CHAPTER 1
Chuuk State Health Care Act
Subchapters:
A General Provisions (§§ 1001-1004)
B Board of Trustees, Officers & Corporate Powers (§§ 1010-1026)
C Eligibility for Benefits (§§ 1030-1031)
D Nature and Scope of Benefits (§§ 1038-1047)
E Assessments and Premiums (§§ 1050-1057)
F Trust Fund (§§ 1060-1062)
G Administration (§§ 1068-1076)
H Support for the Essential Level of Health Insurance Coverage (§§ 1080-1085)
I
Government Assistance (§§ 1090-1092)
J Effective Date (§ 1098)
General Provisions
§ 1001. Short Title.
§ 1002. Purpose.
§ 1003. Establishment.
§ 1004. Definitions.
This Act Chapter may be cited as the "Chuuk State Health Care Act of 1994.'
Source: CSL 2-94-06, § 1-1, modified.
Editor's note: CSL 2-94-06 was signed into law by the Governor on April 24, 1994. See effective date provision of 17 CSC 1098.
Cross-reference: The constitutional provisions on health are found in Art. X, Sections 6 and 7 of the Chuuk State Constitution. Sections 6 and 7 state as follows:
Section 6. The State Government shall provide for the protection and promotion of health, and shall ensure, within the limits of its resources, that no person is discriminated against in the distribution of medical care, or is refused medical care because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
The purpose of this Act Chapter is to improve the provision and quality of health services to residents of the State of Chuuk, to establish a financial system to provide universal coverage of an essential level of health care for all eligible enrollees and to create a means for collection of health care premiums for additional coverage. This Act Chapter establishes a means to control the costs, and to improve of health care providers within and outside of Chuuk State.
Source: CSL 2-94-06, § 1-2, modified.
The Chuuk State Health Care Plan is hereby established as a public corporation under the laws of Chuuk State.
Source: CSL 2-94-06, § 1-3, modified.
As used in this Act Chapter:
(1) "Board" means the Board of Trustees of the Chuuk State Health Care Plan;
(2) "Bylaws" means the bylaws of the Chuuk State Health Care Plan in effect from time to time;
(3) "Dependent" means the spouse and children of an enrollee for additional coverage under this Act Chapter, including stepchildren and adopted children, who are unmarried and under 19 years of age, and handicapped dependent children who are physically or mentally incapable of earning a living; any student under 21 years of age who is unmarried and a full-time student and who is primarily supported by his or her enrollee parents; and unemployed dependent parents over the age of 60 and are citizens of Chuuk State residing in Chuuk State;
(4) "Employee" means any individual who has been employed for wages or salaries for services from an employer as defined in Subsection (5) of this Section for at least 15 working days and who regularly provides such services to the employer for 20 hours or more each week;
(5) "Employer" means any person as defined in Subsection (10) of this Section who employs the services of others and pays them wages or salaries or a person who is self-employed, that is, a person who earns money for labor or goods;
(6) "Enrollee" means any individual eligible to receive benefits under this Act Chapter; provided that an enrollee may be eligible for only the essential level of benefits, or may be eligible for additional levels of benefits as provided for in this Act Chapter and such regulations as may be issued pursuant hereto;
(7) "Executive Director" means the Executive Director of the Chuuk State Health Care Plan;
(8) "Fund" means the Trust Fund to be established by the Board pursuant to Section 6-1 1060 of this Act Chapter;
(9) "Off-island Health Care Facility" means any facility providing covered services as defined in Section 4-4 1041 of this Act Chapter which is located outside of Chuuk State and which is determined by the Board to be a qualified provider (as defined in Section 4-6 1043 of this Act Chapter);
(10) "Person" includes any individual, trust, estate, partnership, corporation, association, joint stock company, bank, insurance company, credit union, cooperative, or other entity or group (including any government, whether local or foreign, or any agency or instrumentality thereof);
(11) "Plan" means the Chuuk State Health Care Plan;
(12) "Provider" means any person furnishing any covered service (as defined in Section 4-4 1041 of this Act Chapter);
(13) "Referral" means a referral of an enrollee to an out of state health care facility granted pursuant to Section 4-2 1039 of this Act Chapter;
(14) "Regulation" means the regulations adopted by the Board and approved by the Governor for the administration of the Plan;
(15) "Resident" means any citizen of Chuuk for whom Chuuk State is his principal residence, or any noncitizen who has established an ongoing physical presence in Chuuk State and whose presence is sanctioned by law and is not merely transitory in nature;
(16) "State" or "Chuuk" means the State of Chuuk; and
(17) "Third-party administrator" means the individual or firm within or outside of Chuuk State, which contracts to perform administrative services in the operation of the Plan.
