044-49 Wyo. Code R. § 49-10

Current through April 27, 2019

Section 49-10 - Qualifying Previous and Qualifying Existing Coverage

(a) For the purposes of W.S. § 26-19-302(a)(xv) and 26-19-306(c)(ii), an individual will be considered to have previous or existing coverage if the previous or existing policy, certificate or other benefit arrangement met the relevant definition of Section 2(c) of this Regulation. The small employer carrier shall interpret W.S. § 26-19-301 et seq. and this Regulation no less favorably to an insured individual than the following:

• (i) A health insurance policy, certificate or other health benefit arrangement shall be considered employer-based if an employer sponsors the plan or arrangement or makes a contribution to the plan or arrangement.

• (ii) A health insurance policy, certificate or other benefit arrangement shall be considered to provide benefits similar to or exceeding the benefits provided under the basic health benefit plan if it provides benefits that:
  • (A) Have an actuarial value as considered for a normal distribution of groups that is not substantially less than the actuarial value of the basic health benefit plan; or
  • (B) Provides coverage for hospitalization and physician services that is substantially similar to or exceeds the coverage for such services in the basic health benefit plan.

(b) In making a determination under subsection (a), a small employer carrier shall evaluate the previous or existing policy, certificate or other benefit arrangement taken as a whole and shall not base its decision solely on the fact that one portion of the previous or existing policy, certificate or benefit arrangement provides less coverage than the comparable portion of the basic health benefit plan.

(c) For the purposes of W.S. § 26-19-306(c)(ii), an individual will be considered to have qualifying previous coverage with respect to a particular service if the previous policy, certificate or other benefit arrangement met the definition in Section 2(c) of this Regulation and provided any benefit with respect to that service.

(d) A small employer carrier shall ascertain the source of previous or existing coverage of each eligible employee and each eligible dependent(s) if dependent coverage is offered at the time such employee or dependent initially enrolls into the health benefit plan. The small employer carrier shall contact the source of such previous or existing coverage to determine the benefits or limitations of the previous or existing coverage.

044-49 Wyo. Code R. § 49-10

Amended, Eff. 10/13/2015.