued to the enrollees;
(vi) A copy of the form or group contract, if any, which is to be issued to employers, unions, trustees or other organizations;
(vii) Financial statements prepared in conformity with the requirements of this code showing the applicant's assets, liabilities and sources of financial support. A copy of the applicant's most recent certified financial statement and an unaudited current financial statement shall be included;
(viii) A financial feasibility plan which includes detailed enrollment projections, the methodology for determining premium rates to be charged during the first twelve (12) months of operations certified by an actuary or other qualified person, a projection of balance sheets, cash flow statements showing any capital expenditures, purchase and sale of investments and deposits with the state and income and expense statements anticipated from the start of operations until the organization has had net income for at least one (1) year and a statement as to the sources of working capital as well as any other sources of funding;
(ix) A power of attorney executed by the applicant, if not domiciled in this state, appointing the commissioner and his successors in office, and authorized deputies, as the true and lawful attorney of the applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served;
(x) A statement reasonably describing the geographic area or areas to be served;
(xi) A description of the complaint procedures to be used as required under W.S. 26-34-112;
(xii) A description of the procedures and programs to be implemented to meet the quality of health care requirements in W.S. 26-34-104(b);
(xiii) Repealed by Laws 1995, ch. 210, § 5.
(xiv) A description of the procedures to be implemented to meet the protection against insolvency requirements in W.S. 26-34-114;
(xv) A list of the names, addresses and professional license numbers of all providers with which the health maintenance organization has agreements;
(xvi) A description of the quality assurance program and the mechanisms in place to assure availability, accessibility and continuity of care required under W.S. 26-34-108;
(xvii) Any other information the commissioner requires to make the determinations specified in W.S. 26-34-104.
(d) Any applicant or health maintenance organization holding a certificate of authority granted under this chapter, unless otherwise provided for in this chapter, shall file a notice describing any material modification of the operation set out in the information required by subsection (c) of this section. The notice shall be filed with the commissioner prior to the modification. If the commissioner does not disapprove within forty-five (45) days of filing, the modification is deemed approved.
(e) The commissioner may promulgate rules and regulations exempting from the filing requirements of subsection (a) of this section those items he deems unnecessary.
(f) Any applicant or health maintenance organization holding a certificate of authority granted under this chapter shall file all contracts of reinsurance with the commissioner. Any agreement between the organization and an insurer is subject to the requirements of this code regarding reinsurance. All reinsurance agreements and any modifications thereto shall be filed and approved before the effective date of any agreement or modification. Reinsurance agreements shall remain in full force and effect for at least ninety (90) days following written notice to the commissioner, by registered mail, of cancellation by either party.
(a) Upon receipt of an application for issuance of a certificate of authority, the commissioner shall immediately transmit a copy of the application and accompanying documents to the administrator.
(b) The administrator shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished has complied with W.S. 26-34-108.
(i) Repealed by Laws 1995, ch. 210, § 5.
(ii) Repealed by Laws 1995, ch. 210, § 5.
(iii) Repealed by Laws 1995, ch. 210, § 5.
(c) Within forty-five (45) days of receipt of the application for issuance of a certificate of authority, the administrator shall certify to the commissioner that the proposed health maintenance organization meets the requirements of W.S. 26-34-108 or notify the commissioner that the health maintenance organization does not meet the requirements and specify in what respects it is deficient.
(d) The commissioner shall issue or deny a certificate of authority to any person filing an application pursuant to W.S. 26-34-103 within fifteen (15) days of receipt of the certification from the administrator. Issuance of a certificate of authority shall be granted upon payment of the application fee prescribed in W.S. 26-34-126 if the commissioner is satisfied that the following conditions are met:
(i) The persons responsible for the conduct of the applicant's affairs are competent and trustworthy;
(ii) The administrator certifies that the health maintenance organization's proposed plan of operation meets the requirements of W.S. 26-34-108;
(iii) The health maintenance organization shall effectively provide or arrange for the provision of basic health care services on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments, coinsurance and deductibles;
(iv) The health maintenance organization is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the commissioner may consider:
(A) The financial soundness of the arrangements for health care services and the schedule of premiums used in connection therewith;
(B) The adequacy of working capital;
(C) Any agreement with an insurer, a hospital or medical service corporation, a government or any other organization or entity for insuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage in the event of discontinuance of the health maintenance organization;
(D) Any agreement with providers for the provision of health care services; and
(E) Any deposit of cash or securities submitted in accordance with W.S. 26-34-114.
(v) Repealed by Laws 1995, ch. 210, § 5.
(vi) Nothing in the proposed method of operation, as shown by the information submitted pursuant to W.S. 26-34-103 or by independent investigation, is contrary to the public interest; and
(vii) Any deficiencies identified by the administrator have been corrected.
(e) A certificate of authority shall be denied only after compliance with the requirements of W.S. 26-34-125.
26-34-105. Powers of health maintenance organizations.
