26-34-109. Requirements for group contract, individual contract, evidence of coverage and premiums for health care services.

(a) Every group and individual contract holder is entitled to a group or individual contract. The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by W.S. 26-34-117(a). The contract shall contain a clear statement of the following:

(i) Name and address of the health maintenance organization;

(ii) Eligibility requirements;

(iii) Benefits and services within the service area;

(iv) Emergency care benefits and services;

(v) Out of area benefits and services, if any;

(vi) Copayments, coinsurance, deductibles or other out-of-pocket expenses;

(vii) Limitations and exclusions, including an explanation of any prescription drug benefits not provided for under a specified health plan;

(viii) Enrollee termination;

(ix) Enrollee reinstatement, if any;

(x) Claims procedures;

(xi) Enrollee complaint procedures;

(xii) Continuation of coverage;

(xiii) Conversion;

(xiv) Extension of benefits, if any;

(xv) Coordination of benefits, if applicable;

(xvi) Subrogation, if any;

(xvii) Description of the service area;

(xviii) Entire contract provision;

(xix) Term of coverage;

(xx) Cancellation of group or individual contract holder;

(xxi) Renewal;

(xxii) Reinstatement of group or individual contract holder, if any;

(xxiii) Grace period as provided in W.S. 26-18-107;

(xxiv) Conformity with state law; and

(xxv) Any withholding agreement pertaining to health care delivery services which requires reimbursement to the provider at a later date dependent upon decisions regarding coverage. The agreement shall specify the requirements in detail. If the existence of a withholding agreement has been disclosed in the contract, the health maintenance organization may alter the terms of the agreement without being deemed to alter the terms of the contract provided the contract holder is notified in detail of the new terms of the agreement at his next renewal.

(b) In addition to those provisions required in subsection (a) of this section, an individual contract shall provide for a ten (10) day period to examine and return the contract and have the premium refunded. If services were received during the ten (10) day period, and the person returns the contract to receive a refund of the premium paid, he shall pay for the services.

(c) Each enrollee residing in this state shall receive an evidence of coverage from the group contract holder or the health maintenance organization. The evidence of coverage shall not contain provisions or statements which are unfair, unjust, inequitable, misleading, deceptive or which encourage misrepresentation as defined by W.S. 26-34-117(a). The evidence of coverage shall contain:

(i) A clear statement of the provisions required in paragraphs (a)(i) through (xvii) of this section; and

(ii) A provision that any subsequent material change shall be evidenced in a separate document issued to the enrollee.

(d) No group or individual contract, evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state:

(i) Until a copy of the form of the contract, evidence of coverage, or amendment thereto, has been filed with and approved by the commissioner.

(e) Every form required by this section shall be filed with the commissioner not less than forty-five (45) days prior to delivery or issue for delivery in this state. At any time during the initial forty-five (45) day period, the commissioner may extend the period for review for an additional forty-five (45) days. Notice of an extension shall be in writing. At the end of the review period, the form is deemed approved if the commissioner has taken no action. The filer shall notify the commissioner in writing prior to using a form that is deemed approved.

(f) At any time, after thirty (30) days notice and for cause shown, the commissioner may withdraw approval of any form, effective at the end of thirty (30) days.

(g) When a filing is disapproved or approval of a form is withdrawn, the commissioner shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within thirty (30) days of receipt of the notice the health maintenance organization may request a hearing. A hearing shall be conducted within thirty (30) days after the commissioner has received the request for hearing.

(h) The commissioner may adopt regulations establishing readability standards for individual contract, group contract, and evidence of coverage forms.

(j) No schedule of premiums or methodology for determining a schedule of premiums for enrollee coverage for health care services, or amendment thereto, may be used until a copy of that schedule, or amendment thereto, has been filed with and approved by the commissioner.

(k) Premiums or methodology for determining a schedule of premiums shall be established in accordance with actuarial principles for various categories of enrollees, provided that premiums applicable to an enrollee may not be individually determined based on the status of his health. However, the premiums shall not be excessive, inadequate or unfairly discriminatory. A certification, by a qualified actuary or other qualified person acceptable to the commissioner, to the appropriateness of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.

(m) The commissioner, within a reasonable period, shall approve any form if the requirements of subsections (a) through (g) of this section are met and any schedule of premiums if the requirements of subsections (j) and (k) of this section are met. It is unlawful to issue a form or to use the schedule of premiums until approved or deemed approved.

(n) The commissioner may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.