Health Care Coverage Plan

    THE STATE                      OF WYOMING

                DAVE FREUDENTHAL

                                                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
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
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.
                                                              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
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
                                                                General Limitations and
Office Surgery. Surgery performed in a physician’s office
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
  Physician Services    No deductible       No deductible          80% of R&C      Surgical Services
   Inpatient and                                                                   Surgeon
   Outpatient Surgery                                                              Assistant Surgeon
  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
  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
  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
 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
                                                                                   Physical Therapy (limited to 20 visits/calendar year)
                                                                                   Chemotherapy and Radiation Therapy
                                                                                   Diabetes services
                                                                                   Spinal Manipulations (limited to $500 per calendar
  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

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