(a) The powers of a health maintenance organization include but are not limited to the:
(i) Purchase, lease, construction, renovation, operation or maintenance of hospitals or medical facilities, or both, and their ancillary equipment, and any property as may reasonably be required for its principal office or for any purposes as may be necessary in the transaction of the business of the organization;
(ii) Making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation or corporations under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees;
(iii) Furnishing of health care services through providers which are under contract with or employed by the health maintenance organization;
(iv) Contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration;
(v) Contracting with an insurance company licensed in this state, or with a hospital or health service corporation authorized to do business in this state, for the provision of insurance, indemnity or reimbursement against the cost of health care services provided by the health maintenance organization;
(vi) Offering of other health care services, in addition to basic health care services. Nonbasic health care services may be offered by a health maintenance organization on a prepaid basis without offering basic health care services to any group or individual;
(vii) The joint marketing of products with an insurance company licensed in this state or with a hospital or medical service corporation authorized to do business in this state as long as the company that is offering each product is clearly identified.
(b) A health maintenance organization shall file notice, with adequate supporting information, with the commissioner prior to the exercise of any power granted in paragraph (a)(i),
(ii) or (iv) of this section. The commissioner shall disapprove any exercise of power only if in his opinion it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the commissioner does not disapprove within forty-five (45) days from the date of the filing, it is deemed approved.
(c) The commissioner may promulgate rules and regulations exempting from the filing requirement of subsection (b) of this section those activities having a de minimis effect.
(a) The governing body of any health maintenance organization may include providers, or other individuals, or both.
(b) Repealed by Laws 1995, ch. 210, § 5.
(c) Any domestic health maintenance organization shall comply with the requirements applicable to a domestic insurer in W.S. 26-24-129 and shall be subject to the penalties provided in W.S. 26-24-129.
(a) Any director, officer, employee or partner of a health maintenance organization who receives, handles, collects, disburses or invests funds in connection with the activities of the organization is responsible for those funds in a fiduciary relationship to the organization and shall not violate the prohibitions specified in W.S. 26-24-127.
(b) A health maintenance organization shall maintain in force a fidelity bond on employees and officers in an amount not less than the greater of two hundred fifty thousand dollars ($250,000.00), ten percent (10%) of the organization's previous year's gross premiums or other amount the commissioner prescribes. All such bonds shall be written with at least a one (1) year discovery period and if written with less than a three (3) year discovery period shall contain a provision that no cancellation or termination of the bond, whether by or at the request of the insured or by the underwriter is effective prior to the expiration of ninety (90) days after written notice of the cancellation or termination has been filed with the commissioner unless the commissioner approves an earlier date of cancellation or termination.
(c) A health maintenance organization shall not make any disbursement of seventy-five dollars ($75.00) or more without complying with the requirements specified for insurers in W.S. 26-24-130.
(a) The health maintenance organization shall establish procedures to assure that the health care services provided to enrollees are rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. The procedures shall include mechanisms to assure availability, accessibility and continuity of care.
(b) The health maintenance organization shall have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and noninstitutional settings. The program shall include, at a minimum, the following:
(i) A written statement of goals and objectives which emphasizes improved health status in evaluating the quality of care rendered to enrollees;
(ii) A written quality assurance plan which describes the following:
(A) The health maintenance organization's scope and purpose in quality assurance;
(B) The organizational structure responsible for quality assurance activities;
(C) Contractual arrangements, where appropriate, for delegation of quality assurance activities;
(D) Confidentiality policies and procedures;
(E) A system of ongoing evaluation activities;
(F) A system of focused evaluation activities;
(G) A system for credentialing providers and performing peer review activities; and
(H) Duties and responsibilities of the designated physician responsible for the quality assurance activities.
(iii) A written statement describing the system of ongoing quality assurance activities including:
(A) Problem assessment, identification, selection and study;
(B) Corrective action, monitoring, evaluation and reassessment; and
(C) Interpretation and analysis of patterns of care rendered to individual patients by individual providers.
(iv) A written statement describing the system of focused quality assurance activities based on representative samples of the enrolled population which identifies method of topic selection, study, data collection, analysis, interpretation and report format; and
(v) Written plans for taking appropriate corrective action whenever, as determined by the quality assurance program, inappropriate or substandard care or services have been provided, or care or services which should have been furnished have not been provided.
(c) The organization shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes shall be available to the administrator. Contents of the minutes shall be confidential to the extent confidentiality is provided under the provisions of W.S. 16-4-203(d)(i) and (vii), 26-34-129, 26-34-130, 35-2-910 or 35-17-105.
(d) The organization shall ensure the use and maintenance of an adequate patient record system which will facilitate documentation and retrieval of clinical information for the purpose of the health maintenance organization evaluating continuity and coordination of patient care and assessing the quality of health and medical care provided to enrollees.
(e) Enrollee clinical records shall be available to the administrator or an authorized designee for examination and review to ascertain compliance with this section, or as deemed necessary by the administrator.
(f) The organization shall establish a mechanism for periodic reporting of quality assurance program activities to the governing body, providers and appropriate organization staff.
26-34-109. Requirements for group contract, individual
contract, evidence of coverage and premiums for health care services.
