(a) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this state unless an outline of coverage is delivered to the applicant at the time application is made.
(b) The commissioner shall prescribe both the format and content of the outline of coverage required by subsection (a) of this section. For purposes of this section, "format" means style, arrangements and overall appearance, including such items as the size, color and prominence of type and arrangement of text and captions. The outline of coverage shall include but is not limited to:
(i) A description of the principal benefits and coverage provided in the policy;
(ii) A statement of the exceptions, reductions and limitations contained in the policy;
(iii) A statement of the renewal provisions, including any reservation by the insurer of a right to change premiums and disclosure of the existence of any automatic renewal premium increases based on the policyholder's age;
(iv) A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.
(c) The commissioner may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer's ability to select the most appropriate coverage and improve the buyer's understanding of Medicare. Except in the case of direct response insurance policies, the commissioner may require by regulation that the information brochure be provided to any prospective insureds eligible for Medicare concurrently with delivery of the outline of coverage. With respect to direct response insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insureds eligible for Medicare, but in no event later than the time the policy is delivered.
(d) The commissioner may adopt reasonable regulations for captions or notice requirements determined to be in the public interest and designed to inform prospective insureds that particular insurance coverages are not Medicare supplement coverages, for all disability insurance policies sold to persons eligible for Medicare, other than:
(i) Medicare supplement policies; or
(ii) Disability income policies.
(iii) Repealed By Laws 1997, ch. 12, § 2.
(iv) Repealed By Laws 1997, ch. 12, § 2.
(e) The commissioner may further adopt reasonable regulations to govern the full and fair disclosure of the information in connection with the replacement of disability policies, subscriber contracts or certificates by persons eligible for Medicare.
Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the full premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the insurer in a timely manner.
Every issuer of Medicare supplement insurance policies or certificates in this state shall provide to the insurance commissioner a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio or television medium, for review by the commissioner.
(a) In addition to any other applicable penalties for violations of this code, the commissioner may:
(i) Require insurers to cease marketing any Medicare supplement policy or certificate in this state which violates any provision of this act, any other law administered by the commissioner, any regulation promulgated pursuant to this act or any other rule promulgated pursuant to the authority of the commissioner; or
(ii) Require the insurer to take any actions necessary to comply with the provisions of this act.
(a) This chapter shall apply to any insurer who has marketed or sold or will market and sell any individual, group or blanket disability insurance contracts to Wyoming residents.
(b) For the purposes of this chapter disability insurance does not include credit disability insurance as defined in W.S. 26-21-102(a)(ii).
(a) As used in this act:
(i) "Block of business" means all those individual, group or blanket disability insurance contracts issued by an insurance company under a particular policy form approved by the Wyoming insurance department;
(ii) "Closed block of business" means a block of business where an insurer ceases to market or sell in Wyoming any new individual, group or blanket disability insurance contracts under a particular policy form and no new contracts are being added to the block;
(iii) "Policy form" means a representative insurance contract which has been filed by an insurer for approval by the Wyoming insurance department pursuant to W.S. 26-15-110 so that other contracts with identical language to that of the policy form may be marketed and sold in Wyoming;
(iv) "This act" means W.S. 26-39-101 through 26-39-104.
If any insurer closes a block of business in this state, the insurer shall spread the claims experience of the closed block of business to, for like insureds without regard to individual health problems, other blocks of business still being marketed and sold by that insurer in this state when determining what premiums are to be charged for the contracts included in the closed block of business.
Any insurer who violates any provisions of this chapter is subject to denial, suspension or revocation of its certificate of authority as well as the imposition of a penalty as set forth in W.S. 26-1-107.
This chapter applies to all insurers who solicit or offer for sale in this state individual, group disability or blanket disability policies covering Wyoming residents.
(a) As used in this chapter:
(i) "Health care provider" means any physician, hospital or other person licensed or otherwise authorized in this or another state to furnish to any individual medical or dental care, vision care or hospitalization incident to the furnishing of that care or hospitalization for the purpose of preventing, alleviating, curing or healing human illness, injury or physical disability;
(ii) "Usual, customary and reasonable basis" means the method by which an insurer determines the amount to be paid on a claim for disability benefits by comparing the amount of the claim to amounts charged by other health care providers for the same or similar medical services or procedures;
(iii) "Medical necessity," means:
(A) A medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that:
(I) Is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury;
(II) Provides for the diagnosis, direct care and treatment of the patient's condition, illness, disease or injury;
(III) Is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care; and
(IV) Is not primarily for the convenience of the patient, physician or other health care provider.
(B) A medical service, procedure or supply shall not be excluded from being a medical necessity under this section solely because the service, procedure or supply is not in common use if the safety and effectiveness of the service, procedure or supply is supported by:
(I) Peer reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE); or
(II) Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act.
(a) If any disability insurance policy provides for settlement of a claim for payment of medical services or procedures provided by a health care provider using a usual, customary and reasonable basis the insurer shall:
(i) Submit to the department upon request statistical data of health care provider's charges on which the insurer bases payment of claims. Such data shall be submitted upon request of the commissioner, provided, however, no insurer may be required to submit data more than once every six (6) months. The data submitted shall contain only charges for services performed not more than one (1) year prior to the date of the most recent data;
(ii) Provide to the claimant, in writing, a complete explanation of the basis of settlement, if requested by the claimant in writing, and maintain the explanation in the claim file. If the basis of payment is less than the actual charge made by the health care provider, the explanation shall state the specific reason for the amount not paid and may not expressly state that the health care provider is overcharging unless the allegation is substantiated by fact set out in the explanation;
(iii) Settle any claim for medical services or procedures only on the basis of charges made by Wyoming health care providers of similar qualifications or experience for the same or similar medical services or procedures if the service or procedure for which payment is sought was obtained in Wyoming. However, if the profile or survey does not contain a statistically credible sample of charges, the insurer may include in the profile or survey charges from another similar geographic and demographic area so that a reliable basis is established.
(b) Statistical data submitted to the department pursuant to this section shall be confidential in nature and not available for public inspection.
(c) When a disability insurance policy provides for settlement of a claim for payment of medical services or procedures provided by a health care provider using a usual, customary and reasonable basis or any similar basis:
(i) If the commissioner, based either on a review of the statistical data submitted pursuant to subsection (a) of this section or on the receipt of complaints from one (1) or more insureds, has reason to suspect that a claim or one (1) or more classes of claims is not being settled on the basis provided by the policy he may order the company to show cause why the settlement or settlements should not be changed;
(ii) If the commissioner finds, after notice and opportunity for hearing, that the company is not settling a claim or one (1) or more classes of claims on the basis provided by the policy, he may order a different settlement or settlements.
(a) No person may make payment on a claim for benefits under an individual, group or blanket disability policy covering residents of this state unless such claim payment is made in compliance with this chapter.
(b) Any person who violates any provisions of this chapter is subject to denial, suspension or revocation of a license or certificate of authority in addition to the imposition of any other penalty provided by W.S. 26-1-107.
26-40-201. Payment of claims under medical necessity standard; review.
(a) As used in this section, "medical necessity or other similar basis" includes, but is not limited to, "medically necessary," "medically necessary care" and "medically necessary and appropriate," as defined in W.S. 26-40-102(a)(iii).
(b) If any insurance policy provides for settlement of a claim for payment of medical services, procedures or supplies provided by a health care provider using a medical necessity or other similar basis the insurer shall:
(i) Define medical necessity or other similar basis as "medical necessity" is defined in this chapter and W.S. 26-40-102(a)(iii);
(ii) Make all determinations whether a medical service, procedure or supply is medically necessary based only upon the factors stated in the definition of medical necessity contained in W.S. 26-40-102(a)(iii);
(iii) Provide internal review and external review procedures for all denied claims as required in this section and disclose all procedures, time lines and requirements for such review procedures in every insurance policy and as otherwise required in this section.
(c) When any claim for the provision of or payment for medical services, procedures or supplies is first denied as not being a medical necessity, or on another similar basis, the insurer shall provide to the claimant, in writing, a complete explanation of the basis for the settlement and shall specify why the services, procedures or supplies requested are not medically necessary. Such explanation shall also include:
(i) A statement in the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You have the right to have our decision reviewed by following the procedures outlined in this notice. You also may have the right to an expedited review under circumstances where a delayed review would adversely affect you."; and
(ii) A statement describing a procedure for having the claim denial reviewed by the insurer, including all applicable time limits, requirements and a process for having a expedited review initiated as expeditiously as the claimant's medical condition or circumstances require, and in any event within seventy-two (72) hours, where:
(A) The timeframe for the completion of a normal review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function; or
(B) The claimant's claim concerns a request for an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a health care facility.
(d) A claimant shall have not less than thirty (30) days in which to file a request for the review provided in subsection
(c) of this section and such review shall be completed by the insurer, and a decision delivered to the claimant, no later than forty-five (45) days after receipt of a request for review.
(e) If a claim for the provision of or payment for medical services, procedures or supplies is denied on the basis that it is not a medical necessity, or on other similar basis, after having been reviewed by the insurer pursuant to subsection (c) or (d) of this section, the insurer shall provide to the claimant, in writing, a complete explanation of the basis for the decision and shall specify why the services, procedures or supplies requested are not medically necessary. Such explanation shall also include:
(i) The signed opinion of at least one (1) credited medical consultant who agrees with the denial and who is not an employee of the insurer if requested by the claimant;
(ii) A statement in the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us and is not the attending physician or the physician's partner by following the procedures outlined in this notice. You also may have the right to an expedited review under circumstances where a delayed review would adversely affect you."; and
(iii) A statement describing the procedure for having the denied claim reviewed by an external review organization pursuant to regulations adopted by the commissioner. The statement shall include a description of all procedures, time limits and requirements, including those related to expedited reviews, which the claimant must follow to obtain an external review and include a request for external review form and release of records form approved by the commissioner.
(f) Within one hundred twenty (120) days of receiving the written explanation required by subsection (e) of this section, a claimant may request an external review of the decision which is the subject of the explanation by filing a written request for such review. The request shall be submitted to the insurer on a form approved by the commissioner, unless such form was not provided to the claimant as required by subsection (e) of this section, in which event any written request for an external review shall be sufficient.
(g) Upon receiving a request for external review, the insurer shall:
(i) Immediately send a copy of the request to the commissioner;
(ii) Assign the request to an independent review organization that has been approved by the commissioner for a preliminary review. The insurer shall provide to the independent review organization all documents and information upon which the insurer relied in denying all claims under review. Failure to provide the documents and other information shall not delay the conduct of the external review. The independent review organization shall determine whether:
(A) The claimant is or was a covered person in the insurance policy at the time the provision of or payment for medical services, procedures or supplies was requested or provided;
(B) The provision of or payment for medical services, procedures or supplies requested by the claimant reasonably appears to be a covered service under the insurance policy, but for the determination by the insurer that the services, procedures or supplies are not a medical necessity;
(C) The insurer has denied the claimant's request for the provision of or payment for medical services, procedures or supplies after having been given the opportunity to review the insurer's first denial one (1) or more times;
(D) The claimant has provided to the insurer all the information and forms required to process an external review, including a release form, approved by the commissioner, by which the claimant authorizes the release of protected health information pertinent to the external review.
