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WYOMING HEALTH INSURANCE POOL Health Care Coverage Plan THE STATE OF WYOMING DAVE FREUDENTHAL GOVERNOR 07/2005 (Internet) Purpose Membership & Eligibility The Wyoming Health Insurance Pool was created by the 1. Applicant must be a resident of the state of Wyoming 1990 Wyoming Legislature to provide health insurance and certify occupation of a dwelling in the state of coverage to residents of Wyoming who are denied adequate Wyoming. health insurance. This plan is specially designed to meet 2. Applicant will be required to complete an application the needs of those individuals who are unable to purchase for coverage. Upon administrative approval, coverage health insurance for themselves because of existing health will begin on the 1st or the 16th of the month. problems. 3. Applicant must meet one of the following eligibility requirements and provide proof of eligibility: a) Applicant has been refused coverage for health Benefits reasons by one insurer; Two options are available from the Wyoming Health b) Applicant has health insurance coverage more Insurance Pool: The Brown Plan and The Gold Plan. restrictive than the Pool; Coverage under both plans includes Type A, Type B and c) Applicant has health insurance coverage at a rate Type C benefits and are differentiated by certain benefits exceeding the Pool; or and how they are paid. d) Applicant is a Federally eligible individual. Type A Benefits: These benefits include high cost 4. The following persons ARE NOT eligible for expenses such as inpatient hospitalization, outpatient and coverage: office surgery, and ambulance services. a) Any person who has coverage under health insurance or an insurance arrangement on the issue date of Pool Type B Benefits: These benefits include the smaller, less coverage. costly items and services such as outpatient prescriptions, b) Persons who are eligible for group heath insurance or a outpatient medical care, office calls and physical therapy. group health insurance arrangement provided in connection with a policy, plan or program sponsored Type C Benefits: These benefits include maternity care by an employer and subject to regulation as a group including prenatal care, delivery and postnatal care. health plan under federal or state law, even though the employer coverage is declined. Out-of-Pocket Cost: The out-of-pocket cost includes the c) Any person who is, at the time of application, eligible deductibles and coinsurance paid by a member. Once the for Medicaid health care benefits or Medicare by out-of-pocket maximum has been met, the plan will pay reason of age. Individuals on Medicare Disability 100% of Reasonable and Customary charges for covered under the age of 65 are eligible. services. d) Any person who terminated coverage in the Pool unless twelve (12) months have elapsed from the Lifetime Maximum: The Wyoming Health Insurance Pool termination date. will pay benefits up to the specified amount during a e) Any person on whose behalf the Pool has paid the life member’s lifetime. time maximum benefit under any Pool plan. f) Any person who is an inmate of a public institution. Brown Plan Gold Plan Out-of-Pocket Maximum Out-of-Pocket Maximum Individual $4,000 Annually $2,000 Annually Adult & Dependent $8,000 Annually $4,000 Annually Two Adult $8,000 Annually $4,000 Annually Family $8,000 Annually $4,000 Annually Brown Plan Gold Plan Lifetime Maximum Lifetime Maximum Per Individual $350,000 $600,000 Affiliated Physician Program the member of the ineligibility of a dependent, a Blue Cross Blue Shield of Wyoming is committed to Certificate of Creditable Coverage will be issued in a finding ways to keep health care costs at an affordable timely fashion thereafter. Certificates of Creditable level. That’s why they are working with a growing number Coverage may also be obtained from Blue Cross Blue of dedicated Wyoming physicians to provide the most Shield of Wyoming upon request within 24 months after affordable and highest quality health care possible. coverage is terminated. Certificates of Creditable Coverage will only reflect continuous coverage provided As participants in the Affiliated Physician Program, all through the Wyoming Health Insurance Pool. member physicians have agreed to send your claims directly to Blue Cross Blue Shield of Wyoming, who will Medicare Disability see that payment is made directly to the physician. This If you meet the eligibility criteria for the Wyoming Health significantly reduces your involvement in the time- Insurance Pool and are on Medicare Disability, your consuming claims process. benefits are identical to those