26-24-130.

26-24-130.

26-34-108. Quality assurance program.

(a) The health maintenance organization shall establish procedures to assure that the health care services provided to enrollees are rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. The procedures shall include mechanisms to assure availability, accessibility and continuity of care.

(b) The health maintenance organization shall have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and noninstitutional settings. The program shall include, at a minimum, the following:

(i) A written statement of goals and objectives which emphasizes improved health status in evaluating the quality of care rendered to enrollees;

(ii) A written quality assurance plan which describes the following:

(A) The health maintenance organization's scope and purpose in quality assurance;

(B) The organizational structure responsible for quality assurance activities;

(C) Contractual arrangements, where appropriate, for delegation of quality assurance activities;

(D) Confidentiality policies and procedures;

(E) A system of ongoing evaluation activities;

(F) A system of focused evaluation activities;

(G) A system for credentialing providers and performing peer review activities; and

(H) Duties and responsibilities of the designated physician responsible for the quality assurance activities.

(iii) A written statement describing the system of ongoing quality assurance activities including:  (A) Problem assessment, identification, selection and study;

(B) Corrective action, monitoring, evaluation and reassessment; and

(C) Interpretation and analysis of patterns of care rendered to individual patients by individual providers.

(iv) A written statement describing the system of focused quality assurance activities based on representative samples of the enrolled population which identifies method of topic selection, study, data collection, analysis, interpretation and report format; and

(v) Written plans for taking appropriate corrective action whenever, as determined by the quality assurance program, inappropriate or substandard care or services have been provided, or care or services which should have been furnished have not been provided.

(c) The organization shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes shall be available to the administrator. Contents of the minutes shall be confidential to the extent confidentiality is provided under the provisions of W.S. 16-4-203(d)(i) and (vii), 26-34- 129, 26-34-130, 35-2-910 or 35-17-105.

(d) The organization shall ensure the use and maintenance of an adequate patient record system which will facilitate documentation and retrieval of clinical information for the purpose of the health maintenance organization evaluating continuity and coordination of patient care and assessing the quality of health and medical care provided to enrollees.

(e) Enrollee clinical records shall be available to the administrator or an authorized designee for examination and review to ascertain compliance with this section, or as deemed necessary by the administrator.

(f) The organization shall establish a mechanism for periodic reporting of quality assurance program activities to the governing body, providers and appropriate organization staff.  26-34-109. Requirements for group contract, individual contract, evidence of coverage and premiums for health care services.

(a) Every group and individual contract holder is entitled to a group or individual contract. The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by W.S. 26-34-117(a). The contract shall contain a clear statement of the following:

(i) Name and address of the health maintenance organization;

(ii) Eligibility requirements;

(iii) Benefits and services within the service area;

(iv) Emergency care benefits and services;

(v) Out of area benefits and services, if any;

(vi) Copayments, coinsurance, deductibles or other out-of-pocket expenses;

(vii) Limitations and exclusions, including an explanation of any prescription drug benefits not provided for under a specified health plan;

(viii) Enrollee termination;

(ix) Enrollee reinstatement, if any;

(x) Claims procedures;

(xi) Enrollee complaint procedures;

(xii) Continuation of coverage;

(xiii) Conversion;

(xiv) Extension of benefits, if any;

(xv) Coordination of benefits, if applicable;

(xvi) Subrogation, if any;  (xvii) Description of the service area;

(xviii) Entire contract provision;

(xix) Term of coverage;

(xx) Cancellation of group or individual contract holder;

(xxi) Renewal;

(xxii) Reinstatement of group or individual contract holder, if any;

(xxiii) Grace period as provided in W.S. 26-18-107;

(xxiv) Conformity with state law; and

(xxv) Any withholding agreement pertaining to health care delivery services which requires reimbursement to the provider at a later date dependent upon decisions regarding coverage. The agreement shall specify the requirements in detail. If the existence of a withholding agreement has been disclosed in the contract, the health maintenance organization may alter the terms of the agreement without being deemed to alter the terms of the contract provided the contract holder is notified in detail of the new terms of the agreement at his next renewal.

(b) In addition to those provisions required in subsection (a) of this section, an individual contract shall provide for a ten (10) day period to examine and return the contract and have the premium refunded. If services were received during the ten (10) day period, and the person returns the contract to receive a refund of the premium paid, he shall pay for the services.

(c) Each enrollee residing in this state shall receive an evidence of coverage from the group contract holder or the health maintenance organization. The evidence of coverage shall not contain provisions or statements which are unfair, unjust, inequitable, misleading, deceptive or which encourage misrepresentation as defined by W.S. 26-34-117(a). The evidence of coverage shall contain:

(i) A clear statement of the provisions required in paragraphs (a)(i) through (xvii) of this section; and  (ii) A provision that any subsequent material change shall be evidenced in a separate document issued to the enrollee.

(d) No group or individual contract, evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state:

(i) Until a copy of the form of the contract, evidence of coverage, or amendment thereto, has been filed with and approved by the commissioner.