(a) Every group and individual contract holder is entitled to a group or individual contract. The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by W.S. 26-34-117(a). The contract shall contain a clear statement of the following:
(i) Name and address of the health maintenance organization;
(ii) Eligibility requirements;
(iii) Benefits and services within the service area;
(iv) Emergency care benefits and services;
(v) Out of area benefits and services, if any;
(vi) Copayments, coinsurance, deductibles or other out-of-pocket expenses;
(vii) Limitations and exclusions, including an explanation of any prescription drug benefits not provided for under a specified health plan;
(viii) Enrollee termination;
(ix) Enrollee reinstatement, if any;
(x) Claims procedures;
(xi) Enrollee complaint procedures;
(xii) Continuation of coverage;
(xiii) Conversion;
(xiv) Extension of benefits, if any;
(xv) Coordination of benefits, if applicable;
(xvi) Subrogation, if any;
(xvii) Description of the service area;
(xviii) Entire contract provision;
(xix) Term of coverage;
(xx) Cancellation of group or individual contract holder;
(xxi) Renewal;
(xxii) Reinstatement of group or individual contract holder, if any;
(xxiii) Grace period as provided in W.S. 26-18-107;
(xxiv) Conformity with state law; and
(xxv) Any withholding agreement pertaining to health care delivery services which requires reimbursement to the provider at a later date dependent upon decisions regarding coverage. The agreement shall specify the requirements in detail. If the existence of a withholding agreement has been disclosed in the contract, the health maintenance organization may alter the terms of the agreement without being deemed to alter the terms of the contract provided the contract holder is notified in detail of the new terms of the agreement at his next renewal.
(b) In addition to those provisions required in subsection
(a) of this section, an individual contract shall provide for a ten (10) day period to examine and return the contract and have the premium refunded. If services were received during the ten (10) day period, and the person returns the contract to receive a refund of the premium paid, he shall pay for the services.
(c) Each enrollee residing in this state shall receive an evidence of coverage from the group contract holder or the health maintenance organization. The evidence of coverage shall not contain provisions or statements which are unfair, unjust, inequitable, misleading, deceptive or which encourage misrepresentation as defined by W.S. 26-34-117(a). The evidence of coverage shall contain:
(i) A clear statement of the provisions required in paragraphs (a)(i) through (xvii) of this section; and
(ii) A provision that any subsequent material change shall be evidenced in a separate document issued to the enrollee.
(d) No group or individual contract, evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state:
(i) Until a copy of the form of the contract, evidence of coverage, or amendment thereto, has been filed with and approved by the commissioner.
(e) Every form required by this section shall be filed with the commissioner not less than forty-five (45) days prior to delivery or issue for delivery in this state. At any time during the initial forty-five (45) day period, the commissioner may extend the period for review for an additional forty-five (45) days. Notice of an extension shall be in writing. At the end of the review period, the form is deemed approved if the commissioner has taken no action. The filer shall notify the commissioner in writing prior to using a form that is deemed approved.
(f) At any time, after thirty (30) days notice and for cause shown, the commissioner may withdraw approval of any form, effective at the end of thirty (30) days.
(g) When a filing is disapproved or approval of a form is withdrawn, the commissioner shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within thirty (30) days of receipt of the notice the health maintenance organization may request a hearing. A hearing shall be conducted within thirty (30) days after the commissioner has received the request for hearing.
(h) The commissioner may adopt regulations establishing readability standards for individual contract, group contract, and evidence of coverage forms.
(j) No schedule of premiums or methodology for determining a schedule of premiums for enrollee coverage for health care services, or amendment thereto, may be used until a copy of that schedule, or amendment thereto, has been filed with and approved by the commissioner.
(k) Premiums or methodology for determining a schedule of premiums shall be established in accordance with actuarial principles for various categories of enrollees, provided that premiums applicable to an enrollee may not be individually determined based on the status of his health. However, the premiums shall not be excessive, inadequate or unfairly discriminatory. A certification, by a qualified actuary or other qualified person acceptable to the commissioner, to the appropriateness of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.
(m) The commissioner, within a reasonable period, shall approve any form if the requirements of subsections (a) through
(g) of this section are met and any schedule of premiums if the requirements of subsections (j) and (k) of this section are met. It is unlawful to issue a form or to use the schedule of premiums until approved or deemed approved.
(n) The commissioner may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.
(a) Each health maintenance organization, annually, on or before March 1, shall file with the commissioner, with a copy to the administrator, a report verified by at least two (2) organization principal officers and covering the immediately preceding calendar year. Each health maintenance organization shall file with the commissioner on a quarterly basis a statement of its financial condition for the preceding quarter. Each quarterly statement shall be filed with the commissioner on or before forty-five (45) days from the end of the quarter being reported. The reports and statements shall be on forms the commissioner prescribes and shall be completed pursuant to the most recent National Association of Insurance Commissioners' accounting practices and procedures manual.
(b) The health maintenance organization shall file on or before March 1, unless otherwise stated:
(i) Audited financial statements in accordance with the provisions of title 26, chapter 3, article 3 of the Wyoming statutes on or before June 1;
(ii) A list of the providers who have executed a contract that complies with W.S. 26-34-114; and
(iii) The report on the complaint system pursuant to W.S. 26-34-112(b).
(c) All annual and quarterly statements filed pursuant to this section shall be accompanied by an electronic version containing the same information as the statement. The commissioner may specify the format of the electronic version. The commissioner may accept, for any health maintenance organization not domiciled in this state which is required to file annual, quarterly and audited financial statements under this section, an electronic filing with the National Association of Insurance Commissioners meeting the requirements of this section as a filing with the commissioner. The commissioner may refuse to continue or may suspend or revoke the certificate of authority of any health maintenance organization failing to file its annual or quarterly statement when due.