outlined in this brochure. Please note that the Pool is the payor of last resort and will The Affiliated Physician Program is an exclusive benefit pay secondary to Medicare. to WHIP members only. We encourage you to choose an Affiliated Physician and start saving time today. Reasonable and Customary (R&C) “Reasonable” is the fee which, in the opinion of Blue If you use non-affiliated physicians you may have to Cross Blue Shield of Wyoming, is justified in the special submit your claims yourself. Always be sure to ask. All circumstances of the particular case in question. claims should be sent to: Blue Cross Blue Shield of “Customary” is the range of fees charged for individual Wyoming, P.O. Box 2266, Cheyenne, WY 82003 procedures by Wyoming providers as represented in files maintained by Blue Cross Blue Shield of Wyoming. The BlueCard® Benefits are paid according to the Reasonable and More than 85% of all hospitals and physicians throughout Customary fees in the state of Wyoming. the United States contract with independent Blue Cross Blue Shield organizations. Your identification card -The Federally Eligible Individual BlueCard® - links these health care providers to an A Federally eligible individual means an individual: electronic data system that quickly delivers your benefit a) Who has had at least 18 months of creditable coverage information anywhere in the country. as of the date the individual seeks coverage under the Pool; and Just show your identification card to any Blue Cross Blue b) Whose most recent prior creditable coverage was Shield participating hospital or physician across the USA under a group private or public health benefit plan; and receive the same special treatment you’re accustomed and to receiving right here in Wyoming. c) Who is not eligible for coverage under a group health plan, part A or part B of title XVIII of the Social Sunset Security Act, or Medicaid, and who does not have The Wyoming Health Insurance Pool is a State of other health insurance coverage; and Wyoming program and its continuance will be subject to d) Whose most recent creditable coverage was not legislative approval. Without legislative approval, this terminated based on nonpayment of premiums or program will end on June 30, 2011. fraud; and e) Who, if offered, elected continuation coverage under a Certificate of Creditable Coverage COBRA continuation provision or under a similar state program and exhausted such continuation When coverage under the WHIP is terminated, Blue Cross coverage. Blue Shield of Wyoming will, within a reasonable period of time, issue a Certificate of Creditable Coverage to the affected member and/or dependents. Upon notification by conditions for a period of twelve (12) months following the Managed Care Program member’s date of enrollment. Pre-existing conditions are The Managed Care features of the Pool’s health care those conditions for which medical advice, diagnosis, care coverage plan are designed to help control the cost of your or treatment was recommended or received in the six (6) health care without reducing your benefits. By using the months immediately preceding the enrollment date of features listed here, you can be assured of receiving coverage. Pregnancy existing on the enrollment date of quality health care in the most cost effective setting. coverage is considered a pre-existing condition. Pre-admission Authorization. This is required on all In determining whether this pre-existing condition non-emergency, non-maternity hospital admissions. It exclusion period applies to an eligible member, the ensures that your hospitalization care is medically Wyoming Health Insurance Pool will credit the time a necessary and performed in the appropriate setting. It also member was previously covered by creditable coverage, allows you to confirm coverage prior to treatment. provided there was not a significant break in coverage (90 days) from the previous creditable coverage. Waiting If pre-admission authorization is not obtained, benefits will periods applicable under this individual health benefit be reduced by $500 under The Brown Plan or $250 under plan shall not be considered in determining if a significant The Gold Plan after the deductible. break in coverage has occurred, and will be credited toward any pre-existing condition exclusion period under Pre-admission Testing. Laboratory and radiology tests this Agreement. can generally be performed prior to the time you enter the hospital. General Limitations and Office Surgery. Surgery performed in a physician’s office Exclusions not only reduces out-of-pocket costs but may also be more We will not pay for: Acupuncture, artificial conception, convenient for you. autopsies, biofeedback services, birth control pills and devices, complications of non-benefit services, Generic Drugs. A generic drug is a generally accepted convalescent care, cosmetic surgery, custodial care, substitute for a name-brand drug which may be more diagnostic admissions, domiciliary care, experimental or costly. You can generally recognize significant savings investigative procedures, eye care, genetic counseling, without sacrificing quality. obesity and weight loss, hair loss, hypnosis, tobacco dependency, orthognathic surgery, eye examinations, foot Second Surgical Opinion. It is suggested that a second care services, hearing examinations, organ and tissue surgical opinion be sought to determine whether a transplants including pre-and post-operative care and recommended surgery is the best course of treatment. immunosuppressant drugs, routine physicals and examinations (Brown Plan only), sex change operations, Pre-existing Conditions subluxation, temporomandibular joint dysfunction, non- This program conforms to all Federal and State medical therapies, travel expenses and services or supplies requirements regarding pre-existing condition exclusion covered under Worker’s Compensation or provided by a periods including the definition of pre-existing conditions government facility or institution. and the portability of pre-existing condition exclusion periods. Benefits will not be provided for pre-existing Summary of Benefits Benefits Brown Plan* Gold Plan* We Pay Features You Pay You Pay Type A Benefits One $500 One $250 deductible 80% of R&C Semi-private room and board Hospital Services deductible per per admission after the Intensive Care Inpatient and admission deductible Ancillary Services Outpatient Surgical Services Outpatient Physician Services No deductible No deductible 80% of R&C Surgical Services Inpatient and Surgeon Outpatient Surgery Assistant Surgeon Anesthesiologist Office Surgery $100 deductible $75 deductible per 80% of R&C Surgery per day day after the Preoperative visits deductible Local administration of anesthesia Follow-up care Recasting Inpatient Medical Subject to the Subject to the $250 80% of R&C In-hospital visits $500 per per admission after the Consultations admission deductible deductible deductible Ambulance Services No deductible No deductible Reimbursed at Ambulance services are covered up to $150/ground 80% of the R&C trip and $2,000/air trip. (subject to contract maximums) Type B Benefits $2,000 $1,000 deductible per 70% of R&C Outpatient Psychotherapeutic (limited to 30 Nervous/Mental deductible per individual per visits/calendar year and up to $30 per visit) Substance Abuse individual per calendar year Inpatient treatment for nervous and mental or psychotherapeutic services is limited to $5,000 per 12 calendar year month period. Alcohol or drug abuse payable to a lifetime maximum of $5,000 Other Covered $2,000 $1,000 deductible per 70% of R&C Rehabilitation Therapy (limited to a lifetime maximum Services deductible per individual per of $20,000 for Brown Plan and $25,000 for Gold Plan) individual per calendar year Physician Office Calls Supplies and Appliances calendar year Durable Medical Equipment Outpatient Prescription Drugs Outpatient Diagnostic, x-ray and lab Outpatient medical services including x-ray and laboratory Physical Therapy (limited to 20 visits/calendar year) Chemotherapy and Radiation Therapy Diabetes services Spinal Manipulations (limited to $500 per calendar year) Wellness Not a benefit No deductible $150 per Preventative and screening services individual per calendar year Type C Benefits $4,000 $2,000 deductible 100% of R&C Prenatal Care Maternity deductible Delivery Postnatal Care * NOTE: As shown above, there are two plan options available: The Brown Plan and The Gold Plan. Upon enrollment in the Wyoming Health Insurance Pool and receipt of premium payment, switching between plan options is not permitted. This sales outline is designed to present the Wyoming Health Insurance Pool’s health care benefits in an easy-to-read format and does not cover all information contained in the subscription agreement. Limitations and exclusions in addition to those presented in this brochure do exist. This brochure is not a contract. For exact benefits and limitations, please refer to t he subscription agreement. Administered by: Blue Cross Blue Shield 4000 House Avenue of Wyoming PO Box 2266 Cheyenne, WY 82003-2266 1-800-442-2376 or (307) 634-1393 Blue Cross Blue Shield of Wyoming is an independent licensee of the Blue Cross Blue Shield Association
"WYOMING HEALTH INSURANCE POOL"