Source: CSL 2-94-06, § 1-4, modified.
Cross-reference: The constitutional provisions on health are found in Art. X, Sections 6 and 7 of the Chuuk State Constitution.
Board of Trustees,
Officers & Corporate Powers
§ 1010. Board of Trustees.
§ 1011. Organization Meeting.
§ 1012. Terms of Office and Reappointment.
§ 1013. Vacancies.
§ 1014. Removal.
§ 1015. Meetings.
§ 1016. Quorum.
§ 1017. Deadlock.
§ 1018. Election of Chairman.
§ 1019. Election of Vice-Chairman.
§ 1020. Compensation of Board members.
§ 1021. Exclusion from Employment.
§ 1022. Bylaws.
§ 1023. Personnel and Procurement.
§ 1024. Officers.
§ 1025. Corporate Powers.
§ 1026. Regulations.
(1) The governing and administrative powers of the Plan shall be vested in a Board of Trustees which shall consist of five voting members and the Executive Director who shall serve as an ex-officio, non-voting member of the Board; and
(2) The Governor shall appoint the five voting members of the Board, with the advice and consent of the Senate. The Board shall be composed of members experienced in financing, health care administration, medical or legal practice, health care development or health care improvement. Within five years following the first organizational meeting of the Board, the Board shall submit to the Governor and the Chuuk State Legislature draft legislation to provide for the periodic popular selection of Board members by citizen enrollees of the Plan.
Source: CSL 2-94-06, § 2-1, modified.
Cross-reference: The constitutional provisions on health are found in Art. X, Sections 6 and 7 of the Chuuk State Constitution. Sections 6 and 7 state as follows:
Section 6. The State Government shall provide for the protection and promotion of health, and shall ensure, within the limits of its resources, that no person is discriminated against in the distribution of medical care, or is refused medical care because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
The first meeting of the Board shall
be held after appointment of at least a quorum of the members of the Board
have been confirmed by the Senate. Such first meeting shall be
called and chaired by the Lt. Governor until the chairman is
elected.
Source: CSL 2-94-06, § 2-2, as amended by CSL 3-95-08, § 1.
Of the voting Board members initially
appointed, one shall serve for a term of one year, two shall serve for a
term of two years, and two shall serve for a term of three years, all as
determined by the drawing of lots at the organizational meeting. A
member appointed to fill a vacancy occurring during the term for which his
predecessor was appointed shall be appointed for the remainder of that
term. Each Board member shall hold office until his successor is
appointed and qualified. Board members shall be eligible for
reappointment.
Source: CSL 2-94-06, § 2-3.
Vacancies in the membership of the
Board shall be filled in the same manner as the original appointment.
A vacancy exists in the case of death, resignation, or removal of
any Board member.
Source: CSL 2-94-06, § 2-4.
Any Board member may be removed
from office by the affirmative vote of four voting Board
members.
Source: CSL 2-94-06, § 2-5.
(1) Regular meetings of the Board shall be held quarterly at such times, at such places, and upon such notice as shall be provided in the bylaws;
(2) Special meetings of the Board shall be called by the Chairman or by any three Board members at such places and upon such notice as provided in the bylaws;
(3) Members of the Board or of any committee of the Board may participate in and act at any meeting of the Board or a committee through the use of a conference telephone or other communication equipment by means of which all persons participating in the meeting can hear each other. Participation in such meeting shall constitute attendance and presence in person at the meeting of the person or persons so participating; and
(4) Full and accurate minutes of all Board meetings shall be kept in such manner as shall be provided in the bylaws.
Source: CSL 2-94-06, § 2-6.
Three voting Board members shall
constitute a quorum and the action of three voting Board members present
at any meeting is valid as a corporate act.
Source: CSL 2-94-06, § 2-7.
In the event that the voting members
of the Board are evenly divided concerning an action or decision of the
Board, the Executive Director shall vote on the action or
decision.
Source: CSL 2-94-06, § 2-8.
The Board shall elect from among its
members a Chairman who will convene and preside over meetings of the
Board. The Chairman shall perform such other duties as may be
prescribed by the bylaws or from time to time assigned by the Board.
