Appendix A -
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 |