(e) Every form required by this section shall be filed with the commissioner not less than forty-five (45) days prior to delivery or issue for delivery in this state. At any time during the initial forty-five (45) day period, the commissioner may extend the period for review for an additional forty-five (45) days. Notice of an extension shall be in writing. At the end of the review period, the form is deemed approved if the commissioner has taken no action. The filer shall notify the commissioner in writing prior to using a form that is deemed approved.

(f) At any time, after thirty (30) days notice and for cause shown, the commissioner may withdraw approval of any form, effective at the end of thirty (30) days.

(g) When a filing is disapproved or approval of a form is withdrawn, the commissioner shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within thirty (30) days of receipt of the notice the health maintenance organization may request a hearing. A hearing shall be conducted within thirty (30) days after the commissioner has received the request for hearing.

(h) The commissioner may adopt regulations establishing readability standards for individual contract, group contract, and evidence of coverage forms.

(j) No schedule of premiums or methodology for determining a schedule of premiums for enrollee coverage for health care services, or amendment thereto, may be used until a copy of that schedule, or amendment thereto, has been filed with and approved by the commissioner.  (k) Premiums or methodology for determining a schedule of premiums shall be established in accordance with actuarial principles for various categories of enrollees, provided that premiums applicable to an enrollee may not be individually determined based on the status of his health. However, the premiums shall not be excessive, inadequate or unfairly discriminatory. A certification, by a qualified actuary or other qualified person acceptable to the commissioner, to the appropriateness of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.

(m) The commissioner, within a reasonable period, shall approve any form if the requirements of subsections (a) through (g) of this section are met and any schedule of premiums if the requirements of subsections (j) and (k) of this section are met. It is unlawful to issue a form or to use the schedule of premiums until approved or deemed approved.

(n) The commissioner may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.

26-34-110. Annual report.

(a) Each health maintenance organization, annually, on or before March 1, shall file with the commissioner, with a copy to the administrator, a report verified by at least two (2) organization principal officers and covering the immediately preceding calendar year. Each health maintenance organization shall file with the commissioner on a quarterly basis a statement of its financial condition for the preceding quarter. Each quarterly statement shall be filed with the commissioner on or before forty-five (45) days from the end of the quarter being reported. The reports and statements shall be on forms the commissioner prescribes and shall be completed pursuant to the most recent National Association of Insurance Commissioners' accounting practices and procedures manual.

(b) The health maintenance organization shall file on or before March 1, unless otherwise stated:

(i) Audited financial statements in accordance with the provisions of title 26, chapter 3, article 3 of the Wyoming statutes on or before June 1;  (ii) A list of the providers who have executed a contract that complies with W.S. 26-34-114; and

(iii) The report on the complaint system pursuant to W.S. 26-34-112(b).

(c) All annual and quarterly statements filed pursuant to this section shall be accompanied by an electronic version containing the same information as the statement. The commissioner may specify the format of the electronic version. The commissioner may accept, for any health maintenance organization not domiciled in this state which is required to file annual, quarterly and audited financial statements under this section, an electronic filing with the National Association of Insurance Commissioners meeting the requirements of this section as a filing with the commissioner. The commissioner may refuse to continue or may suspend or revoke the certificate of authority of any health maintenance organization failing to file its annual or quarterly statement when due.

(d) The commissioner may require any additional reports as are deemed reasonably necessary and appropriate to enable him to carry out his duties under this chapter.

26-34-111. Information to enrollees; claims to be accepted or rejected; attorney's fees.

(a) Each health maintenance organization shall:

(i) Provide promptly to its enrollees notice of any material change in the operation of the organization that will directly affect those enrollees;

(ii) Provide to its subscribers a list of providers, upon enrollment and reenrollment;

(iii) Notify an enrollee in writing of the termination of the primary care provider who provided health care services to that enrollee, and provide assistance to the enrollee in transferring to another participating primary care provider;

(iv) Provide to subscribers information on how services may be obtained, where additional information on access to services can be obtained and a telephone number where the enrollee can contact the organization at no cost to the enrollee.  (b) Any claim for a benefit under a health insurance policy shall be rejected or accepted and paid by the health maintenance organization in accordance with W.S. 26-15-124(a) and (c).

26-34-112. Complaint system.

(a) Each health maintenance organization shall establish and maintain a complaint system which has been approved by the commissioner, after consultation with the administrator, to provide reasonable procedures for the resolution of written complaints initiated by enrollees.

(b) Each health maintenance organization shall submit to the commissioner and the administrator, an annual report, in a form the commissioner prescribes, after consultation with the administrator, which shall include:

(i) A description of the procedures of the complaint system;

(ii) The total number of complaints handled through the complaint system and a compilation of causes underlying the complaints filed; and

(iii) The number, amount and disposition of malpractice claims made by an enrollee of the organization that were settled during the year by the health maintenance organization. All such information shall be held in confidence by the commissioner.

(c) The commissioner or the administrator may examine the complaint system at any time.

26-34-113. Investments.

With the exception of investments made in accordance with W.S.