The Chairman shall serve for a term of one year and shall not be
eligible for consecutive one-year terms as Chairman.
Source: CSL 2-94-06, § 2-9.
The Board shall elect from among its
members a Vice-Chairman who shall, in the absence of the Chairman, perform
the duties of the Chairman. The Vice-Chairman shall serve for a term
of one year and shall not be eligible for consecutive one-year terms as
Vice-Chairman.
Source: CSL 2-94-06, § 2-10.
Board members who are employees of the Chuuk State Government or of any other cooperating entity shall serve without compensation paid by the Plan, but may continue to receive their regular salaries. Board members who are not employees of the Chuuk State Government or of any other cooperating entities shall be entitled to compensation at rates established by the Board but not to exceed $20.00 per day while attending to the business of the Plan. Board members shall be entitled to payment for travel expenses necessarily incurred when serving the Plan away from their places of residence at rates not to exceed that accorded to Chuuk State Government
employees.
Source: CSL 2-94-06, § 2-11, modified.
No Board member (other than the
Executive Director) shall be an employee of the Plan during his term of
office as a Board member or for one year thereafter.
Source: CSL 2-94-06, § 2-12.
The Board shall adopt, amend, or
repeal such bylaws as are necessary to provide for the management of the
business of the Plan, the organization, meetings and procedures of the
Board, the duties of officers and employees, and the preparation and
submission of required reports.
Source: CSL 2-94-06, § 2-13.
(1)
Officers and employees of the Plan shall be exempt from the
provisions of the Public Service System Act and compensation plan of the
Chuuk State Government; provided that within
120 days following its first organization meeting the Board shall provide
in the bylaws of the Plan a complete personnel system for the recruitment,
management and compensation of officers and employees of the
Plan;
(2) The Plan shall be subject to State procurement
and contracting laws until such time that the Board has established and
maintained in its bylaws a contraction and procurement code certified by
the Director of the Chuuk State Department of
Treasury to be sufficient to meet United States standards for state and
local government administration of federal grants;
(3) The personnel and procurement systems
established by the Board may provide for reasonable preferences for the
employment of qualified citizens of this State and procurement for
businesses resident within the State; provided, however, that the systems
shall have as their primary objective in employment and procurement the
fulfillment of the purposes for which the Plan has been established.
Source: CSL 2-94-06, § 2-14,
modified.
(1) The Board shall select an Executive Director
for the Plan who shall serve at the pleasure of the Board;
(2) The Executive Director shall administer the
Plan and manage the day-to-day operations of the Plan, in accordance with
policies, procedures, rules, regulations, standards, and criteria
established by the Board. The Executive Director shall also perform
such other duties as may be set forth in this Act Chapter, the
bylaws, or by the Board. Except as provided in Section 2-8 1017 of this
Act Chapter, the Executive Director shall serve as an
ex-officio, non-voting member of the Board;
(3) The Executive Director of the Plan shall have
a minimum of five years experience in the health finance, or health
administration profession; and
(4) The Executive Director may, with approval of
the Board, delegate to other officers or employees of the Plan, or to a
third-party administrator, any of the duties or functions of the Executive
Director.
Source: CSL 2-94-06, § 2-15,
modified.
In addition to any other authority
granted under this Act Chapter, the Plan shall have the capacity to
exercise all powers normally exercised by a public corporation, including,
but not limited to, the following:
(1) To adopt, alter, and use a corporate
seal;
(2) To sue and be sued in its corporate
name;
(3) To acquire, in any lawful manner, real, personal or
mixed property, either tangible or intangible; to hold, maintain,
use, and operate such property; and to sell, lease, or otherwise dispose
of such property;
(4) To take and otherwise acquire and hold shares,
stocks, mortgages, bonds, obligations, securities, and investments of all
kinds, foreign and domestic, and to sell or otherwise alienate the
same;
(5) To acquire and take over in any lawful manner the
business, property, goodwill, and liabilities of any entity, including
debts, liabilities, and obligations incurred prior to the time of
acquisition;
(6)
To make contracts and incur liabilities, and to borrow or raise any sum or
sums of money and issue corporate bonds on such security and upon such
terms as may from time to time be deemed necessary for the expansion and
improvement of the Plan;
(7) To lend money for its corporate purposes, and to
invest or reinvest its funds;
(8) To retain and terminate the services of employees,
agents, attorneys, auditors, and independent contractors upon such terms
and conditions as it may deem appropriate, subject to the provisions of
this Act Chapter;
(9) To conduct its business, carry on its operations,
have an office, and to exercise the powers
granted herein in any locality of the State, in the Federated States of
Micronesia, or in any foreign country; provided that its principal office
shall be in the State of Chuuk; and
(10) To do all such other things as may be deemed
incidental or conducive to the fulfillment of the responsibilities of the
Plan.
