The national Medical Plans guide covers plan types (indemnity, HMO, PPO, POS, HDHP with HSA), cost sharing and the federal ACA rules. This guide covers the Wyoming rules: HMOs, mandated coverage for children and diabetes, the ban on discretionary clauses, accident and sickness advertising, and Wyoming's public programs for children and hard-to-insure residents.

HMOs (Wyo. Stat. 26-34)

• An HMO provides or arranges basic health care services on a prepaid basis, apart from copays, coinsurance and deductibles. Dental-only and vision-only plans aren't HMOs.
• Basic health care services are emergency care, inpatient hospital and physician care, and outpatient medical services. They don't include mental health or substance abuse services.
• Each enrollee gets an evidence of coverage: the certificate or contract describing the coverage.
• An individual HMO contract has a 10-day right to examine and return it. The premium is refunded, less the cost of any services received (26-34-109(b)).
• HMOs give subscribers a provider list at enrollment and re-enrollment. An HMO notifies an enrollee in writing when their primary care provider leaves the network and helps them move to another one.

Coverage for children

• Newborns are covered automatically from birth, including congenital defects and birth abnormalities (26-20-101, -102).
• Adopted children are covered from the earlier of the filing of the adoption petition or the child's entry into the home, including conditions that existed before placement. For children in state custody, coverage starts at the final decree.
• A child can't be denied coverage because they were born out of wedlock, aren't claimed as a tax dependent, or don't live with the parent (26-15-135).
• When parents share custody, either parent may submit claims, and the insurer pays the parent who paid for the care. A child under a court order may be enrolled outside the enrollment season.
• A family policy may cover children up to a stated age of no more than 19 (26-18-103).
• A child who is incapacitated and chiefly dependent stays covered past the limiting age if proof is given within 31 days of reaching it (26-22-401).

Other mandates and contract rules

• Diabetes: coverage includes a one-time education session within a year of diagnosis, plus training after a significant change, up to three hours a year. It applies to insulin-dependent, non-insulin-dependent and gestational diabetes, with the plan's normal cost sharing (26-20-201).
• Discretionary clauses, which let a carrier interpret the contract in its own favor, are prohibited. ERISA plans may use one if they disclose the required de novo review (26-13-304).

Advertising accident and sickness coverage (Rule Ch. 21)

• An ad can't call a product a "plan" without clearly identifying it as an accident and sickness insurance policy.
• Words like "all," "full," "complete," "comprehensive" or "unlimited" can't exaggerate the benefits.
• Phrases like "no red tape" are banned.
• Testimonials must be genuine and current. One used more than a year after it was given needs written reconfirmation. A paid or financially interested spokesperson must be disclosed.

Public programs

• Children's health insurance (Wyo. Stat. 35-25) serves children under 19 with family income no more than 200% of the federal poverty level.
  • The child can't be eligible for Medicaid and must have been without other health coverage for at least one month.
  • Eligibility lasts 12 months and is redetermined each year.
  • Benefits include hospital, physician, well-child, prescription, vision and dental care.
• Health insurance pool (Wyo. Stat. 26-43):
  • Eligibility is shown by a health-based rejection, or by an offer only at higher rates or with restrictive exclusions.
  • People with other coverage, or eligible for Medicaid or for Medicare by age, aren't eligible.

Common exam traps

• An individual HMO contract has a 10-day free look, less the cost of services used.
• HMO basic services don't include mental health or substance abuse services.
• Adopted children are covered from the petition or placement, whichever is first.
• A family policy may cover children up to age 19. Proof for an incapacitated child is due within 31 days.
• Discretionary clauses are banned.
• The children's program covers families up to 200% of the poverty level and children under 19.