2020 Wyoming Statutes
Title 26 - Insurance Code
Chapter 19 - Group and Blanket Disability Insurance
Article 3 - Small Employer Health Insurance Availability
Section 26-19-306 - Availability of Coverage.

26-19-306. Availability of coverage.

(a) Within one hundred eighty (180) days after the commissioner's approval of the basic health benefit plan and the standard health benefit plan developed pursuant to W.S. 26-19-308, but in no case prior to March 31, 1993, every small employer carrier shall, as a condition of transacting business in this state with small employers, actively offer to small employers all health benefit plans which it actively markets to small employers in this state, including at least two (2) health benefit plans. One (1) plan to be offered by each small employer carrier shall be a basic health benefit plan and one (1) plan shall be a standard health benefit plan. Except as provided in this section, all small employer carriers shall issue any health benefit plan to any eligible small employer that applies for the plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the plan. Carriers or multiple employer welfare associations whose bylaws or charters do not permit them to issue coverage on a marketwide basis shall only be required to guarantee issue to those small employers which meet the requirements of the bylaws or charters. Charter or bylaw provisions which prohibit issuance to specific populations based on health status or health risk shall not be considered as exceptions to the requirements of this subsection.

(b) A small employer carrier shall file with the commissioner, in a format and manner prescribed by the commissioner, the basic health benefit plan and the standard health benefit plan to be used by the carrier. A plan filed pursuant to this section may be used by a small employer carrier beginning forty-five (45) days after it is filed unless the commissioner disapproves its use. The commissioner at any time may, after providing notice and an opportunity for a hearing to the small employer carrier, disapprove the continued use by a small employer carrier of a basic or standard health benefit plan on the grounds that the plan does not meet the requirements of this section.

(c) All health benefit plans covering small employers shall comply with the following provisions:

(i) Preexisting condition provisions shall not exclude coverage for a period beyond twelve (12) months following the individual's effective date of coverage and shall only relate to conditions for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the effective date of coverage. Pregnancy shall not be treated as a preexisting condition. Genetic information shall not be treated as a preexisting condition in the absence of a diagnosis of a condition related to such information;

(ii) In determining whether a preexisting condition provision applies to an eligible employee or dependent, all health benefit plans shall credit the time the person was previously covered by public or private health insurance or other health benefit arrangement if the previous coverage was continuous to a date not more than ninety (90) days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan;

(iii) Late enrollees may be excluded from coverage for the greater of eighteen (18) months or an eighteen (18) month preexisting condition exclusion, provided that if both a period of exclusion from coverage and a preexisting condition exclusion are applicable to a late enrollee, the combined period shall not exceed eighteen (18) months;

(iv) Any requirement used by a small employer carrier in determining whether to provide coverage to a small employer group, including requirements for minimum participation of eligible employees and minimum employer contributions, shall be applied uniformly among all small employer groups with the same number of eligible employees applying for coverage or receiving coverage from the small employer carrier. A small employer carrier may vary application of minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group;

(v) In applying minimum participation requirements with respect to a small employer, a small employer carrier shall not consider employees or dependents who are otherwise covered by a public or an employment based health benefit plan in determining whether the applicable percentage of participation is met;

(vi) If a small employer carrier offers coverage to a small employer, it shall offer coverage to all of the small employer's eligible employees and may offer coverage to their dependents. A small employer carrier shall not offer coverage to only certain persons in a group or to only part of a group, except in the case of late enrollees as provided in paragraph (iii) of this subsection. Except as permitted under paragraphs (i) and (iii) of this subsection, a small employer carrier shall not modify a health benefit plan with respect to a small employer or any eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage or benefits for specified diseases, medical conditions or services otherwise covered by the plan;

(vii) In the case of a group health plan that offers medical care through health insurance coverage offered by a health maintenance organization, the plan may provide for an affiliation period with respect to coverage through the health maintenance organization only if:

(A) No preexisting condition exclusion is imposed with respect to such coverage;

(B) The affiliation period is applied uniformly without regard to any health status related factors; and

(C) The affiliation period does not exceed two (2) months, or three (3) months in the case of a late enrollee.

(d) No small employer carrier shall be required to offer coverage or accept applications pursuant to subsection (a) of this section in the case of the following:

(i) To a small employer, where the small employer is not physically located in the small employer carrier's established geographic service area;

(ii) To an employer whose employees do not work or reside within the small employer carrier's established geographic service area; or

(iii) Within an area where the small employer carrier reasonably anticipates, and demonstrates to the satisfaction of the commissioner, that it will not have the capacity within its established geographic service area to deliver service adequately to the members of such groups because of its obligations to existing group contract holders and enrollees.

(e) A small employer carrier that cannot offer coverage pursuant to paragraph (d)(iii) of this section shall not offer coverage in the applicable area to new cases of employer groups with more than fifty (50) eligible employees or small employer groups until the later of one hundred eighty (180) days following each such refusal or the date on which the carrier notifies the commissioner that it has regained capacity to deliver services to small employer groups.

(f) If any carrier has insured a disproportionate number of small employer groups with employees requiring reinsurance, the carrier may petition the commissioner to temporarily suspend the requirement to accept every small employer applying for coverage. The suspension may be granted only if the commissioner finds:

(i) The carrier is reasonably reinsuring lives at a rate of at least one hundred thirty percent (130%) of the statewide average for reinsurance; and

(ii) The rate of reinsurance is having a significant disproportional adverse effect on the carrier that is impairing its ability to offer policies at competitive rates in the small group market.

(g) A small employer carrier shall not be required to offer coverage or accept applications pursuant to subsection (a) of this section for so long as the commissioner finds that the acceptance of an application or applications would place the small employer carrier in a financially impaired condition.

(h) The requirements of subsections (a) and (b) of this section shall not apply to any carrier which maintains existing health benefit plans covering eligible employees of one (1) or more small employers but is no longer enrolling new small employers.

(j) In addition to the prohibition on the use of genetic testing information provided in paragraph (c)(i) of this section, all health benefit plans covering small employers shall not, based on the genetic testing information of an individual or a family member of an individual:

(i) Establish rules of eligibility to enroll in the plan;

(ii) Deny eligibility;

(iii) Adjust premium rates;

(iv) Adjust contribution rates;

(v) Request or require predictive genetic testing information concerning an individual or a family member of the individual, except the health benefit plan may only request, but not require, predictive genetic testing information if needed for diagnosis, treatment or payment. As part of a request under this paragraph, the plan or issuer shall provide a description of the procedures in place to safeguard confidentiality of the information.