(h) The independent review organization shall within five (5) days determine whether the documentation is complete and immediately notify the claimant and the insurer in writing whether the documentation is complete and, if not, what information or documentation is missing. The claimant may submit in writing to the independent review organization any additional supporting documentation that the independent review organization should consider or may require when conducting its external review. If the request for review is not complete, the independent review organization shall require from the insurer or the claimant the information or materials needed to make the request complete.
(j) The independent review organization shall, within one (1) business day of its receipt, forward all documentation and information it receives from an insurer or claimant to the opposing insurer or claimant. The insurer may use any documentation or other information provided by the claimant to reconsider its settlement of the claims. If the insurer chooses to reverse its prior decision, it shall immediately provide written notice to the claimant, the independent review organization and the commissioner, at which time the review shall be terminated.
(k) In addition to the documents and information provided pursuant to this section, the independent review organization, to the extent the information is available and the independent review organization considers them appropriate, shall consider the following in reaching its decision:
(i) The claimant's medical records;
(ii) The attending health care professional's recommendation;
(iii) Consulting reports from appropriate health care professionals and other documents submitted by the insurer, claimant or the claimant's treating provider;
(iv) The terms of coverage under the claimant's insurance policy;
(v) The standards identified in W.S. 26-40-102(a)(iii);
(vi) All evidence based research used in the insurer's denial of the claim.
(m) Within forty-five (45) days after the date of receipt of the request for external review, the assigned independent review organization shall provide written notice to the claimant, the insurer and the commissioner of its decision to uphold or reverse the decision of the insurer that the provision of or payment for medical services, procedures or supplies requested by the claimant are not medically necessary. Such written notice shall include:
(i) A general description of the reason for the request for external review;
(ii) The date the independent review organization received the assignment from the insurer to conduct the review;
(iii) The date the external review was conducted;
(iv) The date of its decision;
(v) The principal reasons for its decision;
(vi) The rationale for its decision; and
(vii) References to the evidence or documentation considered in reaching its decision.
(n) In the event the external review organization determines the claims should be allowed, the insurer shall approve the request for the provision of or payment for medical services, procedures or supplies that was the subject of the review and notify the claimant of such approval within five (5) days.
(o) The engagement by an insurer of an independent review organization to conduct an external review in accordance with this section shall be fair and impartial. The insurer, insured and the independent review organization shall comply with regulations promulgated by the commissioner to ensure fairness and impartiality in the engagement of approved independent review organizations, in the terms, termination and payment of independent review organizations and in the review process.
(p) The commissioner shall adopt regulations establishing an expedited review by an external review organization as expeditiously as the claimant's medical condition or circumstances require, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review, and which allows an expedited external review where:
(i) The timeframe for the completion of a normal external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function; or
(ii) The claimant's claim concerns a request for an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a health care facility.
(q) The insurer against whom a request for external review is filed shall pay the costs of the independent review organization's external review.
(r) The commissioner shall adopt such regulations as are necessary to promote the purposes of this section, which regulations shall include:
(i) Fees, including the waiver of fees for indigent persons;
(ii) Standards and procedures for the approval of independent review organizations;
(iii) External review organization reporting and record retention requirements.
(s) An insurer required to comply with the notification and appeal procedures of the Employee Retirement Income Security Act, and being compliant therewith, shall be deemed in compliance with this section.
Any insurer which is organized under the laws of any jurisdiction other than this state and is admitted to do business in this state for the purpose of writing insurance may become a domestic insurer by meeting the substantive requirements of law relative to the organization and licensing of a domestic insurer of the same type, by designating its principal place of business at a place in this state, and by receiving from the commissioner certification that it is a domestic insurer as if originally formed in the state. The domesticated insurer thereafter will be entitled to domestic certificates and licenses to transact business in this state, and shall be subject to the authority and jurisdiction of this state as a domestic insurer.
Any domestic insurer may, upon the approval of the commissioner, transfer its domicile to any other state in which it is admitted to transact the business of insurance, and upon such a transfer shall cease to be a domestic insurer, and shall be admitted to this state if qualified as a foreign insurer. The commissioner shall approve any proposed transfer unless he shall determine the transfer is not in the interest of the policyholders of this state.
(a) The certificate of authority, agent appointments and licenses, rates, and other items which the commissioner of insurance allows, in his discretion, which are in existence at the time any insurer licensed to transact the business of insurance in this state transfers its corporate domicile to this or any other state by merger, consolidation, continuance, transfer or any other lawful method shall continue in full force and effect upon the transfer if the insurer remains duly qualified to transact the business of insurance in this state. All outstanding policies of any transferring insurer shall remain in full force and effect and need not be endorsed as to the new name of the company or its new location unless so ordered by the commissioner. Every transferring insurer shall file new policy forms with the commissioner on or before the effective date of the transfer, but may use existing policy forms with appropriate endorsements if allowed by, and under conditions approved by, the commissioner.
(b) The procedures for filing and approval of articles of domestication by the corporate directors shall be the same as those set forth in W.S. 26-24-104 concerning the filing and approval of articles of incorporation for proposed domestic insurers.
(c) The articles of domestication of any insurer transferring its domicile into this state shall be deemed the articles of incorporation of the insurer. The domestication of an insurer into this state shall have the same effect upon the insurer as in the case of a corporation continuing in Wyoming pursuant to W.S. 17-16-1810.
(a) As used in this act:
(i) "Account" means any of the three (3) accounts created by W.S. 26-42-104(a);
(ii) "Association" means the Wyoming life and health insurance guaranty association created by W.S. 26-42-104;
(iii) "Authorized assessment" or the term "authorized" when used in the context of assessments means a resolution by the board of directors has been passed whereby an assessment will be called immediately or in the future from member insurers for a specified amount. An assessment is authorized when the resolution is passed;
(iv) "Benefit plan" means a specific employee, union or association of natural persons benefit plan;
(v) "Called assessment" or the term "called" when used in the context of assessments means that a notice has been issued by the association to member insurers requiring that an authorized assessment be paid within the time frame set forth within the notice. An authorized assessment becomes a called assessment when notice is mailed by the association to member insurers;
(vi) "Contractual obligation" means any obligation under a policy or contract or certificate under a group policy or contract, or portion thereof for which coverage is provided under W.S. 26-42-103;
(vii) "Covered policy" or "covered contract" means any policy or contract or portion of a policy or contract for which coverage is provided by W.S. 26-42-103;
(viii) "Extra-contractual claims" shall include claims relating to bad faith in the payment of claims, punitive or exemplary damages or attorneys' fees and costs;
(ix) "Impaired insurer" means a member insurer which is not an insolvent insurer and is placed under an order of rehabilitation or conservation by a court of competent jurisdiction;
(x) "Insolvent insurer" means a member insurer which after the effective date of this act, is placed under an order of liquidation by a court of competent jurisdiction with a finding of insolvency;
(xi) "Member insurer" means any insurer or health maintenance organization which is licensed or holds a certificate of authority to transact in this state any kind of insurance or health maintenance organization business for which coverage is provided by W.S. 26-42-103 and includes any insurer or health maintenance organization business whose license or certificate of authority in this state may have been suspended, revoked, not renewed or voluntarily withdrawn, but does not include:
(A) Repealed By Laws 1997, ch. 125, § 1.
(B) Repealed by Laws 1995, ch. 210, § 5.
(C) A fraternal benefit society;
(D) A mandatory state pooling plan;
(E) A stipulated premium insurance company;
(F) A local mutual burial association;
(G) A mutual assessment company or any entity that operates on an assessment basis;
(H) An insurance exchange; or
(J) Any entity similar to any of the above.
(xii) "Moody's Corporate Bond Yield Average" means the Monthly Average Corporates as published by Moody's Investors Service, Inc., or any successor thereto;
(xiii) "Owner" of a policy or contract, "contract owner", "policyholder" and "policy owner" mean the person who is identified as the legal owner under the terms of the policy or contract or who is otherwise vested with legal title to the policy or contract through a valid assignment completed in accordance with the terms of the policy or contract and properly recorded as the owner on the books of the member insurer. The terms "owner", "contract owner", "policyholder" and "policy owner" do not include persons with a mere beneficial interest in a policy or contract;
(xiv) "Plan sponsor" means:
(A) The employer in the case of a benefit plan established or maintained by a single employer;
(B) The employee organization in the case of a benefit plan established or maintained by an employee organization; or
(C) In a case of a benefit plan established or maintained by two (2) or more employers or jointly by one (1) or more employers and one (1) or more employee organizations, the association, committee, joint board of trustees or other similar group of representatives of the parties who establish or maintain the benefit plan.
(xv) "Premiums" means amounts received on covered policies or contracts less premiums, considerations and deposits returned thereon, and less dividends and experience credits thereon, but does not include any amounts received for any policies or contracts or for the portions of any policies or contracts for which coverage is not provided by W.S. 26-42-103(b) except that assessable premium shall not be reduced due to W.S. 26-42-103(c)(iii) relating to interest limitations and W.S. 26-42-103(d)(ii) relating to limitations with respect to any one (1) individual, one (1) participant and one (1) policy owner or contract owner. "Premiums" shall not include:
(A) Premiums on an unallocated annuity contract; or
(B) With respect to multiple nongroup policies of life insurance owned by one (1) owner, whether the policy owner or contract owner is an individual, firm, corporation or other person, and whether the persons insured are officers, managers, employees or other persons, premiums in excess of five million dollars ($5,000,000.00) with respect to these policies or contracts, regardless of the number of policies or contracts held by the owner.
(xvi) "Principal place of business" of:
(A) A plan sponsor or a person other than a natural person means the single state in which the natural persons who establish policy for the direction, control and coordination of the operations of the entity as a whole primarily exercise that function, determined by the association in its reasonable judgment by considering the following factors:
(I) The state in which the primary executive and administrative headquarters of the entity is located;
(II) The state in which the principal office of the chief executive officer of the entity is located;
(III) The state in which the board of directors, or similar governing person or persons, of the entity conducts the majority of its meetings;
(IV) The state in which the executive or management committee of the board of directors, or similar governing person or persons, of the entity conducts the majority of its meetings;
(V) The state from which the management of the overall operations of the entity is directed; and
(VI) In the case of a benefit plan sponsored by affiliated companies comprising a consolidated corporation, the state in which the holding company or controlling affiliate has its principal place of business as determined using the above factors. However, in the case of a plan sponsor, if more than fifty percent (50%) of the participants in the benefit plan are employed in a single state, that state shall be deemed the principal place of business for the plan sponsor.
