Wyoming Administrative Code › Agency 044 - Insurance Dept › Sub-Agency 0002 - General Agency, Board or Commission Rules › Chapter 41 - SCOPE OF POOL COVERAGE AND SCHEDULE OF BENEFITS OFFERED BY WYOMING HEALTH INSURANCE POOL › Appendix A

Current through July 13, 2024
WYOMING HEALTH INSURANCE POOL
SUMMARY OF BENEFIT FEATURES
CONTRACT MAXIMUMS
Lifetime Maximum of: $[250,000]*
Out-of-Pocket Maximum of: $[3,000] per individual
$[9,000] per family of 3 or more
BENEFIT LEVELS
Type A (reimbursed at [80]% of R&C after deductibles have
				  been met)
Inpatient Surgical $[500] deductible per admission
Inpatient Medical $[500] deductible per admission
Outpatient Surgery $[500] deductible
Inpatient Physician [No deductible]
Outpatient Physician Surgery [No deductible]
Office Surgery $[100] deductible per surgery
Ambulance [No deductible]/subject to contract
				  limitations
Type B (reimbursed at [70%] of R&C after $[2,000]
				  deductible has been met)
Office calls
Outpatient drugs
Outpatient diagnostic, x-ray and laboratory
Nervous/Mental treatment subject to contract
				  limitations
Alcohol or drug abuse subject to contract limitations
Emergency Room Medical Treatment
Type C (reimbursed at [100]% of R&C after $[4,000]
				  deductible has been met)
Pre-natal care
Delivery
Post-natal care
Routine newborn care
This is intended as a brief overview of benefits for the
				  Wyoming Health Insurance Pool.
*Hereinafter, every amount that appears in brackets is
				  subject to change by the Wyoming Health Insurance Pool Board. Current amounts
				  may be obtained from the Wyoming Insurance Department.
WYOMING HEALTH INSURANCE POOL
BENEFIT STRUCTURE
$[250,000] lifetime maximum*
Total out-of-pocket cost - $[3,000] per individual. $[9,000]
				  per family of 3 or more
TYPE A BENEFITS
Benefits
Deductible
Reimbursement
Program Features
Hospital Services
$[500] per admission
[80%] of R&C after deductible
.Semi-private room & board
.Intensive Care
.Ancillary Services
.Outpatient Emergency room surgery
Inpatient Medical
$[500] per admission
[80%] of R&C after Deductible
.In-hospital visits
.Consultations
Physician Services (Inpatient & Outpatient
							 Surgery)
[No deductible]
[80%] of R&C
.Surgical Services
.Surgeon
.Assistant Surgeon
.Anesthesiologist
Ambulance Services
[No deductible]
[80%] of covered charges up to Contract
							 maximum
.Ambulance services are covered up to $[150] per
							 ground trip and $[2000] per air trip
Office Surgery$[100]
deductible
[80%] of R&C after Deductible
.Surgery
.Preoperative visits
.Local
administration of anesthesia
.Follow-up care
.Recasting
*Hereinafter, every amount that appears in brackets is
				  subject to change by the Wyoming Health Insurance Pool Board. Current amount
				  may be obtained from the Wyoming Insurance Department.
TYPE B BENEFITS
Benefits
Deductible
Reimbursement
Program Features
Covered Services
$[2000] total on all Type B Benefits
[70%] of R&C after deductible
.Office calls
.Outpatient drugs
.Outpatient diagnostic, x-ray and laboratory
.Outpatient psycho therapeutic (limited to 20 visits
							 per calendar year and up to $30 per visit)
.Physical therapy (limited to 20 visits per calendar
							 year)
.Chiropractic services (limited to $500 per calendar
							 year)
.Rehabilitation therapy (limited to a lifetime
							 maximum of $20,000)
.Outpatient emergency room medical care
Nervous/Mental
[same as above]
[70%] of R&C after deductible
.Inpatient treatment for nervous and mental or
							 psychotherapeutic services is limited to $5000 per 12 month period
Substance Abuse
[same as above]
[70%] or R&C after deductible
.Alcohol or drug abuse payable to a lifetime maximum
							 of$5000
TYPE C BENEFITS
Benefits
Deductible
Reimbursement
Program Features
Maternity Service
$[4000] deductible
[100%] of R&C after deductible
.Pre-natal care
.Delivery
.Post-natal care
.Routine newborn care