(d) The commissioner may require any additional reports as are deemed reasonably necessary and appropriate to enable him to carry out his duties under this chapter.
26-34-111. Information to enrollees; claims to be accepted or rejected; attorney's fees.
(a) Each health maintenance organization shall:
(i) Provide promptly to its enrollees notice of any material change in the operation of the organization that will directly affect those enrollees;
(ii) Provide to its subscribers a list of providers, upon enrollment and reenrollment;
(iii) Notify an enrollee in writing of the termination of the primary care provider who provided health care services to that enrollee, and provide assistance to the enrollee in transferring to another participating primary care provider;
(iv) Provide to subscribers information on how services may be obtained, where additional information on access to services can be obtained and a telephone number where the enrollee can contact the organization at no cost to the enrollee.
(b) Any claim for a benefit under a health insurance policy shall be rejected or accepted and paid by the health maintenance organization in accordance with W.S. 26-15-124(a) and (c).
(a) Each health maintenance organization shall establish and maintain a complaint system which has been approved by the commissioner, after consultation with the administrator, to provide reasonable procedures for the resolution of written complaints initiated by enrollees.
(b) Each health maintenance organization shall submit to the commissioner and the administrator, an annual report, in a form the commissioner prescribes, after consultation with the administrator, which shall include:
(i) A description of the procedures of the complaint system;
(ii) The total number of complaints handled through the complaint system and a compilation of causes underlying the complaints filed; and
(iii) The number, amount and disposition of malpractice claims made by an enrollee of the organization that were settled during the year by the health maintenance organization. All such information shall be held in confidence by the commissioner.
(c) The commissioner or the administrator may examine the complaint system at any time.
With the exception of investments made in accordance with W.S. 26-34-105(a)(i), the funds of a health maintenance organization shall be invested only in securities or other investments permitted by chapter 7 of this code.
(a) Before issuing any certificate of authority, the commissioner shall require that the health maintenance organization have an initial net worth of one million five hundred thousand dollars ($1,500,000.00) and shall thereafter maintain the minimum net worth required under subsection (b) of this section.
(b) Except as provided in subsection (c) of this section, every health maintenance organization must maintain a minimum net worth equal to the greater of:
(i) Two percent (2%) of annual premium revenues as reported on the most recent annual financial statement filed with the commissioner on the first seventy-five million dollars ($75,000,000.00) of premium and one percent (1%) of annual premium revenues on the premium in excess of seventy-five million dollars ($75,000,000.00);
(ii) Three (3) times the average monthly uncovered health care expenditures as reported on the most recent financial statement filed with the commissioner;
(iii) One million dollars ($1,000,000.00); or
(iv) An amount equal to the sum of:
(A) Eight percent (8%) of annual health care expenditures except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the commissioner; and
(B) Four percent (4%) of annual hospital expenditures paid on a managed hospital payment basis as reported on the most recent financial statement filed with the commissioner.
(c) A health maintenance organization licensed before July 1, 1995 shall maintain a minimum net worth of:
(i) Twenty-five percent (25%) of the amount required by subsection (b) of this section by December 31, 1995;
(ii) Fifty percent (50%) of the amount required by subsection (b) of this section by December 31, 1996;
(iii) Seventy-five percent (75%) of the amount required by subsection (b) of this section by December 31, 1997;
(iv) One hundred percent (100%) of the amount required by subsection (b) of this section by December 31, 1998.
(d) In determining net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the commissioner. Any interest obligation relating to the repayment of any subordinated debt must be similarly subordinated.
(e) The interest expenses relating to the repayment of any fully subordinated debt shall be considered covered expenses.
(f) Any fully subordinated debt incurred by a note meeting the requirements of subsections (d) and (e) of this section, and otherwise acceptable to the commissioner, shall not be considered a liability and shall be recorded as equity.
(g) Unless otherwise provided in this section, each health maintenance organization shall deposit with the commissioner or, at the discretion of the commissioner, with any organization or trustee acceptable to him through which a custodial or controlled account is utilized, cash, securities or any combination of these or other measures that are acceptable to him which at all times shall have a value of not less than three hundred thousand dollars ($300,000.00).
(h) An organization that is in operation on July 1, 1995, shall make a deposit of cash, securities, combination thereof or other measures of equal amount acceptable to the commissioner of one hundred fifty thousand dollars ($150,000.00) on or before August 1, 1995, and an additional deposit of cash, securities, combination thereof or other measures of equal amount acceptable to the commissioner of one hundred fifty thousand dollars ($150,000.00) on or before July 1, 1996.
(j) The deposit shall be an admitted asset of the health maintenance organization in the determination of net worth. All income from deposits belongs to the depositing organization, shall be paid to it as it becomes available and shall be an asset of the organization. A health maintenance organization that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities or any combination thereof or other measures of equal amount and value. Any securities shall be approved by the commissioner before being substituted.
(k) The deposit shall be used to protect the interests of the health maintenance organization's enrollees and to assure continuation of health care services to enrollees of a health maintenance organization which is in rehabilitation or conservation. The commissioner may use the deposit for administrative costs directly attributable to a receivership or liquidation. If the health maintenance organization is placed in receivership or liquidation, the deposit shall be an asset subject to chapter 28 of this code.
