26-19-302. Definitions.

(a) As used in this act:

(i) "Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with the provisions of W.S. 26-19-304, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the small employer carrier in establishing premium rates for applicable health benefit plans;

(ii) "Base premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business, by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage;

(iii) "Basic health benefit plan" means a low cost health benefit plan developed pursuant to W.S. 26-19-308;

(iv) "Board" means the board of directors of the program;

(v) "Carrier" means any person who provides any health benefit plan in this state subject to state insurance regulation and includes, but is not limited to, an insurance company, a fraternal benefit society, a prepaid hospital or medical care plan, a health maintenance organization and a multiple employer welfare arrangement. For purposes of this act, companies that are affiliated companies or that are eligible to file a consolidated tax return shall be treated as one (1) carrier except that any insurance company, health service corporation, hospital service corporation or medical service corporation that is an affiliate of a health maintenance organization located in this state, or any health maintenance organization located in this state which is an affiliate of an insurance company, health service corporation, hospital service corporation or medical service corporation may treat the health maintenance organization as a separate carrier and each health maintenance organization that operates only one (1) health maintenance organization in an established geographic service area of this state may be considered a separate carrier;

(vi) "Case characteristics" means demographic or other objective characteristics of a small employer, as determined by a small employer carrier, that are considered by the small employer carrier in the determination of premium rates for the small employer, provided, however, that claim experience, health status and duration of coverage since issue are not case characteristics for the purposes of this act;

(vii) "Class of business" means all of a distinct grouping of small employers as shown on the records of the small employer carrier, and provided:

(A) A distinct grouping may only be established by the small employer carrier on the basis that the applicable health benefit plans:

(I) Are marketed and sold through individuals and organizations which are not participating in the marketing or sale of other distinct groupings of small employers for such small employer carrier;

(II) Have been acquired from another small employer carrier as a distinct grouping of plans; or

(III) Are provided through an association with membership of not less than two (2) small employers.

(B) A small employer carrier may establish no more than two (2) additional groupings under each subdivision (I) through (III) of subparagraph (A) of this paragraph on the basis of underwriting criteria which are expected to produce substantial variation in the health care costs;

(C) The commissioner may approve the establishment of additional distinct groupings upon application to the commissioner and a finding by the commissioner that such action would enhance the efficiency and fairness of the small employer marketplace.

(viii) Repealed by Laws 1995, ch. 94, § 3.

(ix) "Dependent" means:

(A) A spouse or unmarried child under the age of nineteen (19) years;

(B) An unmarried child who is a full-time student under the age of twenty-three (23);

(C) A child of any age who is disabled and dependent upon the parent;

(D) Any other individual defined to be a dependent in the health benefit plan covering the employee.

(x) "Eligible employee" means an employee who works on a full-time basis, with a normal work week of thirty (30) or more hours and has met any applicable waiting period requirements. The term includes a sole proprietor, a partner of a partnership or an independent contractor, if the sole proprietor, partner or independent contractor is included as an employee under a health benefit plan of a small employer, but does not include employees who work on a part-time, temporary, seasonal or substitute basis;

(xi) "Established geographic service area" means a geographical area approved by the commissioner in conjunction with the carrier's certificate of authority to transact insurance in this state, within which the carrier is authorized to provide coverage;

(xii) "Health benefit plan" means any hospital or medical policy or certificate, major medical expense insurance, hospital or medical service plan contract or health maintenance organization subscriber contract. "Health benefit plan" does not include accident-only, credit, dental, vision, Medicare supplement, long-term care or disability income insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance or automobile medical-payment insurance, nor does it include policies or certificates of specified disease, hospital confinement indemnity or limited benefit health insurance if the carrier offering the policies or certificates certifies to the commissioner that policies or certificates described in this paragraph are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance or major medical expense insurance;

(xiii) Repealed by Laws 1993, ch. 83, § 2.

(xiv) "Index rate" means, for each class of business as to a rating period for small employers with similar case characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate;

(xv) "Late enrollee" means an eligible employee or dependent who requests enrollment in a health benefit plan of a small employer following the initial enrollment period provided under the terms of the health benefit plan, provided that the initial enrollment period shall be a period of at least thirty (30) days. An eligible employee or dependent shall not be considered a late enrollee if:

(A) The individual:

(I) Was covered under a public or private health insurance or other health benefit arrangement at the time the individual was eligible to enroll;

(II) Has lost coverage under a public or private health insurance or other health benefit arrangement as a result of termination of employment or eligibility, the termination of the other plan's coverage, death of a spouse, divorce, legal separation or termination of employer contribution; and

(III) Requests enrollment within thirty (30) days after termination of coverage provided under a public or private health insurance or other health benefit arrangement.

(B) The individual is employed by an employer which offers multiple health benefit plans and the individual elects a different plan during an open enrollment period; or

(C) A court has ordered coverage be provided for a spouse or minor child under a covered employee's health benefit plan and request for enrollment is made within thirty (30) days after issuance of the court order.

(xvi) "New business premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or offered, or which could have been charged or offered, by the small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage;

(xvii) "Participating carrier" means all small employer carriers issuing health benefit plans in this state. "Participating carrier" shall also include any carrier that maintains an existing health benefit plan covering eligible employees of one (1) or more small employers;

(xviii) "Plan of operation" means the plan of operation of the program, including articles, bylaws and operating rules adopted by the board pursuant to W.S. 26-19-307;

(xix) "Preexisting condition provision" means a policy provision that excludes coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage, as to a condition which, during a specified period immediately preceding the effective date of coverage, medical advice, diagnosis, care or treatment was recommended or received;

(xx) "Program" means the Wyoming small employer health reinsurance program created by W.S. 26-19-307;

(xxi) "Rating period" means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier;

(xxii) "Small employer" means any person, firm, corporation, partnership or association who is actively engaged in business who, on at least fifty percent (50%) of its working days during the preceding calendar quarter, employed at least two (2) but no more than fifty (50) eligible employees, the majority of whom were employed within this state or were residents of Wyoming. In determining the number of eligible employees, companies which are affiliated companies, or which are eligible to file a combined tax return for purposes of any state taxation, shall be considered one (1) employer;

(xxiii) "Small employer carrier" means any carrier that offers health benefit plans covering eligible employees of one (1) or more small employers;

(xxiv) "Standard health benefit plan" means a health benefit plan developed pursuant to W.S. 26-19-308;

(xxv) "Taft-Hartley trust" means a trust formed pursuant to a collective bargaining agreement under the federal Labor Management Relations Act of 1947;

(xxvi) "Affiliation period" means a period which, under the terms of the health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective. The health maintenance organization is not required to provide health care services or benefits during an affiliation period and no premiums shall be charged to the participant or beneficiary for any coverage during the period;

(xxvii) "Provider network" means health insurance coverage offered by a health insurance issuer under which the financing and delivery of medical care, including items and services paid for as medical care, is provided in whole or in part, through a defined set of providers under contract with the issuer;

(xxviii) "This act" means W.S. 26-19-301 through 26-19-310.