(B) A plan sponsor of a benefit plan shall be deemed to be the principal place of business of the association, committee, joint board of trustees or other similar group of representatives of the parties who establish or maintain the benefit plan that, in lieu of a specific or clear designation of a principal place of business, shall be deemed to be the principal place of business or the employer or employee organization that has the largest investment in the benefit plan in question.
(xvii) "Receivership court" means the court in the insolvent or impaired insurer's state having jurisdiction over the conservation, rehabilitation or liquidation of the member insurer;
(xviii) "Resident" means a person to whom a contractual obligation is owed and who resides in this state on the date of entry of a court order that determines a member insurer to be an impaired insurer or a court order that determines a member insurer to be an insolvent insurer. A person may be a resident of only one (1) state, which in the case of a person other than a natural person is its principal place of business. Citizens of the United States who are either residents of foreign countries or residents of United States possessions, territories or protectorates that do not have an association similar to the association created by this act, shall be deemed residents of the state of domicile of the member insurer that issued the policies or contracts;
(xix) "Structured settlement annuity" means an annuity purchased in order to fund periodic payments for a plaintiff or other claimant in payment for or with respect to personal injury suffered by the plaintiff or other claimant;
(xx) "Supplemental contract" means a written agreement entered into for the distribution of proceeds under a life, health or annuity policy or life, health or annuity contract;
(xxi) "Unallocated annuity contract" means an annuity contract or group annuity certificate which is not issued to and owned by an individual, except to the extent of any annuity benefits guaranteed to an individual by an insurer under the contract or certificate;
(xxii) "Enrollee" means an individual who is enrolled in a health maintenance organization;
(xxiii) "Health benefit plan" means any hospital or medical expense policy or certificate, or health maintenance organization subscriber contract or any other similar health contract. "Health benefit plan" does not include any of the following:
(A) Accident only insurance;
(B) Credit insurance;
(C) Dental only insurance;
(D) Vision only insurance;
(E) Medicare supplement insurance;
(F) Benefits for long term care, home health care, community based care or any combination thereof;
(G) Disability income insurance;
(H) Coverage for on-site medical clinics;
(J) Specified disease, hospital confinement indemnity or limited benefit health issuance if the types of coverage do not provide coordination of benefits and are provided under separate policies or certificates.
(xxiv) "This act" means W.S. 26-42-101 through 26-42-118.
(a) This act shall provide coverage for the policies and contracts specified in subsection (b) of this section and provide coverage as follows:
(i) To persons who are owners, certificate holders or enrollees under the policies or contracts other than structured settlement annuities and in each case who:
(A) Are residents; or
(B) Are not residents but only under all of the following conditions:
(I) The member insurer that issued the policies or contracts is domiciled in this state;
(II) The states in which the persons reside have associations similar to the association created by this act; and
(III) The persons are not eligible for coverage by an association in any other state due to the fact that the insurer or health maintenance organization was not licensed in the state at the time specified in the state's guaranty association law.
(ii) To persons who are the beneficiaries, assignees or payees of the persons described in paragraph (a)(i) of this section, including health care providers rendering services covered under health insurance policies or certificates, regardless of where they reside except for nonresident certificate holders under group policies or contracts;
(iii) For structured settlement annuities specified in subsection (b) of this section, paragraphs (i) and (ii) of this subsection shall not apply, and this act shall, except as provided in paragraphs (iv) and (v) of this subsection, provide coverage to a person who is a payee under a structured settlement annuity or beneficiary of a payee if the payee is deceased, if the payee:
(A) Is a resident, regardless of where the contract owner resides; or
(B) Is not a resident, but only under both of the following conditions:
(I) The contract owner of the structured settlement annuity is a resident, or the contract owner of the structured settlement annuity is not a resident, but the insurer that issued the structured settlement annuity is domiciled in this state and the state in which the contract owner resides has an association similar to the association created by this act; and
(II) Neither the payee or beneficiary of the contract owner nor the contract owner is eligible for coverage by the association of the state in which the payee or contract owner resides.
(iv) This act shall not provide coverage to:
(A) A person who is a payee or beneficiary of a contract owner resident of this state, if the payee or beneficiary is afforded any coverage by the association of another state; or
(B) A person who acquires rights to receive payments through a structured settlement factoring transaction as defined in 26 U.S.C. §5891(c)(3)(A), regardless if the transaction occurred before or after 26 U.S.C. § 5891(c)(3)(A) became effective.
(v) This act is intended to provide coverage to a person who is a resident of this state and, in special circumstances, to a nonresident. In order to avoid duplicate coverage, if a person who would otherwise receive coverage under this act is provided coverage under the laws of any other state, the person shall not be provided coverage under this act. In determining the application of the provisions of this paragraph in situations where a person could be covered by the association of more than one (1) state, whether as an owner, payee, enrollee, beneficiary or assignee, this act shall be construed in conjunction with other state laws to result in coverage by only one (1) association.
(b) This act shall provide coverage to persons specified in subsection (a) of this section for policies or contracts of direct, nongroup life insurance, health insurance including health maintenance organization subscriber contracts and certificates, annuities and supplemental contracts to any of these policies or contracts and for certificates under direct group policies and contracts issued by member insurers except as limited by this act. Annuity contracts and certificates under group annuity contracts include allocated funding agreements, structured settlement annuities and any immediate or deferred annuity contracts.
(c) This act shall not provide coverage for:
(i) Any portion of a policy or contract not guaranteed by the insurer or under which the risk is borne by the policyholder or contract holder;
(ii) Any policy or contract of reinsurance unless assumption certificates have been issued pursuant to the reinsurance policy or contract;
(iii) Excluding any portion of a policy or contract, including a rider, that provides long term care or other health insurance benefits, any portion of a policy or contract to the extent that the rate of interest on which it is based:
(A) Averaged over the period of four (4) years prior to the date on which the member insurer becomes an impaired or insolvent insurer under this act, exceeds a rate of interest determined by subtracting two (2) percentage points from Moody's Corporate Bond Yield Average averaged for that same four (4) year period or for a lesser period if the policy or contract was issued less than four (4) years before the member insurer becomes an impaired or insolvent insurer under this act; and
(B) On and after the date on which the member insurer becomes an impaired or insolvent insurer under this act, exceeds the rate of interest determined by subtracting three (3) percentage points from the most recent and available Moody's Corporate Bond Yield Average.
(iv) Any portion of a policy or contract issued to a plan or program of an employer, association or other person to provide life, health or annuity benefits to its employees, members or others to the extent that the plan or program is self-funded or uninsured, including but not limited to benefits payable by an employer, association or similar entity under:
(A) A multiple employer welfare arrangement as defined in Section 3(40) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(40);
(B) A minimum premium group insurance plan;
(C) A stop-loss group insurance plan; or
(D) An administrative services only contract.
(v) Any portion of a policy or contract to the extent it provides dividends or experience rating credits, voting rights or provides payment of any fees or allowances to any person, including the policyholder or contract holder, in connection with the service to or administration of the policy or contract;
(vi) Any policy or contract issued in this state by a member insurer at a time when it was not licensed or did not have a certificate of authority to issue the policy or contract in this state;
(vii) Any annuity contract or group annuity certificate which is not issued to and not owned by an individual, except to the extent of any annuity benefits guaranteed to an individual by an insurer under the contract or certificate;
(viii) Any annuity contract or group annuity certificate which is issued by a nonprofit insurance company exclusively for the benefit of nonprofit educational institutions and their employees for the purpose of providing retirement benefits;
(ix) A portion of a policy or contract to the extent that the assessments required by W.S. 26-42-107 with respect to the policy or contract are preempted or otherwise not permitted by federal or state law;
(x) An obligation that does not arise under the express written terms of the policy or contract issued by the member insurer to the enrollee, certificate holder, contract owner or policy owner, including without limitation:
(A) Claims based on marketing materials;
(B) Claims based on side letters, riders or other documents that were issued by the member insurer without meeting applicable policy or contract form filing or approval requirements;
(C) Misrepresentations of or regarding policy or contract benefits;
(D) Extra-contractual claims; or
(E) A claim for penalties or consequential or incidental damages.
(xi) A contractual agreement that establishes the member insurer's obligations to provide a book value accounting guaranty for defined contribution benefit plan participants by reference to a portfolio of assets that is owned by the benefit plan or its trustee, which in each case is not an affiliate of the member insurer;
(xii) An unallocated annuity contract;
(xiii) A policy or contract providing any hospital, medical, prescription drug or other health care benefits pursuant to Part C or Part D of Subchapter XVIII, Chapter 7 of Title 42 of the United States Code (commonly known as Medicare Part C & D) or Subchapter XIX, Chapter 7 of Title 42 of the United States Code (commonly known as Medicaid) or any regulations issued pursuant thereto;
(xiv) A portion of a policy or contract to the extent it provides for interest or other changes in value to be determined by the use of an index or other external reference stated in the policy or contract, but which have not been credited to the policy or contract, or as to which the policy or contract owner's rights are subject to forfeiture, as of the date the member insurer becomes an impaired or insolvent insurer under this act, whichever is earlier. If a policy's or contract's interest or changes in value are credited less frequently than annually, then for purposes of determining the values that have been credited and are not subject to forfeiture under this provision, the interest or change in value determined by using the procedures defined in the policy or contract will be credited as if the contractual date of crediting interest or changing values was the date of impairment or insolvency, whichever is earlier, and will not be subject to forfeiture;
(xv) Structured settlement annuity benefits to which a payee or beneficiary has transferred his rights in a structured settlement factoring transaction as defined in 26 U.S.C. § 5891(c)(3)(A), regardless if the transaction occurred before or after 26 U.S.C. § 5891(c)(3)(A) became effective.
(d) The benefits for which the association may be liable shall in no event exceed the lesser of:
(i) The contractual obligations for which the member insurer is liable or would have been liable if it was not an impaired or insolvent insurer; or
(ii) With respect to any one (1) life, regardless of the number of policies or contracts:
(A) Three hundred thousand dollars ($300,000.00) in life insurance death benefits but not more than one hundred thousand dollars ($100,000.00) in net cash surrender and net cash withdrawal values for life insurance;
(B) For health insurance benefits:
(I) One hundred thousand dollars ($100,000.00) for coverages not defined as disability insurance, disability income insurance, health benefit plan or long term care insurance including any net cash surrender and net cash withdrawal values;
(II) Three hundred thousand dollars ($300,000.00) for disability insurance, disability income insurance and long-term care insurance;
(III) Three hundred thousand dollars ($300,000.00) for health benefit plans.
(C) Two hundred fifty thousand dollars ($250,000.00) in the present value of annuity benefits including net cash surrender and net cash withdrawal values;
(D) With respect to each payee of a structured settlement annuity or beneficiary or beneficiaries of the payee if deceased, two hundred fifty thousand dollars ($250,000.00) in present value annuity benefits, in the aggregate, including net cash surrender and net cash withdrawal values;
(E) However, in no event shall the association be obligated to cover more than:
(I) An aggregate of five hundred thousand dollars ($500,000.00) in benefits with respect to any one (1) life under paragraphs (A) through (D) of this subsection; or
(II) With respect to one (1) owner of multiple nongroup policies of life insurance, whether the policy owner or contract owner is an individual, firm, corporation or other person, and whether the persons insured are officers, managers, employees or other persons, more than five million dollars ($5,000,000.00) in benefits, regardless of the number of policies and contracts held by the owner.