(m) The commissioner may reduce or eliminate any of the deposit requirements set forth in this section if he is satisfied that the health maintenance organization has deposited with the state treasurer, insurance commissioner, or other official body of the state or jurisdiction of domicile for the protection of all subscribers and enrollees, wherever located, of the health maintenance organization, cash, acceptable securities or surety, and delivers to the commissioner a certificate to that effect, duly authenticated by the appropriate state official holding the deposit.
(n) Every health maintenance organization shall, when determining liabilities, include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for health care expenditures which have been incurred, whether reported or unreported, which are unpaid and for which the organization is or may be liable, and to provide for the expense of adjustment or settlement of those claims. The liabilities shall be computed in accordance with accounting principles established by the commissioner upon reasonable consideration of the ascertained experience and character of the health maintenance organization.
(o) Every contract between a health maintenance organization and a participating provider of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the contract, the subscriber or enrollee shall not be liable to the provider for any sums owed by the health maintenance organization.
(p) In the event that the participating provider contract has not been reduced to writing as required by this section or that the contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health maintenance organization.
(q) No participating provider, or agent, trustee or assignee thereof, may maintain any action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization.
(r) The commissioner shall require that each health maintenance organization have a plan for handling insolvency which allows for continuation of benefits for the duration of the contract period for which premiums have been paid and continuation of benefits to members who are confined on the date of insolvency in an inpatient facility until their discharge or expiration of benefits. In considering such a plan, the commissioner may require:
(i) Insurance to cover the expenses to be paid for continued benefits after an insolvency;
(ii) Provisions in provider contracts that obligate the provider to provide services for the duration of the period after the health maintenance organization's insolvency for which premium payment has been made and until the enrollees' discharge from inpatient facilities;
(iii) Insolvency reserves;
(iv) Acceptable letters of credit;
(v) Any other arrangements to assure that benefits are continued as specified in this subsection.
(s) An agreement to provide health care services between a provider and a health maintenance organization shall require that if the provider terminates the agreement, the provider shall give the organization at least sixty (60) days advance notice of termination.
(a) If at any time uncovered expenditures exceed ten percent (10%) of total health care expenditures, a health maintenance organization shall place an uncovered expenditures insolvency deposit with the commissioner, or with any organization or trustee acceptable to the commissioner through which a custodial or controlled account is maintained, cash or securities that are acceptable to the commissioner. The deposit shall at all times have a fair market value in an amount of one hundred twenty percent (120%) of the organization's outstanding liability for uncovered expenditures for enrollees in this state, including incurred but not reported claims, and shall be calculated as of the first day of the month and maintained for the remainder of the month. If a health maintenance organization is not otherwise required to file a quarterly report, it shall file a report within forty-five (45) days of the end of the calendar quarter with information sufficient to demonstrate compliance with this section.
(b) The deposit required under this section is in addition to the deposit required under W.S. 26-34-114(g) and (h) and is an admitted asset of the health maintenance organization in the determination of net worth. All income from such deposits or trust account shall be assets of the health maintenance organization and may be withdrawn quarterly with the approval of the commissioner.
(c) A health maintenance organization that has made a deposit may withdraw that deposit or any part of the deposit if:
(i) A substitute deposit of cash or securities of equal amount and value is made;
(ii) The fair market value exceeds the amount of the required deposit; or
(iii) The required deposit under subsection (a) of this section is reduced or eliminated.
(d) Deposits, substitutions or withdrawals may be made only with the prior written approval of the commissioner.
(e) The deposit required under this section is in trust and may be used only as provided under this section. The commissioner may use the deposit of an insolvent health maintenance organization for administrative costs associated with administering the deposit and payment of claims of enrollees of this state for uncovered expenditures in this state. Claims for uncovered expenditures shall be paid on a pro rata basis based on assets available to pay the ultimate liability for incurred expenditures. Partial distribution may be made pending final distribution. Any amount of the deposit remaining shall be paid into the liquidation or receivership of the health maintenance organization.
(f) The commissioner may by regulation prescribe the time, manner and form for filing claims under subsection (e) of this section.
(g) The commissioner may by regulation or order require health maintenance organizations to file annual, quarterly or more frequent reports as he deems necessary to demonstrate compliance with this section. The commissioner may require that the reports include liability for uncovered expenditures as well as an audit opinion.
26-34-116. Enrollment period, replacement coverage in the event of insolvency.
(a) In the event of an insolvency of a health maintenance organization, upon order of the commissioner all other carriers that participated in the enrollment process with the insolvent health maintenance organization at a group's last regular enrollment period shall offer the group's enrollees of the insolvent health maintenance organization a thirty (30) day enrollment period commencing upon the date of insolvency. Each carrier shall offer the enrollees of the insolvent health maintenance organization the same coverages and rates that it had offered to the enrollees of the group at its last regular enrollment period.