Source: CSL 2-94-06, § 2-16,
modified.
The Board shall with the approval of
the Governor adopt, amend, or repeal regulations for the administration of
the Plan or its successor in State law. Such regulations shall
determine, among other things, assessments for universal coverage, premium
amounts, professional service standards, and standards and procedures for
referrals, collections, disbursements, and appeals from determinations
made in the implementation of the Plan. The regulations shall
further provide for specific notice to enrollees and opportunity to be
heard for termination of benefits under the Plan, and shall provide for
specific procedures for administrative review and decision on actions
taken by the Plan consistent with Section 7-4 1071 of this
Act Chapter.
Source: CSL 2-94-06, § 2-17,
modified.
Cross-reference: The constitutional provisions on health
are found in Art. X, Sections 6 and 7 of the Chuuk State
Constitution.
Eligibility For Benefits
§ 1030.
Basic Eligibility.
§ 1031.
Agreements for Eligibility of Others.
Every resident of Chuuk State shall be enrolled in and shall be eligible
to receive benefits as provided under this Act Chapter,
except that unemployed noncitizen residing in the State who are not
dependents of enrollees are not eligible, except as provided in Section
3-2 1031
of this Act Chapter.
Source: CSL 2-94-06, § 3-1,
modified.
Cross-reference: The constitutional provisions on health
are found in Art. X, Sections 6 and 7 of the Chuuk State Constitution.
Sections 6 and 7 state as follows:
Section 6. The State Government shall
provide for the protection and promotion of health, and shall ensure,
within the limits of its resources, that no person is discriminated
against in the distribution of medical care, or is refused medical care
because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
The Board is authorized to enter into
agreements with the National Government, international organizations, or
other entities to extend the benefits of this Act Chapter to
persons within Chuuk State not otherwise
eligible therefor. The Board, in entering into such agreements,
shall be subject to other State laws, regulations, and agreed-upon
practices regarding negotiating agreements with non-State
entities.
Source: CSL 2-94-06, § 3-2.
Nature and Scope of Benefits
§ 1038.
Payment for Services.
§ 1039.
Medical Referral Committee.
§
1040.
Supervision.
§
1041. Covered Services.
§
1042. Benefit Amounts.
§
1043. Qualified Providers.
§
1044. Universal Coverage.
§
1045. Optional Benefits.
§
1046. Other Coverage.
§
1047. Claims Procedures.
(1) The plan shall pay the benefit amount for any
covered service which is furnished to an enrollee by a qualified provider
outside of Chuuk State if such covered service
is authorized in a referral granted under Section 4-2 1039 of this
Act Chapter;
(2) The Board may by regulation establish and
implement a program for payments of benefit amounts by the Plan for
covered services furnished to enrollees by qualified providers within
Chuuk State, and for assessment and collection
of additional premiums; and
(3) The Board by regulation shall establish and
implement a program for payments of benefit amounts by the Plan for
covered services rendered by the qualified providers to enrollees of the
Plan who are outside of Chuuk State.
Source: CSL 2-94-06, § 4-1,
modified.
Cross-reference: The constitutional provisions on health
are found in Art. X, Sections 6 and 7 of the Chuuk State Constitution.
Sections 6 and 7 state as follows:
Section 6. The State Government shall
provide for the protection and promotion of health, and shall ensure,
within the limits of its resources, that no person is discriminated
against in the distribution of medical care, or is refused medical care
because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
(1) The Chuuk State Department of Health Services shall
establish a medical referral committee, which shall be composed of, at a
minimum, three physicians or medical officers who regularly practice in
Chuuk State. The Department may appoint to its
medical referral committee additional members with such qualifications as
it deems appropriate;
(2) Except as provided
in Subsection (5) of this Section, referrals must be authorized by the
Chuuk State medical referral committee.