(F) The limitations set forth in this subsection are limitations on the benefits for which the association is obligated before taking into account either its subrogation and assignment rights or the extent to which those benefits could be provided out of the assets of the impaired or insolvent insurer attributable to covered policies. The costs of the association's obligations under this act may be met by the use of assets attributable to covered policies or reimbursed to the association pursuant to its subrogation and assignment rights;
(G) For purposes of this act, benefits provided by a long term care rider to a life insurance policy or annuity contract shall be considered the same type of benefits as the base life insurance policy or annuity contract to which it relates.
(e) The liability of the association is strictly limited by the express terms of the covered policies and contracts and by the provisions of this act and is not affected by the contents of any brochures, illustrations, advertisements or oral statements by agents, brokers or others used or made in connection with their sale. The association is not liable for any extracontractual, exemplary or punitive damages, attorney's fees or interest other than as provided for by the terms of such policies or contracts, as limited by this act.
(f) Repealed By Laws 2014, Ch. 21, § 2.
(g) In performing its obligations to provide coverage under W.S. 26-42-106, the association shall not be required to guarantee, assume, reinsure, reissue or perform, or cause to be guaranteed, assumed, reinsured, reissued or performed, the contractual obligations of the insolvent or impaired insurer under a covered policy or contract that do not materially affect the economic values or economic benefits of the covered policy or contract.
(a) There is created a nonprofit legal entity to be known as the Wyoming life and health insurance guaranty association. All member insurers are members of the association as a condition of their authority to transact insurance or health maintenance organization business in this state. The association shall perform its functions under the plan of operation established and approved under W.S. 26-42-108 and shall exercise its powers through a board of directors provided by W.S. 26-42-105. For purposes of administration and assessment the association shall maintain the three (3) following accounts:
(i) The life insurance account;
(ii) The health account; and
(iii) The annuity account.
(b) The association is under the supervision of the commissioner and is subject to the applicable provisions of the insurance laws of this state. Meetings or records of the association may be opened to the public upon majority vote of the board of directors of the association.
(a) The board of directors of the association consists of not less than five (5) nor more than nine (9) member insurers serving terms as established in the plan of operation provided by W.S. 26-42-108. Membership on the board shall be subject to the following:
(i) The members of the board shall be selected by member insurers subject to the approval of the commissioner;
(ii) A majority of the members shall be domestic insurers. If there are not enough domestic insurers for a majority, then all domestic insurers shall be on the board. The domestic insurers shall hold the positions of chairman and at least one (1) other officer position on the board if possible;
(iii) Each member insurer selected shall identify the individual representing the member insurer on the board and shall provide the individual's name, address, biographical information and position in an affidavit to the commissioner for review and approval;
(iv) Vacancies on the board shall be filled for the remaining period of the term by a majority vote of the remaining board members subject to the approval of the commissioner.
(b) In approving selections or in appointing members to the board, the commissioner shall consider, among other factors, whether all member insurers are fairly represented.
(c) Members of the board shall be reimbursed from the assets of the association for expenses incurred by them as members of the board of directors. Members of the board shall not otherwise be compensated by the association for their services.
(a) If a member insurer is an impaired insurer, the association may in its discretion and subject to any conditions imposed by the association that do not impair the contractual obligations of the impaired insurer, that are approved by the commissioner:
(i) Guarantee, assume, reissue or reinsure or cause to be guaranteed, assumed, reissued or reinsured any or all of the policies or contracts of the impaired insurer;
(ii) Provide monies, pledges, loans, notes, guarantees, or other means proper to effectuate this subsection and assure payment of the contractual obligations of the impaired insurer pending action taken as authorized by this subsection.
(iii) Repealed By Laws 2014, Ch. 21, § 2.
(b) Repealed By Laws 2014, Ch. 16, § 2.
(c) Repealed By Laws 2014, Ch. 16, § 2.
(d) If a member insurer is an insolvent insurer, the association shall, in its discretion, do one (1) of the following:
(i) Guaranty, assume, reissue or reinsure or cause to be guaranteed, assumed, reissued or reinsured, the policies or contracts of the insolvent insurer and provide monies, pledges, guarantees or other means as reasonably necessary to discharge the duties;
(ii) Assure payment of the contractual obligations of the insolvent insurer and provide monies, pledges, guarantees or other means as reasonably necessary to discharge the duties;
(iii) With respect to life and health insurance policies and annuities, provide benefits and coverages in accordance with subsection (e) of this section; or
(iv) With respect to health benefit plans that are subject to state or federal guaranteed issue requirements, terminate the policies no later than sixty (60) days after the entry of an order of liquidation with the approval of the commissioner.
(e) With respect to policies and contracts and when proceeding under paragraph (d)(iii) of this section, the association:
(i) Shall assure payment of benefits that would have been payable under the policies or contracts of the insolvent insurer for claims incurred:
(ii) Shall make diligent efforts to provide all known insureds, enrollees or annuitants for nongroup policies and contracts, or group policy owners or contracts owners with respect to group policies and contracts, thirty (30) days notice of the termination of the benefits provided;
(iii) For nongroup policies and contracts covered by the association, shall make available to each known insured, enrollee or annuitant, or owner if other than the insured or annuitant and with respect to an individual formerly an insured, enrollee or annuitant under a group policy or contract who is not eligible for replacement group coverage, make available substitute coverage on an individual basis in accordance with the provisions of paragraph (iv) of this subsection, if the insureds, enrollees or annuitants had a right under law or the terminated policy, contract or annuity to convert coverage to individual coverage or to continue an individual policy, contract or annuity in force until a specified age or for a specified time during which the insurer or health maintenance organization had no right unilaterally to make changes in any provisions of the policy, contract or annuity or had a right only to make changes in premium by class;
(iv) In providing the substitute coverage required under paragraph (iii) of this subsection, may offer either to reissue the terminated coverage or to issue an alternative policy or contract at actuarially justified rates subject to the prior approval of the commissioner. Alternative or reissued policies or contracts shall be offered without requiring evidence of insurability and shall not provide for any waiting period or exclusion that would not have applied under the terminated policy or contract. The association may reinsure any alternative or reissued policy or contract;
(v) May adopt alternative policies or contracts of various types for future issuance without regard to any particular impairment or insolvency. The alternative policies:
(A) Are subject to the approval of the commissioner;
(B) Shall contain at least the minimum statutory provisions required in this state and provide benefits that are not unreasonable in relation to the premium charged;
(C) Shall have premiums set by the association in accordance with a table of rates which it adopts and which reflect the amount of insurance to be provided and the age and class of risk of each insured but do not reflect any changes in the health of the insured after the original policy or contract was last underwritten;
(D) Shall provide coverage of a type similar to that of the policy or contract issued by the impaired or insolvent insurer, as determined by the association.
(vi) If the association elects to reissue terminated coverage at a premium rate different from that charged under the terminated policy or contract, shall set the premium at actuarially justified rates and in accordance with the amount of insurance or coverage provided and the age and class of risk, subject to prior approval of the commissioner or a court of competent jurisdiction; and
(vii) With respect to coverage under any policy or contract of the impaired or insolvent insurer or under any reissued or alternative policy or contract, shall have its obligations cease on the date coverage or the policy or contract is replaced by another similar policy or contract by the policy owner or contract owner, the insured, the enrollee or the association.
(f) When proceeding under subsection (d) of this section with respect to any policy or contract carrying guaranteed minimum interest rates, the association shall assure the payment or crediting of a rate of interest consistent with W.S. 26-42-103(c)(iii).
(g) Nonpayment of premiums within thirty-one (31) days after the date required under the terms of any guaranteed, assumed, alternative or reissued policy or contract or substitute coverage shall terminate the association's obligations under the policy, contract or coverage incurred pursuant to this act, except with respect to any claims incurred or any net cash surrender value which may be due in accordance with the provisions of this act.
(h) Premiums due for coverage after entry of an order of liquidation of an insolvent insurer belongs to and is payable at the direction of the association, and the association is liable for unearned premiums due to policy or contract owners arising after the entry of the order.
(j) The protection provided by this act shall not apply where any guaranty protection is provided to residents of this state by the laws of the domiciliary state or jurisdiction of the impaired or insolvent insurer other than this state.
(k) In carrying out its duties under subsection (d) of this section the association may, subject to approval by a court of competent jurisdiction:
(i) Impose permanent policy or contract liens in connection with any guarantee, assumption or reinsurance agreement, if the association finds that the amounts which may be assessed under this act are less than the amounts needed to assure full and prompt performance of the association's duties under this act or that the economic or financial conditions as they affect member insurers are sufficiently adverse that it is within the public interest to render the imposition of the permanent policy or contract liens;
(ii) Impose temporary moratoriums or liens on payments of cash values and policy loans or any other right to withdraw funds held in conjunction with policies or contracts in addition to any contractual provisions for deferral of cash or policy loan value. In addition, in the event of a temporary moratorium or moratorium charge imposed by the receivership court on payment of cash values or policy loans, or on any other right to withdraw funds held in conjunction with policies or contracts, out of the assets of the impaired or insolvent insurer, the association may defer the payment of cash values, policy loans or other rights by the association for the period of the moratorium or moratorium charge imposed by the receivership court, except for claims covered by the association to be paid in accordance with a hardship procedure established by the liquidator or rehabilitator and approved by the receivership court.
(m) A deposit in this state, held pursuant to law or required by the commissioner for the benefit of creditors, including policy owners or contract owners, not turned over to the domiciliary liquidator upon the entry of a final order of liquidation or order approving a rehabilitation plan of a member insurer domiciled in this state or in a reciprocal state shall be promptly paid to the association. The association shall be entitled to retain a portion of any amount so paid to it equal to the percentage determined by dividing the aggregate amount of policy owners' or contract owners' claims related to that insolvency for which the association has provided statutory benefits by the aggregate amount of all policy owners' or contract owners' claims in this state related to that insolvency and shall remit to the domiciliary receiver the amount so paid to the association less the amount retained pursuant to this subsection. Any amount so paid to the association and retained by it shall be treated as a distribution of estate assets pursuant to applicable state receivership law dealing with early access disbursements.
(n) If the association fails to act within a reasonable period of time as provided in subsections (d) and (e) of this section, the commissioner shall have the powers and duties of the association under this act with respect to insolvent insurers.
(o) The association may render assistance and advice to the commissioner upon his request concerning rehabilitation, payment of claims, continuance of coverage or the performance of other contractual obligations of any impaired or insolvent insurer.