(b) If no other carrier had been offered to some groups enrolled in the insolvent health maintenance organization, or if the commissioner determines that the other health benefit plan lacks sufficient health care delivery resources to assure that health care services will be available and accessible to all of the group enrollees of the insolvent health maintenance organization, the commissioner shall allocate equitably the insolvent health maintenance organization's group contracts for those groups among all health maintenance organizations which operate within a portion of the insolvent health maintenance organization's service area, taking into consideration the health care delivery resources of each health maintenance organization. Each health maintenance organization to which a group is so allocated shall offer the group the health maintenance organization's existing coverage which is most similar to the group's coverage with the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization's existing rating methodology.
(c) The commissioner shall equitably allocate the insolvent health maintenance organization's nongroup enrollees who are unable to obtain other coverage, among all health maintenance organizations which operate within a portion of the insolvent health maintenance organization's service area, taking into consideration the health care delivery resources of each health maintenance organization. Each health maintenance organization to which nongroup enrollees are allocated shall offer the nongroup enrollees the health maintenance organization's existing coverage for individual or conversion coverage as determined by the enrollee's type of coverage in the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization's existing rating methodology. Successor health maintenance organizations which do not offer direct nongroup enrollment may aggregate all of the allocated nongroup enrollees into one (1) group for rating and coverage purposes.
(d) Any carrier providing replacement coverage with respect to group hospital, medical or surgical expense or service benefits within a period of sixty (60) days from the date of discontinuance of a prior health maintenance organization contract or policy providing the hospital, medical or surgical expense or service benefits shall immediately cover all enrollees who were validly covered under the previous health maintenance organization contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding carrier's contract, regardless of any provisions of the contract relating to active employment or hospital confinement or pregnancy.
(e) Except to the extent benefits for the condition would have been reduced or excluded under the prior carrier's contract or policy, no provision in a succeeding carrier's contract of replacement coverage which would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier's contract shall be applied with respect to those enrollees validly covered under the prior carrier's contract or policy on the date of discontinuance.
(a) No health maintenance organization, or representative thereof, shall cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading or any form of evidence of coverage which is deceptive. For purposes of this chapter:
(i) A statement or item of information is:
(A) Untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of or person considering enrollment with a health maintenance organization;
(B) Misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee of, or person considering enrollment in a health maintenance organization if the benefit or advantage or absence of limitation, exclusion or disadvantage does not in fact exist.
(ii) An evidence of coverage is deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, is such as to cause a reasonable person, not possessing special knowledge regarding health maintenance organizations and evidences of coverage therefor, to expect benefits, services, premiums or other advantages which the evidence of coverage does not provide or which the health maintenance organization issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage.
(b) Chapter 13 of this code applies to health maintenance organizations and evidences of coverage except to the extent that the commissioner determines that the nature of health maintenance organizations and evidences of coverage render that chapter, or any section thereof, clearly inappropriate.
(c) A health maintenance organization shall not cancel or refuse to review an enrollee, except for reasons stated in the organization's rules applicable to all enrollees or for the failure to pay the premiums for coverage, or for any other reasons the commissioner may specify by rule and regulation.
(d) No health maintenance organization unless licensed as an insurer shall refer to itself as an insurer or use a name deceptively similar to the name or description of any insurance or surety corporation doing business in the state.
(e) Any person not in possession of a valid certificate of authority issued pursuant to this chapter shall not use the phrase "health maintenance organization" or "HMO" in the course of operation.
(f) A health care maintenance organization shall not refuse to contract with or compensate for covered services an otherwise eligible health care provider solely because that provider has in good faith communicated with one (1) or more of his current, former or prospective patients regarding the provisions, terms or requirements of the organization's products as they related to the needs of that provider's patients.
(g) A health care maintenance organization shall not prohibit or restrict any health care provider from disclosing to any subscriber, enrollee or member any medically appropriate health care information the provider deems appropriate regarding the:
(i) Nature of treatment, risks or alternatives;
(ii) Decision of any plan to authorize or deny services;
(iii) Process used to authorize or deny health care services or benefits.
26-34-118. Regulation of health maintenance organization producers.
(a) The commissioner, after notice and hearing, may promulgate reasonable rules and regulations as necessary to provide for the licensing of health maintenance organization producers. The rules shall establish:
(i) The requirements for licensure of resident health maintenance organization producers;
(ii) The conditions for entering into reciprocal agreements with other jurisdictions for the licensure of nonresident health maintenance organization producers;
(iii) Any examination, prelicensing or continuing education requirements;
(iv) The requirements for registering and terminating the appointment of health maintenance organization producers;
(v) Any requirements for registering any assumed names or office locations in which a health maintenance organization producer does business;
(vi) The conditions for health maintenance organization producer license renewal;
(vii) The grounds for denial, refusal, suspension or revocation of a health maintenance organization producer's license;
(viii) Any required fees for the licensing activities of health maintenance organization producers; and
(ix) Any other requirement or procedure and any form reasonably necessary to provide for the effective administration of the licensing of health maintenance organization producers under this section.
