2023 Wyoming Statutes › Title 26 - Insurance Code › Chapter 34 - Health Maintenance Organizations › Section 26-34-102 - Definitions.

26-34-102. Definitions.
(a) As used in this chapter:
(i) "Administrator" means the director of the department of health;
(ii) "Basic health care services" means emergency care, inpatient hospital and physician care, and outpatient medical services, but does not include mental health services or services for alcohol or drug abuse;
(iii) "Capitated basis" means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided. For purposes of this definition, "capitated basis" includes the cost associated with operating staff model facilities;
(iv) "Carrier" means a health maintenance organization, an insurer, a hospital and medical service corporation or other entity responsible for the payment of benefits or the provision of services under a group contract;
(v) "Commissioner" means the insurance commissioner of this state;
(vi) "Coinsurance" means a percentage of eligible charges payable by an enrollee directly to a provider for covered services rendered;
(vii) "Copayment" means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid;
(viii) "Deductible" means the amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment;
(ix) "Discontinuance" means the termination of the contract between the group contract holder and a health maintenance organization due to the insolvency of the health maintenance organization, and does not refer to the termination of any agreement between any individual enrollee and the health maintenance organization;
(x) "Enrollee" means an individual who is enrolled in a health maintenance organization;
(xi) "Evidence of coverage" means any certificate, agreement or contract issued to an enrollee setting out the coverage to which the enrollee is entitled;
(xii) "Extension of benefits" means the continuation of coverage under a particular benefit provided under a contract following termination with respect to an enrollee who is totally disabled on the date of termination;
(xiii) "Group contract" means a contract for health care services which by its terms limits eligibility to members of a specified group. The group contract may include coverage for dependents;
(xiv) "Group contract holder" means the person to which a group contract has been issued;
(xv) "Health care services" means any services included in the furnishing to any individual of medical or dental care, vision care or hospitalization or incident to the furnishing of that care or hospitalization, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing or healing human illness, injury or physical disability;
(xvi) "Health maintenance organization" means any person, except a person offering a dental only or vision only plan, who undertakes to provide or arrange for basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments, coinsurance or deductibles, and may include providing or arranging for:
(A) Physician services directly through physician employees or under arrangements with individual physicians or groups of physicians;
(B) Other health care services on a prepayment or other financial basis.
(xvii) "Health maintenance organization producer" means a person who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for health maintenance organization membership, or who takes or transmits a membership fee or premium for such a policy or contract, other than for himself, or a person who advertises or otherwise holds himself out to the public as undertaking any of the activities of a health maintenance organization producer;
(xviii) "Individual contract" means a contract for health care services issued to and covering an individual. The individual contract may include dependents of the subscriber;
(xix) "Insolvent" or "insolvency" means that the organization has been declared insolvent and placed under an order of liquidation by a court of competent jurisdiction;
(xx) "Managed hospital payment basis" means agreements under which the financial risk is primarily related to the degree of utilization rather than to the cost of services;
(xxi) "Net worth" means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt;
(xxii) "Participating provider" means a provider as defined in paragraph (xxiv) of this subsection who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment, coinsurance or deductible, directly or indirectly from the health maintenance organization;
(xxiii) "Person" means as defined by W.S. 26-1-102(a)(xx);
(xxiv) "Provider" means any physician, hospital or other person which is licensed or otherwise authorized to furnish health care services in the state in which the services are rendered;
(xxv) "Replacement coverage" means the benefits provided by a succeeding carrier;
(xxvi) "Subscriber" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization, or in the case of an individual contract, the person in whose name the contract is issued;
(xxvii) "Uncovered expenditures" means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organization's insolvency and for which no alternative arrangements have been made that are acceptable to the commissioner;
(xxviii) "This code" means title 26 of the Wyoming statutes;
(xxix) "This act" means W.S. 26-34-101 through 26-34-134.