(p) The association shall have standing to appear before any court or agency in this state with jurisdiction over an impaired or insolvent insurer concerning which the association is or may become obligated under this act or with jurisdiction over any person or property against which the association may have rights through subrogation or otherwise. Standing shall extend to all matters germane to the powers and duties of the association, including but not limited to, proposals for reinsuring, reissuing, modifying or guaranteeing the policies or contracts of the impaired or insolvent insurer and the determination of the policies or contracts and contractual obligations. The association shall also have the right to appear or intervene before a court or agency in any state with jurisdiction over an impaired or insolvent insurer if the association is or may become obligated or with jurisdiction over any person or property against whom the association may have rights through subrogation or otherwise.
(q) Any person receiving benefits under this act shall be deemed to have assigned the rights under and any causes of action against any person for losses arising under, resulting from or otherwise relating to the covered policy or contract to the association to the extent of the benefits received because of this act, whether the benefits are payments of or on account of contractual obligations, continuation of coverage or provision of substitute or alternative policies, contracts or coverages. The association may require an assignment to it of the rights and cause of action by any enrollee, payee, policy or contract owner, beneficiary, insured or annuitant as a condition precedent to the receipt of any right or benefits conferred by this act upon the person. The subrogation rights of the association under this subsection shall have the same priority against the assets of the impaired or insolvent insurer as that possessed by the person entitled to receive benefits under this act. In addition, the association shall have all common law rights of subrogation and any other equitable or legal remedy that would have been available to the impaired or insolvent insurer or owner, beneficiary, enrollee or payee of a policy or contract with respect to the policy or contracts and shall include, in the case of a structured settlement annuity, any rights of the owner, beneficiary or payee of the annuity, to the extent of benefits received pursuant to this act, against a person originally or by succession responsible for the losses arising from the personal injury relating to the annuity or payment therefor, excluding any person responsible solely by reason of serving as an assignee in respect to a qualified assignment under section 130 of the Internal Revenue Code. If the provisions of this subsection are invalid or ineffective with respect to any person or claim for any reason, the amount payable by the association with respect to the related covered obligations shall be reduced by the amount realized by any other person with respect to the person or claim that is attributable to the policies or portion thereof covered by the association. If the association has provided benefits with respect to a covered obligation and a person recovers amounts as to which the association has rights as described in this subsection, the person shall pay to the association the portion of the recovery attributable to the policies or portion thereof covered by the association.
(r) The association may:
(i) Enter into contracts as necessary or proper to carry out the provisions and purposes of this act;
(ii) Sue or be sued including taking any legal actions necessary or proper to recover any unpaid assessments under W.S. 26-42-107 and to settle claims or potential claims against it;
(iii) Borrow money to effect the purposes of this act. Any notes or other evidence of indebtedness of the association not in default are legal investments for domestic member insurers and may be carried as admitted assets;
(iv) Employ or retain persons as necessary to handle the financial transactions of the association and to perform other functions as necessary or proper under this act;
(v) Take legal action as necessary or appropriate to avoid or recover payment of improper claims;
(vi) Exercise, for the purposes of this act and to the extent approved by the commissioner, the powers of a domestic life insurer, health maintenance organization or health insurer. The association shall not issue policies or contracts other than those issued to perform its obligations under this act;
(vii) Organize itself as a corporation or in other legal form permitted by the laws of the state;
(viii) Request information from a person seeking coverage from the association in order to aid the association in determining its obligations under this act with respect to the person, and the person shall promptly comply with the request;
(ix) Unless prohibited by law, in accordance with the terms and conditions of the policy or contract, file for actuarially justified rate or premium increases for any policy or contract for which it provides coverage under this act;
(x) Take other necessary or appropriate action to discharge its duties and obligations under this act or to exercise its powers under this act.
(s) The association may join an organization of one (1) or more other state associations of similar purposes to further the purposes and administer the powers and duties of the association.
(t) With respect to covered policies or contracts for which the association becomes obligated after an entry of an order of liquidation or rehabilitation, the association may elect to succeed to the rights of the insolvent insurer arising after the date of the order of liquidation or rehabilitation under any contract of reinsurance to which the insolvent insurer was a party, to the extent that the contract provides coverage for losses occurring after the date of the order of liquidation or rehabilitation. As a condition to making this election, the association shall pay all unpaid premiums due under the contract for coverage relating to periods before and after the date of the order of liquidation or rehabilitation.
(u) The board of directors of the association shall have discretion and may exercise reasonable business judgment to determine the means by which the association is to provide the benefits of this act in an economical and efficient manner.
(w) Where the association has arranged or offered to provide the benefits of this act to a covered person under a plan or arrangement that fulfills the association's obligations under this act, the person shall not be entitled to benefits from the association in addition to or other than those provided under the plan or arrangement.
(y) The association shall not be required to give an appeal bond in an appeal that relates to a cause of action arising under this act.
(z) In carrying out its duties in connection with guaranteeing, assuming, reissuing or reinsuring policies or contracts under subsection (a) or (d) of this section, the association may, subject to approval of the commissioner, issue substitute coverage for a policy or contract that provides an interest rate, crediting rate or similar factor determined by use of an index or other external reference stated in the policy or contract employed in calculating returns or changes in value by issuing an alternative policy or contract in accordance with the following provisions:
(i) In lieu of the index or other external reference provided for in the original policy or contract, the alternative policy or contract provides for a fixed interest rate, payment of dividends with minimum guarantees or a different method for calculating interest or changes in value;
(ii) There is no requirement for evidence of insurability, waiting period or other exclusion that would not have applied under the replaced policy or contract; and
(iii) The alternative policy or contract is substantially similar to the replaced policy or contract in all other material terms.
(a) For the purpose of providing the funds necessary to carry out the powers and duties of the association, the board of directors shall assess the member insurers separately for each account and at a time and for amounts as the board finds necessary. Assessments are due not less than thirty (30) days after prior written notice to the member insurers and shall accrue interest at the rate set by 28 U.S.C. § 1961 on and after the due date.
(b) There shall be two (2) assessments as follows:
(i) Class A assessments shall be authorized and called to pay administrative and legal costs and other expenses and examinations conducted under the authority of W.S. 26-42-110(e). Class A assessments may be authorized and called whether or not related to a particular impaired or insolvent insurer;
(ii) Class B assessments shall be authorized and called as necessary to carry out the powers and duties of the association under W.S. 26-42-106 with regard to an impaired or an insolvent insurer.
(c) The amount of any Class A assessment shall be determined at the discretion of the board of directors and those assessments may be authorized and called on a non pro rata basis. The amount of any Class B assessment shall be allocated for assessment purposes among the accounts pursuant to an allocation formula which may be based on the premiums or reserves of the impaired or insolvent insurer or any other standard deemed by the board in its sole discretion as fair and reasonable under the circumstances.
(d) Class B assessments against member insurers for each account shall be in the proportion that the premiums received on business in this state by each assessed member insurer or policies or contracts covered by each account for the three (3) most recent calendar years for which information is available preceding the year in which the insurer became insolvent, or in the case of an assessment with respect to an impaired insurer, the three (3) most recent calendar years for which information is available preceding the year in which the insurer became impaired, bears to the premiums received on business in this state for the calendar years by all assessed member insurers. The amount of the Class B assessment for long term care insurance written by the impaired or insolvent insurer shall be allocated according to a methodology included in the plan of operation and approved by the commissioner. The methodology shall provide for fifty percent (50%) of the assessment to be allocated to accident and health member insurers and fifty percent (50%) to be allocated to life and annuity member insurers.
(e) Assessments for funds to meet the requirements of the association with respect to an impaired or insolvent insurer shall not be made until necessary to implement the purposes of this act. Classification of assessments under subsection (b) of this section and computation of assessments under subsections
(c) and (d) of this section shall be made with a reasonable degree of accuracy, recognizing that exact determinations may not always be possible. The association shall notify each member insurer of its anticipated pro-rata share of an authorized assessment not yet called within one hundred eighty (180) days after the assessment is authorized.
(f) The association may abate or defer, in whole or in part, the assessment of a member insurer if, in the opinion of the board, payment of the assessment would endanger the ability of the member insurer to fulfill its contractual obligations. In the event an assessment against a member insurer is abated or deferred in whole or in part, the amount by which the assessment is abated or deferred may be assessed against the other member insurers in a manner consistent with the basis for assessments set forth in this section. Once the conditions that caused a deferral have been removed or rectified, the member insurer shall pay all assessments that were deferred pursuant to a repayment plan approved by the association.
(g) The total of all assessments imposed upon a member insurer for each account are subject to the following:
(i) Subject to paragraph (ii) of this subsection, the total of all assessments authorized by the association with respect to a member insurer for each account shall not in any one (1) calendar year exceed two percent (2%) of the insurer's average premiums received in this state on the policies and contracts covered by the account during the three (3) calendar years preceding the year in which the member insurer became an impaired or insolvent insurer;
(ii) If two (2) or more assessments are authorized in one (1) calendar year with respect to member insurers that become impaired or insolvent in different calendar years, the average annual premiums for purposes of the aggregate assessment percentage limitation referenced in paragraph (i) of this subsection shall be equal and limited to the higher of the three (3) year average annual premiums for the applicable subaccount or account as calculated pursuant to this subsection;
(iii) If the maximum assessment including the other assets of the association in any account does not provide in any one (1) year in either account an amount sufficient to carry out the responsibilities of the association, the necessary additional funds shall be assessed as soon thereafter as permitted by this act;
(iv) The board may provide in the plan of operation provided by W.S. 26-42-108 a method of allocating funds among claims, whether relating to one (1) or more impaired or insolvent insurers when the maximum assessment will be insufficient to cover anticipated claims.
(h) The board may refund to member insurers the amount by which the assets of the account exceed the amount the board finds is necessary to carry out during the coming year the obligations of the association with regard to the account, including assets accruing from assignment, subrogation, net realized gains and income from investments. The board shall use an equitable method to make the refunds and the refunds shall be in proportion to the contribution of each member insurer to the account. A reasonable amount may be retained in any account to provide funds for the continuing expenses of the association and for future losses.
(j) Any member insurer may, in determining its premium rates and policy owner dividends as to any kind of insurance or health maintenance organization business within the scope of this act, consider the amount reasonably necessary to meet its assessment obligations under this act.
(k) The association shall issue to each member insurer paying an assessment under this act, other than a Class A assessment, a certificate of contribution in a form prescribed by the commissioner for the amount of the assessment paid. All outstanding certificates shall be of equal dignity and priority without reference to amounts or dates of issue. A certificate of contribution may be shown by the member insurer in its financial statement as an asset in a form and for an amount, if any, and a period of time as approved by the commissioner.