(b) None of the following shall be required to hold a health maintenance organization producer license:
(i) Any regular salaried officer or employee of a health maintenance organization who devotes substantially all of his time to activities other than the taking or transmitting of applications or membership fees or premiums for health maintenance organization membership, or who receives no commission or other compensation directly dependent upon the business obtained and who does not solicit or accept from the public applications for health maintenance organization membership;
(ii) Employers or their officers or employees or the trustees of any employee benefit plan to the extent that the employers, officers, employees or trustees are engaged in the administration or operation of any program of employee benefits involving the use of health maintenance organization memberships, provided that the employers, officers, employees or trustees are not in any manner compensated directly or indirectly by the health maintenance organization issuing the health maintenance organization memberships;
(iii) Banks or their officers and employees to the extent that the banks, officers and employees collect and remit premiums by charging the same against accounts of depositors on the orders of the depositors; or
(iv) Any person or the employee of any person who has contracted to provide administrative, management or health care services to a health maintenance organization and who is compensated for those services by the payment of an amount calculated as a percentage of the revenues, net income or profit of the health maintenance organization, if that method of compensation is the sole basis for subjecting that person or the employee of the person to this act.
(c) The commissioner, by rule, may exempt certain classes of persons from the requirement of obtaining a license if:
(i) The functions they perform do not require special competence, trustworthiness or the regulatory surveillance made possible by licensing; or
(ii) Other existing safeguards make regulation unnecessary.
26-34-119. Powers of insurers and hospital and health service corporations.
(a) Any insurance company licensed in this state, or a hospital or health service corporation authorized to do business in this state, either directly or through a subsidiary or affiliate, may organize and operate a health maintenance organization under this chapter. Notwithstanding any other law to the contrary, any two (2) or more such insurance companies, hospitals or health service corporations, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.
(b) Notwithstanding any other provision of this code, any insurer or any hospital or health service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations.
(c) The enrollees of a health maintenance organization constitute a permissible group under this code or any other laws of this state. Among other things, under any contract specified the insurer or hospital or health service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers.
(a) The commissioner may make an examination of the affairs of any health maintenance organization and providers with whom that organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state but not less frequently than once every five (5) years.
(b) The administrator may make an examination concerning the quality of health care service and the adequacy of quality assurance programs of any health maintenance organization and providers with whom that organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state but not less frequently than once every five (5) years.
(c) Each health maintenance organization and provider shall submit its relevant books and records for the examinations specified in this section and in every way facilitate those examinations. For the purpose of examinations, the commissioner and the administrator may administer oaths to and examine the officers and agents of the health maintenance organization and the principals of any providers concerning their business.
(d) Repealed by Laws 1995, ch. 210, § 3.
(e) Instead of the examinations under this section the commissioner or administrator may accept the report of an examination made by the insurance commissioner or public health commissioner of another state. A report from another state's insurance commissioner shall only be accepted if:
(i) The insurance department preparing the report was, at the time of the examination, accredited under the National Association of Insurance Commissioners' financial regulation standards and accreditation program; or
(ii) The examination is performed under the supervision of an accredited insurance department or with the participation of one (1) or more examiners who are employed by an accredited insurance department and who, after the review of the examination work papers and report, state under oath that the examination was performed in a manner consistent with the standards and procedures required by their insurance department.
26-34-121. Suspension or revocation of certificate of authority.
(a) The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if:
(i) The commissioner finds the health maintenance organization:
(A) Is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under W.S. 26-34-103, unless amendments to those submissions have been filed with and approved by the commissioner;
(B) Issues evidence of coverage or uses a schedule of premiums for health care services which do not comply with W.S. 26-34-109;
(C) Does not provide or arrange for basic or nonbasic health care services;
(D) Is no longer financially responsible and is reasonably expected to be unable to meet its obligations to enrollees or prospective enrollees;
(E) Has failed to correct, within the time prescribed by subsection (c) of this section, any deficiency occurring due to the health maintenance organization's prescribed minimum net worth being impaired;
(F) Has failed to implement the complaint system required by W.S. 26-34-112 in a reasonable manner to resolve valid complaints;
(G) Any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner; or
(H) Has otherwise failed substantially to comply with this chapter.
(ii) The administrator certifies to the commissioner that the health maintenance organization either does not meet the requirements of W.S. 26-34-104(b) or is unable to fulfill its obligations to furnish health care services;
(iii) The commissioner finds the continued operation of the health maintenance organization would be hazardous to its enrollees. The commissioner may consider the factors specified in W.S. 26-3-116(c) and 26-3-132(a) when making this finding.
(b) In addition to or in lieu of suspension or revocation of a certificate of authority pursuant to this section, the applicant or health maintenance organization may be subjected to an administrative penalty of up to ten thousand dollars ($10,000.00) for each cause for suspension or revocation.
(c) Whenever the commissioner finds that the net worth maintained by any health maintenance organization subject to the provisions of this act is less than the minimum net worth required to be maintained by W.S. 26-34-114, he shall give written notice to the health maintenance organization of the amount of the deficiency and require:
(i) Filing with the commissioner a plan for correction of the deficiency acceptable to the commissioner; and
(ii) Correction of the deficiency within a reasonable time, not to exceed sixty (60) days, unless an extension of time, not to exceed sixty (60) additional days, is granted by the commissioner.
(d) A deficiency shall be deemed an impairment, and failure to correct the impairment in the prescribed time shall be grounds for suspension or revocation of the certificate of authority or for placing the health maintenance organization in conservation, rehabilitation or liquidation.
