WYOMING HEALTH INSURANCE POOL
Health Care Coverage Plan
THE STATE OF WYOMING
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
will pay benefits up to the specified amount during a
e) Any person on whose behalf the Pool has paid the life
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
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
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
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.
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
Alcohol or drug abuse payable to a lifetime maximum
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
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
Spinal Manipulations (limited to $500 per calendar
Wellness Not a benefit No deductible $150 per Preventative and screening services
Type C Benefits $4,000 $2,000 deductible 100% of R&C Prenatal Care
Maternity deductible Delivery
* 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
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