(m) A member insurer that wishes to protest all or part of an assessment shall pay when due the full amount of the assessment as set forth in the notice provided by the association. The payment shall be available to meet association obligations during the pendency of the protest or any subsequent appeal. Payment shall be accompanied by a statement in writing that the payment is made under protest and setting forth a brief statement of the grounds for the protest. Within sixty (60) days following the payment of an assessment under protest by a member insurer, the association shall notify the member insurer in writing of its determination with respect to the protest unless the association notifies the member insurer that additional time is required to resolve the issues raised by the protest. Within thirty (30) days after a final decision has been made, the association shall notify the protesting member insurer in writing of that final decision. Within sixty (60) days of receipt of notice of the final decision, the protesting member insurer may appeal that final action to the commissioner. In the alternative to rendering a final decision with respect to a protest based on a question regarding the assessment base, the association may refer protests to the commissioner for a final decision, with or without a recommendation from the association. If the protest or appeal on the assessment is upheld, the amount paid in error or excess shall be returned to the member insurer. Interest on a refund due a protesting member insurer shall be paid at the rate actually earned by the association.
(n) The association may request information of member insurers in order to aid in the exercise of its power under this section and member insurers shall promptly comply with a request.
(a) The association shall maintain a plan of operation to assure the fair, reasonable and equitable administration of the association. The plan of operation and any amendments to the plan of operation shall be submitted to the commissioner and are effective upon the commissioner's written approval or after thirty (30) days if he has not disapproved them.
(b) If the association fails to submit a suitable plan of operation or suitable amendments to the plan, the commissioner shall after notice and hearing adopt and promulgate reasonable rules as necessary or advisable to implement the provisions of this act. The rules shall continue in force until modified by the commissioner or superseded by a plan submitted by the association and approved by the commissioner.
(c) All member insurers shall comply with the plan of operation.
(d) The plan of operation shall, in addition to requirements enumerated in other provisions of this act:
(i) Establish procedures for handling the assets of the association;
(ii) Establish the amount and method of reimbursing members of the board of directors under W.S. 26-42-105;
(iii) Establish regular places and times for meetings including telephone conference calls of the board of directors;
(iv) Establish procedures for records to be kept of all financial transactions of the association, the association's agents and the board of directors;
(v) Establish the procedures for making selections for the board of directors and submitting them to the commissioner;
(vi) Establish any additional procedures for assessments under W.S. 26-42-107;
(vii) Contain additional provisions necessary or proper for the execution of the powers and duties of the association.
(e) The plan of operation may provide that any or all powers and duties of the association, except those under W.S. 26-42-106(p) and 26-42-107, are delegated to a corporation, association or other organization which performs or will perform functions similar to those of the association or its equivalent in two (2) or more states. The corporation, association or organization shall be reimbursed for any payments made on behalf of the association and shall be paid for its performance of any function of the association. A delegation under this subsection shall take effect only with the approval of both the board of directors and the commissioner and may be made only to a corporation, association or organization which extends protection similar to that provided by this act.
(a) In addition to the duties and powers enumerated in other provisions of this act, the commissioner shall:
(i) Upon request of the board of directors, provide the association with a statement of the premiums in this and any other appropriate state for each member insurer;
(ii) When an impairment is declared and the amount of the impairment is determined, serve a demand upon the impaired insurer to eliminate the impairment within a reasonable time. Notice to the impaired insurer shall constitute notice to its shareholders, if any. The failure of the impaired insurer to promptly comply with the demand shall not excuse the association from the performance of its powers and duties under this act;
(iii) In any liquidation or rehabilitation proceeding involving a domestic insurer, be appointed as the liquidator, rehabilitator or conservator.
(b) The commissioner may suspend or revoke after notice and hearing the certificate of authority to transact business in this state of any member insurer which fails to pay an assessment when due or fails to comply with the plan of operation. As an alternative the commissioner may levy a forfeiture on any member insurer which fails to pay an assessment when due. Such forfeiture shall not exceed five percent (5%) of the unpaid assessment per month, but no forfeiture shall be less than one hundred dollars ($100.00) per month.
(c) Any action of the board of directors or the association may be appealed to the commissioner by any member insurer if an appeal is taken within sixty (60) days of the final action being appealed. Any final action or order of the commissioner is subject to judicial review in a court of competent jurisdiction.
(d) The liquidator, rehabilitator or conservator of any impaired insurer may notify all interested persons of the effect of this act.
(a) To aid in the detection and prevention of member insurer insolvencies or impairments, the commissioner shall:
(i) Notify the commissioners of all the other states, territories of the United States and the District of Columbia by mail within thirty (30) days of any of the following actions taken against a member insurer:
(A) Revocation of license;
(B) Suspension of license; or
(C) Issuance of any formal order requiring the member insurer to:
(I) Restrict its premium writing;
(II) Obtain additional contributions to surplus;
(III) Withdraw from the state;
(IV) Reinsure all or any part of its business; or
(V) Increase capital, surplus or any other account for the security of policy owners, contract owners, certificate holders or creditors.
(ii) Report to the board of directors when he has taken any actions provided by paragraph (i) of this subsection or has received a report from any other commissioner indicating that any action provided by paragraph (i) of this subsection has been taken in another state. The report to the board of directors shall contain all significant details of the action taken or the report received from another commissioner;
(iii) Report to the board of directors when he has reasonable cause to believe from any completed or pending examination of any member company that the company may be an impaired or insolvent insurer;
(iv) Furnish to the board of directors the national association of insurance commissioners insurance regulatory information system ratios and listings of companies not included in the ratios developed by the national association of insurance commissioners, and the board may use this information in carrying out its duties and responsibilities under this section. The report and its information shall be kept confidential by the board of directors until the commissioner or other lawful authority makes it a public record.
(b) The commissioner may seek the advice and recommendations of the board of directors concerning any matter affecting his duties and responsibilities regarding the financial condition of member insurers and insurers or health maintenance organizations seeking admission to transact business in this state.
(c) The board of directors may by majority vote make reports and recommendations to the commissioner upon any matter germane to the solvency, liquidation, rehabilitation or conservation of any member insurer or germane to the solvency of any insurers or health maintenance organizations seeking to do any business in this state. The reports and recommendations are confidential and shall not be considered public documents.
(d) It is the duty of the board of directors by majority vote to notify the commissioner of any information indicating any member insurer may be an impaired or insolvent insurer.
(e) The board of directors may by majority vote request that the commissioner order an examination of any member insurer which the board in good faith believes may be an impaired or insolvent insurer. Within thirty (30) days of the receipt of a request, the commissioner shall begin an examination. The examination may be conducted as a national association of insurance commissioners examination or may be conducted by persons designated by the commissioner. The cost of the examination shall be paid by the association and the examination report shall be treated the same as other examination reports. In no event shall the examination report be released to the board of directors prior to its release to the public, but this shall not preclude the commissioner from complying with subsection (a) of this section. The commissioner shall notify the board of directors when the examination is completed. The request for an examination shall be kept on file by the commissioner but it shall not be open to public inspection prior to the release of the examination report to the public.
(f) The board of directors may by majority vote make recommendations to the commissioner for the detection and prevention of member insurer insolvencies.
(g) The board of directors shall at the conclusion of any insurer insolvency in which the association was obligated to pay covered claims prepare a report to the commissioner containing information it has in its possession bearing on the history and causes of the insolvency. The board shall cooperate with the boards of directors of guaranty associations in other states in preparing a report on the history and causes of insolvency of a particular insurer and may adopt by reference any report prepared by other associations.
26-42-111. Credits for assessments paid; tax offsets.
(a) A member insurer may offset against its premium tax liability to this state an assessment described in W.S. 26-42-107(k) to the extent of ten percent (10%) of the amount of the assessment for each of the ten (10) calendar years following the year in which the assessment was paid. If a member insurer ceases doing business, all uncredited assessments may be credited against its premium tax liability for the year it ceases doing business.
(b) Any sums which are acquired by refund pursuant to W.S. 26-42-107(h) from the association by member insurers and which have been offset against premium taxes as provided in subsection
(a) of this section, shall be paid by the member insurers to this state as required by the commissioner. The association shall notify the commissioner that the refunds have been made.
26-42-112. Assessment liability; records; assets; proceedings against impaired or insolvent insurer.
(a) This act shall not be construed to reduce the liability for unpaid assessments of the insureds of an impaired or insolvent insurer operating under a plan with assessment liability.
(b) Records shall be kept of all meetings in which the board of directors discuss the activities of the association in carrying out its powers and duties under W.S. 26-42-106. The records of the association with respect to an impaired or insolvent insurer shall not be disclosed prior to the termination of a liquidation, rehabilitation or conservation proceeding involving the impaired or insolvent insurer except upon the termination of the impairment or insolvency of the insurer or upon the order of a court of competent jurisdiction. Nothing in this subsection shall limit the duty of the association to render a report of its activities under W.S. 26-42-113.
(c) For the purpose of carrying out its obligations under this act, the association is deemed to be a creditor of the impaired or insolvent insurer to the extent of assets attributable to covered policies or contracts reduced by any amounts to which the association is entitled as assignee or subrogee pursuant to W.S. 26-42-106(q). Assets of the impaired or insolvent insurer attributable to covered policies or contracts shall be used to continue all covered policies or contracts and pay all contractual obligations of the impaired or insolvent insurer as required by this act. As used in this subsection, "assets attributable to covered policies or contracts" means that proportion of the assets which the reserves that should have been established for such policies or contracts bear to the reserves that should have been established for all policies or contracts of insurance or health benefits plans written by the impaired or insolvent insurer.
(d) Prior to the termination of any liquidation, rehabilitation or conservation proceeding the court may consider the contributions of the respective parties including the association, the shareholders, contract owners, certificate holders, enrollees and policy owners of the insolvent insurer, and any other party with a bona fide interest, in making an equitable distribution of the ownership rights of the insolvent insurer. In such a determination consideration shall be given to the welfare of the owners, contract owners, certificate holders and enrollees of the continuing or successor insurer. No distribution to stockholders, if any, of an impaired or insolvent insurer shall be made until and unless the total amount of valid claims and interest on the claims of the association for funds expended in carrying out its powers and duties under W.S. 26-42-106 with respect to the member insurer have been fully recovered by the association.
(e) If an order for liquidation or rehabilitation of a member insurer domiciled in this state is entered, the receiver appointed under the order shall have a right to recover on behalf of the member insurer from any affiliate that controlled it, the amount of distributions other than stock dividends paid by the member insurer on its capital stock, made at any time during the five (5) years preceding the petition for liquidation or rehabilitation subject to the limitations of subsections (f),
(g) and (h) of this section.
(f) No distribution pursuant to subsection (e) of this section is recoverable if the member insurer shows that when paid the distribution was lawful and reasonable and that the member insurer did not know and could not reasonably have known the distribution might adversely affect the ability of the member insurer to fulfill its contractual obligations.
(g) Any person who was an affiliate that controlled the member insurer at the time the distributions were paid is liable up to the amount of distributions he received. Any person who was an affiliate that controlled the member insurer at the time the distributions were declared is liable up to the amount of distributions he would have received if they had been paid immediately. If two (2) or more persons are liable with respect to the same distributions they are jointly and severally liable.
(h) The maximum amount recoverable under subsections (e) through (g) of this section is the amount needed in excess of all other available assets of the insolvent insurer to pay the contractual obligations of the insolvent insurer.