(e) Unless allowed by the commissioner, no health maintenance organization or person acting on its behalf may, directly or indirectly, renew, issue or deliver any certificate, agreement or contract of coverage in this state, for which a premium is charged or collected, when the health maintenance organization writing the coverage is impaired, and the impairment is known to the health maintenance organization or to the person. However, the existence of an impairment shall not prevent the issuance or renewal of a certificate, agreement or contract when the enrollee exercises an option granted under the plan to obtain a new, renewed or converted coverage.
(f) A certificate of authority shall be suspended or revoked, or an administrative penalty levied pursuant to subsection (b) of this section, only after compliance with W.S. 26-34-125.
(g) If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization, during the period of suspension, shall not enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation of any kind.
(h) If the certificate of authority of a health maintenance organization is revoked, that organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of its affairs. It shall engage in no further advertising or solicitation of any kind. The commissioner, by written order, may permit any further operation of the organization as he finds to be in the best interest of enrollees, to the end that enrollees are afforded the greatest practical opportunity to obtain continuing health care coverage.
26-34-122. Rehabilitation, liquidation or conservation of a health maintenance organization.
(a) Any rehabilitation, liquidation or conservation of a health maintenance organization is deemed to be the rehabilitation, liquidation or conservation of an insurance company and shall be conducted under the commissioner's supervision pursuant to the provisions of this code governing the rehabilitation, liquidation or conservation of insurance companies. The commissioner may apply for an order directing him to rehabilitate, liquidate or conserve a health maintenance organization upon any one (1) or more grounds set out in chapter 28 of this code, or if in his opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this state. Enrollees have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.
(b) For purposes of determining the priority of distribution of general assets, claims of enrollees and enrollees' beneficiaries shall have the same priority as established by chapter 28 of this code for policyholders and beneficiaries of insureds of insurance companies. If an enrollee is liable to any provider for services provided pursuant to and covered by the health care plan, that liability shall have the status of an enrollee claim for distribution of general assets.
(c) Any provider who is obligated by statute or agreement to hold enrollees harmless from liability for services provided pursuant to and covered by a health care plan shall have a priority of distribution of the general assets immediately following that of enrollees and enrollees' beneficiaries as described herein, and immediately preceding the priority of distribution described in W.S. 26-28-125(a)(iv).
(a) Whenever the commissioner determines that the financial condition of any health maintenance organization is such that its continued operation might be hazardous to its enrollees, creditors, or the general public, or that it has violated any provision of this act, he may, after notice and hearing, order the health maintenance organization to take action reasonably necessary to rectify the condition or violation, including but not limited to one (1) or more of the following:
(i) Reduce the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the commissioner;
(ii) Reduce the volume of new business being accepted;
(iii) Reduce expenses by specified methods;
(iv) Suspend or limit the writing of new business for a period of time;
(v) Increase the health maintenance organization's capital and surplus by contribution; or
(vi) Take other steps the commissioner deems appropriate under the circumstances, including those steps authorized in W.S. 26-3-132(b) and (c) for insurers.
(b) For purposes of this section, the violation by a health maintenance organization of any law of this state to which the health maintenance organization is subject shall be deemed a violation of this act.
(c) The commissioner is authorized, by rules and regulations, to set uniform standards and criteria for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors or the general public and to set standards for evaluating the financial condition of any health maintenance organization. The standards shall be consistent with the purposes expressed in subsection (a) of this section.
(d) The remedies and measures available to the commissioner under this section shall be in addition to, and not in lieu of, the remedies and measures available to the commissioner under the provisions of chapter 28 of this code.
The commissioner, after notice and hearing, may promulgate reasonable rules and regulations necessary or proper to carry out this chapter. The rules and regulations are subject to review in accordance with W.S. 28-9-101 through 28-9-108.
(a) If the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority or for the imposition of an administrative penalty exist, he shall notify the health maintenance organization and the administrator by written order specifically stating the grounds for denial, suspension, revocation or administrative penalty. The health maintenance organization or applicant may in writing request a hearing within thirty (30) days from the date of mailing of the order. If no written request is made, the order shall be final upon the expiration of the thirty (30) days.
(b) If the health maintenance organization or applicant requests a hearing pursuant to this section, the commissioner shall issue a written notice of hearing and send it to the health maintenance organization or applicant by certified or registered mail and to the administrator stating:
(i) A specific time for the hearing, which may not be less than twenty (20) nor more than thirty (30) days after mailing of the notice of hearing; and
(ii) A specific place for the hearing, which may be either in Cheyenne or in the county where the health maintenance organization's or applicant's principal place of business is located.
(c) If a hearing is requested, the administrator, or his designated representative, shall be in attendance at the hearing and shall participate in the proceedings. The administrator's recommendations and findings with respect to matters relating to the quality of health care services provided in connection with any decision regarding denial, suspension or revocation of a certificate of authority, are conclusive and binding upon the commissioner. After the hearing, or upon the failure of the health maintenance organization to appear at the hearing, the commissioner shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization with a copy thereof to the administrator. The commissioner's action and the administrator's recommendations and findings are subject to review by the district court. The court, in disposing of the issue before it, may modify, affirm or reverse the commissioner's order in whole or in part.
(d) The Wyoming Administrative Procedure Act applies to proceedings under this section to the extent it is not in conflict with this section.