(j) If any person liable under subsection (g) of this section is insolvent, all its affiliates that controlled it at the time the distribution was paid are jointly and severally liable for any resulting deficiency in the amount recovered from the insolvent affiliate.
(k) As a creditor of the impaired or insolvent insurer as established in subsection (c) of this section, the association and other similar associations shall be entitled to receive a disbursement of assets out of the marshaled assets, from time to time as the assets become available to reimburse it, as a credit against contractual obligations under this act. If the liquidator has not, within one hundred twenty (120) days of a final determination of insolvency of a member insurer by the receivership court, made an application to the court for the approval of a proposal to disburse assets out of marshaled assets to guaranty associations having obligations because of the insolvency, then the association shall be entitled to make application to the receivership court for approval of its own proposal to disburse these assets.
26-42-113. Examination of the association; annual report.
The association is subject to examination and regulation by the commissioner. The board of directors shall submit to the commissioner each year not later than one hundred twenty (120) days after the association's fiscal year, a financial report in a form approved by the commissioner and a report of its activities during the preceding fiscal year.
26-42-115. Stay of proceedings; reopening default judgments.
All proceedings in which the insolvent insurer is a party in any court in this state shall be stayed one hundred eighty (180) days from the date an order of liquidation, rehabilitation or conservation is final to permit proper legal action by the association on any matters germane to its powers or duties. As to judgment under any decision, order, verdict or finding based on default the association may apply to have the judgment set aside by the same court that made the judgment and shall be permitted to defend against the suit on the merits.
26-42-116. Prohibited advertisement of association chapter in insurance sales; notice.
(a) No person including a member insurer, agent or affiliate of an insurer shall make, publish, disseminate, circulate or place before the public, or cause directly or indirectly to be made, published, disseminated, circulated or placed before the public in any newspaper, magazine or other publication, in the form of a notice, circular, pamphlet, letter or poster, over any radio station or television station, or in any other way, any advertisement, announcement or written or oral statement which uses the existence of the association of this state for the purpose of sales, solicitation or inducement to purchase any form of insurance or other coverage covered by this act. This subsection shall not apply to the association or any other entity which does not sell or solicit insurance or health maintenance organization coverage.
(b) Within one hundred eighty (180) days of the effective date of this act, the association shall prepare a summary document describing the general purposes and current limitations of the act and complying with subsection (c) of this section and submit it to the commissioner for approval. Sixty (60) days after receiving approval, no member insurer may deliver a policy or contract described in W.S. 26-42-103(b) to a policy owner, contract owner, certificate holder or enrollee unless the document provided in subsections (b) and (c) of this section is delivered to the policy owner, contract owner, certificate holder or enrollee prior to or at the time of delivery of the policy or contract except if subsection (d) of this section applies. The document shall be available upon request by a policy owner, contract owner, certificate holder or enrollee. The distribution, delivery or contents or interpretation of the document shall not mean that either the policy or the contract or the policy owner, contract owner, certificate holder or enrollee would be covered in the event of impairment or insolvency of a member insurer. The description document shall be revised by the association as required by this act. Failure to receive the document does not give the policy owner, contract owner, certificate holder or enrollee any greater rights than those stated in this act.
(c) The document prepared under subsection (b) of this section shall contain a clear and conspicuous disclaimer on its face. The commissioner shall promulgate a rule establishing the form and content of the disclaimer. The disclaimer shall:
(i) State the name and address of the life and health insurance guaranty association and insurance department;
(ii) Prominently warn the policy owner, contract owner, certificate holder or enrollee that the association may not cover the policy or contract or if coverage is available, it will be subject to substantial limitations and exclusions and conditioned on continued residence in the state;
(iii) State that the member insurer and its agents are prohibited by law from using the existence of the association for the purpose of sales, solicitation or inducement to purchase any form of insurance or health maintenance organization coverage;
(iv) Emphasize that the policy owner, contract owner, certificate holder or enrollee should not rely on coverage under the association when selecting an insurer or health maintenance organization;
(v) Provide other information as directed by the commissioner.
(d) Insurers and agents shall deliver the document and disclaimer described under subsections (b) and (c) of this section when a customer is solicited if a "free look" period is not provided in the policy.
(e) Repealed By Laws 2014, Ch. 21, § 2.
Except as provided by W.S. 26-42-106(r)(ii), 26-42-109(b) and 26-42-112, there shall be no liability on the part of and no cause of action of any nature shall arise against any member insurer or its agents or employees, the association or its agents or employees, members of the board of directors or the commissioner or his representatives, for any action or omission by them in the performance of their powers and duties under this act. Immunity shall extend to the participation in any organization of one (1) or more other state associations of similar purposes and to any such organization and its agents or employees.
(a) Except as provided in subsection (b) of this section, this act shall apply to any member insurer which is placed under an order of liquidation with a finding of insolvency on or after July 1, 2014.
(b) The amendments provided in the 2014 amendments to W.S. 26-24-103(a) and (d) shall not apply to any member insurer placed under an order of liquidation with a finding of insolvency prior to July 1, 2014.
(c) The amendments provided in the 2019 amendments to this act shall not apply to any member insurer placed under an order of liquidation with a finding of insolvency prior to July 1, 2019.
(a) As used in this act:
(i) "Account" means the account provided by W.S. 26-43-112;
(ii) "Administrator" means the insurer, insurers or third party administrator or administrators selected pursuant to W.S. 26-43-104(a) to administer the pool;
(iii) "Board" means the board of directors of the pool;
(iv) "Commissioner" means the insurance commissioner;
(v) "Department" means the insurance department;
(vi) "Health insurance" means any public health benefit plan, private health benefit plan, hospital and medical expense incurred policy, Medicare supplement policy, nonprofit health care service plan contract and health maintenance organization subscriber contract. The term does not include any hospital or medical service plan which by contract or product design is intended to provide coverage for six (6) months or less, fixed indemnity, limited benefit or credit insurance, coverage issued as a supplement to liability insurance, insurance arising from a workers' compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance;
(vii) "Health maintenance organization" means as defined by W.S. 26-34-102;
(viii) "Hospital" means a facility licensed as a hospital by the department of health;
(ix) "Insurance arrangement" means any plan, program, contract or any other arrangement under which one (1) or more employers, unions or other organizations provide to their employees or members, either directly or indirectly through a trust or third party administrator, health care services or benefits other than through an insurer. For purposes of assessments under this act "insurance arrangement" does not include any plan, program, contract or other arrangement under which the state of Wyoming, its political subdivisions or school districts provide health care services or benefits pursuant to the authority granted under W.S. 9-3-201;
(x) "Insured" means any individual resident of this state who is eligible to receive benefits from any insurer or insurance arrangement;
(xi) "Insurer" means any insurance company authorized to transact disability insurance business in this state, Medicare supplement insurance issuer, health maintenance organization or health service plan operation under W.S. 26-22-301;
(xii) "Medicare" means coverage under both Part A and B of Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq.;
(xiii) "Member" means all insurers and insurance arrangements participating in the pool;
(xiv) "Plan of operation" means the plan of operation of the pool, including articles, bylaws and operating rules adopted by the board pursuant to W.S. 26-43-102;
(xv) "Pool" means the Wyoming health insurance pool created by W.S. 26-43-102;
(xvi) Repealed by Laws 2019, ch. 16, § 2.
(xvii) "Creditable coverage" means, with respect to an individual, coverage of the individual provided under any private health benefit plan or public health benefit plan;
(xviii) "Federally defined eligible individual" means an individual:
(A) For whom, as of the date on which the individual seeks coverage under this act, the aggregate of the periods of creditable coverage, is eighteen (18) or more months;
(B) Whose most recent prior creditable coverage was under a group private or public health benefit plan;
(C) Who is not eligible for coverage under a group health plan, part A or part B of Medicare or Medicaid, and who does not have other health insurance coverage;
(D) With respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud;
(E) Who, if offered the option of continuation coverage under a COBRA continuation provision or under a similar state program, elected such coverage; and
(F) Who has exhausted such continuation coverage under such provision or program, if the individual elected the continuation coverage described in subparagraph (E) of this paragraph.
(xix) "Eligibility level" means a percentage of the federal poverty guideline for level of coverage under the plan of operation;
(xx) "This act" means W.S. 26-43-101 through 26-43-114.
26-43-102. Operation of the pool; board membership; board powers and duties.
(a) There is created a nonprofit entity known as the Wyoming health insurance pool. All insurers issuing health insurance in this state and to the extent not preempted by federal law, insurance arrangements providing health plan benefits in this state on and after July 1, 1990, are members of the pool. The commissioner shall give notice to all member insurers and insurance arrangements of the time and place for the initial meeting of the board appointed pursuant to W.S. 26-43-102(b).
(b) The board shall consist of seven (7) members including the commissioner or his designated representative. The commissioner shall appoint three (3) members from participating insurers and three (3) members from the general public. Terms of office for the appointed board members are four (4) years except initial terms shall be less than four (4) years and staggered as determined by the commissioner. The commissioner shall establish procedures for filling vacancies on the board.
(c) Members of the board shall serve without compensation but shall receive travel expenses and per diem from pool funds in the same manner and amount as state employees for services incurred for the board.
(d) The board shall:
(i) Select an administrator of the pool;
(ii) Submit to the commissioner a plan of operation for the pool and any amendments to the plan necessary or suitable to assure the fair, reasonable and equitable administration of the pool. The commissioner shall approve the plan of operation after notice and hearing provided the plan is determined suitable to assure the fair, reasonable and equitable administration of the pool and provides for the sharing of pool gains or losses on an equitable proportionate basis. The plan of operation is effective upon approval in writing by the commissioner. If the board at any time thereafter fails to submit suitable amendments to the plan, the commissioner shall adopt reasonable rules after notice and hearing as necessary or advisable to effectuate the provisions of this section. The rules shall continue in force until modified by the commissioner or superseded by a plan submitted by the board and approved by the commissioner;
(iii) Have the general powers and authority granted under the laws of this state to insurance companies licensed to transact health insurance;
(iv) Establish for each eligibility level appropriate rates, rate schedules, rate adjustments, expense allowances, agents' referral fees, claim reserve formulas and any other actuarial functions appropriate to the operation of the pool. Rates and rate schedules may be adjusted for appropriate risk factors such as age and area variation in claim cost and shall take into consideration appropriate risk factors in accordance with established actuarial and underwriting practices;
(v) Assess members of the pool in accordance with the provisions of this act;
(vi) Issue policies of insurance in accordance with the requirements of this act;
(vii) Repealed by Laws 2019, ch. 16, § 2.
(e) The plan of operation provided by paragraph (d)(ii) of this section shall:
(i) Establish procedures for the handling, investing and accounting of assets and monies of the pool;
(ii) Identify the administrator in accordance with W.S. 26-43-104;
(iii) Establish procedures for the collection of assessments to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessments are made;
(iv) Establish the level of assessment payments pursuant to W.S. 26-43-105;
(v) Develop and implement a program to publicize and to maintain public awareness of the existence of the plan, the eligibility requirements and procedures for enrollment;
(vi) Establish procedures for termination of pool coverage of any person who ceases to meet the eligibility requirements provided by W.S. 26-43-103;
(vii) Provide as necessary for audits of the pool and the administration of the pool;
(viii) Allow every insurance agent licensed to sell insurance in Wyoming to sell the policy.
(f) The board may:
(i) Enter into contracts as necessary or proper to carry out the provisions and purposes of this act, including but not limited to the authority, with the approval of the insurance commissioner, to enter into contracts with similar pools of other states for the joint performance of common administrative functions or with persons or other organizations for the performance of administrative functions;
(ii) Sue or be sued, including but not limited to taking any legal actions necessary or proper for recovery of any assessments for, on behalf of, or against pool members;
(iii) Take legal action as necessary to avoid the payment of improper claims against the pool or the coverage provided by or through the pool;
(iv) Appoint from among members appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the pool, policy and other contract design and any other function within the authority of the board;
(v) Repealed by Laws 2019, ch. 16, § 2.
(a) Except as provided in subsections (b) and (e) of this section, any individual person who is a resident of this state is eligible for pool coverage under eligibility level one (1) or eligibility level two (2) if evidence of the following is provided:
(i) Rejection of or refusal to issue health insurance for health reasons by one insurer;
(ii) Refusal to issue health insurance except at a rate exceeding the applicable pool rate for the coverage applied for under the pool; or
(iii) Refusal to issue health insurance except with a reduction or exclusion of coverage for a preexisting health condition which reduction or exclusion is more restrictive than the reduction or exclusion provided by the applicable pool coverage for which application is being made.
(b) The following persons are not eligible for pool coverage:
(i) Persons who have coverage under health insurance or an insurance arrangement on the issue date of pool coverage;
(ii) Any person who is at the time of pool application eligible for Medicaid health care benefits or any person who is eligible for Medicare by reason of age;
(iii) Any person who terminated coverage in the pool unless twelve (12) months have elapsed from the termination date;
(iv) Any person on whose behalf the pool has paid two hundred fifty thousand dollars ($250,000.00) in benefits. The board shall adjust these amounts annually to reflect the effects of inflation. 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 statistics, unless the board proposes and the commissioner approves a lower adjustment factor;
(v) Inmates of public institutions;
(vi) Persons who are eligible for group health insurance or a group health insurance arrangement provided in connection with a policy, plan or program sponsored by an employer and subject to regulation as a group health plan under federal or state law, even though the employer coverage is declined, unless:
(A) The cost to insure the individual is offered at a rate to the individual or his employed family member exceeding the applicable pool rate by at least twelve and one-half percent (12.5%) for the coverage applied for under the pool; and
(B) At the time of enrollment, plan enrollment does not exceed ninety-five percent (95%) of maximum enrollment capacity as determined under W.S. 26-43-114.
(c) Repealed by Laws 2019, ch. 16, § 2.
(d) For purposes of catastrophic health insurance pursuant to W.S. 26-43-106(b)(vi), in addition to the requirements of subsection (a) of this section, eligibility shall be limited to those individuals whose total household income does not exceed four hundred percent (400%) of the federal poverty level.
(e) Notwithstanding subsection (a) of this section, the commissioner shall have authority to terminate eligibility and disenroll from coverage under the pool some or all of the individuals who are enrolled in the plan as of July 1, 2015, subject to the following:
(i) The commissioner has determined that all individuals or groups of individuals who are to be disenrolled have reasonable access to health insurance;
(ii) All individuals who are to be disenrolled shall receive prior notice of disenrollment at least ninety (90) days prior to the effective date of the disenrollment;
(iii) The commissioner shall have authority to reenroll any individual or group who were disenrolled pursuant to this subsection if it is demonstrated that the individual or group cannot otherwise be insured at reasonable expense.
(a) The board shall select an insurer, insurers or a third party administrator or administrators through a competitive bidding process to administer the pool. The board shall evaluate bids based on criteria established by the board which shall include but are not limited to:
(i) The proven ability of the administrator to handle individual accident and health insurance;
(ii) The efficiency of the claim paying procedures of the administrator;
(iii) An estimate of total charges for administering the plan;
(iv) The ability of the administrator to administer the pool in a cost efficient manner.
(b) The administrator shall serve for a period determined by the board of not less than three (3) years and not more than five (5) years and is subject to removal for cause. At least one (1) year prior to the expiration of the period of service by an administrator, the board shall invite all insurers, including the current administrator to submit bids to serve as the administrator for the succeeding period. Selection of the administrator for the succeeding period shall be made at least six (6) months prior to the end of the current period.
(c) The administrator shall:
(i) Perform all eligibility and administrative claims payment functions relating to the pool;
(ii) Establish a premium billing procedure for collection of premiums from insureds. Billings shall be made periodically as determined by the board;
(iii) Perform all necessary functions to assure timely payment of benefits to covered persons under the pool including but not limited to:
(A) Making available information relating to the proper manner of submitting a claim for benefits to the pool and distributing forms upon which submission is made;
(B) Evaluating the eligibility of each claim for payment by the pool.
(iv) Submit regular reports to the board regarding the pool operation. The board shall determine the frequency, content and form of the report;
(v) Determine net written and earned premiums, the expense of administration and the paid and incurred losses for the year and report the information to the board and the department on a form and in the manner prescribed by the commissioner;
(vi) Receive payment as provided in the plan of operation for its expenses incurred in the performance of its services.
(a) After each calendar year, the administrator shall determine the pool net premiums which are premiums less administrative expense allowances, the pool administrative expenses and the pool incurred losses for the calendar year considering investment income and other appropriate gains and losses.
(b) Each insurer's assessment shall be determined by multiplying the total cost of pool operation by a fraction the numerator of which equals the insurer's premium and subscriber contract charges for health insurance written in the state during the preceding calendar year and the denominator of which equals the total of all premiums, subscriber contract charges written in the state and to the extent not preempted by federal law, one hundred ten percent (110%) of all claims paid by insurance arrangements in the state during the preceding calendar year. To the extent not preempted by federal law, each insurance arrangement's assessment shall be determined by multiplying the total cost of pool operation by a fraction the numerator of which equals one hundred ten percent (110%) of the benefits paid by the insurance arrangement on behalf of insureds in this state during the preceding calendar year and the denominator of which equals the total of all premiums, subscriber contract charges and one hundred ten percent (110%) of all benefits paid by insurance arrangements made on behalf of insureds in the state during the preceding calendar year. Health insurance premiums and benefits paid by an insurance arrangement that are less than an amount determined by the board to justify the cost of collection shall not be considered for purposes of determining assessments. To the extent not preempted by federal law, insurance arrangements shall report to the board on an annual basis on a form prescribed by the commissioner. Members shall file with the board annual reports and other reports deemed necessary by the board to determine each member's proportion of participation.
(c) On or before March 1 of each year, the board shall determine each member's proportion of participation in the pool for the calendar year based on annual statements and other reports deemed necessary by the board and filed by the member with the board. Any deficit incurred by the pool shall be recouped by assessments apportioned under subsection (b) of this section by the board among members. Notification of assessments shall be mailed by the board not later than March 1 of each year. Assessments are due and payable within thirty (30) days after receipt of the assessment notice.
(d) For the total amount of assessments due from all members in any one (1) calendar year pursuant to this section up to four million dollars ($4,000,000.00), eighty percent (80%) of each member's proportionate contribution to the first two million dollars ($2,000,000.00) and fifty percent (50%) of the next two million dollars ($2,000,000.00) shall be allowed as a credit against any premium tax owed by the member under this code in the year for which the assessment is payable. The board shall not make a total assessment against all members of more than six million dollars ($6,000,000.00) in any one (1) fiscal year. Assessments received shall be used to defray the total cost of level one (1) pool operations first. Assessment amounts not required to support level one (1) pool operations will be used to support level two (2) operations before any general fund appropriation is used. The general fund appropriation shall only be used to support level two (2) operations. The board shall ensure that all expenses directly attributable to level one (1) individuals are paid from premiums, assessments and any withdrawals from previous reserves.
(e) The board may abate or defer, in whole or in part, the assessment of a member if, in the opinion of the board, payment of the assessment would endanger the ability of the member to fulfill its contractual obligations. In the event an assessment against a member is abated or deferred in whole or in part, the amount by which the assessment is abated or deferred may be assessed against the other members in a manner consistent with the basis for assessments set forth in subsection (b) of this section. The member receiving an abatement or deferment shall remain liable to the pool for the deficiency for four (4) years.
(f) If assessments exceed actual losses and administrative expenses of the pool, the excess shall be paid to the state treasurer, credited to the account and used by the board to offset future losses or to reduce pool premiums. As used in this subsection, "future losses" includes reserves for incurred but unreported claims.
(g) The board may require initial and interim assessments as reasonable and necessary for the organizational, administrative and interim operating expenses and to pay claims in excess of premiums collected. Any initial or interim assessments shall be credited as offsets against any regular assessments due following the close of the calendar year.
(h) Assessments collected pursuant to this act shall be paid to the state treasurer and credited to the account.
(a) Pool coverage shall be offered to eligible persons subject to the termination and disenrollment provisions of W.S 26-43-103(e). The commissioner shall establish by rule and regulation the pool coverage, its schedule of benefits, exclusions and other limitations consistent with this act and taking into consideration the advice and recommendations of the board. The commissioner and the board annually shall review the pool coverage, its schedule of benefits, exclusions and limitations and make changes to reflect the levels of health insurance coverage provided in this state.
(b) In establishing the pool coverage, the commissioner shall:
(i) Consider the levels of health insurance provided in the state, medical economic factors deemed appropriate and the advice and recommendations of the board;
(ii) Promulgate benefit levels, deductibles, coinsurance factors, exclusions and limitations determined to be generally reflective of and commensurate with health insurance plans marketed in the state and required by this act. The commissioner shall offer at least two (2) plans that may include a higher deductible option or a health savings account option in order to provide less expensive coverage alternatives for pool participants;
(iii) Repealed by Laws 2005, ch. 57, § 2.
(iv) Repealed By Laws 2005, ch. 57, § 2.
(v) Design and employ cost containment measures and controls which may include but are not limited to, preadmission certification, concurrent inpatient review, case management, utilization reviews, exclusions or limitations concerning treatment and services, and member deductibles;
(vi) Offer for those individuals described in W.S. 26-43-103(d) a catastrophic health plan having a deductible level of twenty-five thousand dollars ($25,000.00), subject to the termination and disenrollment provisions of W.S. 26-43-103(e).
(c) Pool coverage shall not include medical costs associated with:
(i) Repealed by Laws 2019, ch. 16, § 2.
(ii) Cosmetic surgery;
(iii) Other procedures as determined by the board.
(d) Repealed by Laws 2019, ch. 16, § 2.