The Chuuk State medical referral
committee shall consider as soon as possible a written request made by an
enrollee's attending physician or medical officer and shall determine
whether a referral of the enrollee to an out of State health care facility
is necessary or appropriate for the diagnosis or treatment of, or
rehabilitation following injury or illness, or for health maintenance.
The medical referral committee shall determine in
writing:
(a) Whether it
recommends a referral;
(b) Where covered
services are to be provided;
(c) What covered
services are necessary or appropriate for the enrollee to receive at such
facility; and
(d) The projected
length of stay.
(3) All
recommendations by a medical referral committee or other authorizations
for referral as provided under this Section which will result in financial
obligations against the Plan must be approved by the Executive Director in
accordance with Section 4-4 1041 of this Act Chapter
before any financial obligation may be incurred against the Plan for any
out of State expenses;
(4) The Board shall,
in consultation with the Director of the Chuuk State Department of Health Services, by
regulation establish standards and procedures for payment of
referrals costs, and lists of
eligible services and permissible charges that may be imposed against the
Plan. Such standards, and procedures and lists shall assure that all
referrals services and costs charged
to the Plan are consistent with the purposes and the objectives of the
Plan;
(5) The Director of
the Department of Health services shall by regulation provide for
alternative means for the authorization of medical referrals in the event
of serious and immediate medical emergencies involving situations in which
the medial referral committee is unable to meet for the purposes
prescribed in Subsection (2) of this Section.
Source: CSL
2-94-06, § 4-2, modified.
The Board by regulation
shall establish policies and procedures to supervise the provision of covered services at health care
facilities.
Source: CSL
2-94-06, § 4-3, modified.
Covered services
are:
(1) Professional
services of physicians, dentists, and other health
practitioners;
(2) Direct services of
health institutions;
(3) Support services
derived from the use of pharmaceuticals, devices, appliances, and other
equipment, which the Board by regulation determines are eligible for
payment by the Plan;
(4) Essential air and
sea transportation and ambulatory service to the point of treatment for
approved referrals among the islands of Chuuk State and from the State to
out of State centers of care;
(5) The requisite
costs of essential medical attendees and organ donors and of reasonable
lodging for out patient care whit authorized by the Plan as provided in
its regulations issued pursuant to Section 2-17 1026 of
this Act Chapter; and
(6) Preventative
health care programs sponsored by the Plan on its own initiative or in
conjunction with the Chuuk State Department of
Health Services.
Source: CSL
2-94-06, § 4-4, modified.
Benefit amounts are the
amounts which the Board, by regulation, determines are eligible to be paid
by the Plan. Said regulations may provide for reasonable amounts of
co-payments to be paid by enrollees or other sources for covered
services.
Source: CSL
2-94-06, § 4-5.
A
qualified provider is a person furnishing any covered service who the
Board, by regulation, determines meets the generally accepted standards of
the profession or who is licensed in Chuuk State. The Board shall maintain a list of
qualified providers.
Source: CSL
2-94-06, § 4-6.
The Board, by
regulation, shall provide for an essential bevel of health coverage to be
financed in accordance with Title
VIII Subchapter H of this Act Chapter,
which coverage shall extend to all eligible enrollees.
Source: CSL
2-94-06, § 4-7, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
The Board, by
regulation, may provide for and offer to enrollees additional benefits,
either in the form of covered services in addition to those defined
pursuant to Section 4-4 1041 of this Act Chapter or
higher benefit amounts than those set pursuant to Section 4-5 1042 of this
Act Chapter, an shall provide for payment of
additional premiums by or on behalf of enrollees for such benefits.
Notwithstanding the foregoing language of this Section, the Board
shall establish and maintain at least one level of optional coverage
available to enrollees and their dependents and prescribe the benefits and
premiums pertaining thereto.
Source: CSL
2-94-06, § 4-8, modified.
The obligations of the
Plan to make payment of benefits under this Act Chapter is
secondary to the obligation of any other individual or entity to make
payment for the same service. The Board, by regulation, shall
establish policies and procedures for the coordination of benefits
provided by this Act Chapter and other sources, which policies and
procedures shall establish a secondary nature of benefits under this
Act Chapter. Any overpayments of benefits made
under this Act Chapter may be recovered by the Plan from any
person to or for whom the payment was made or from any company or
organization which is obligated to pay for such services.
Source: CSL
2-94-06, § 4-9, modified.
The Board, by
regulation, shall establish policies ad procedures for the identification
of enrollees by providers, filing of claims, and disbursement of payment
for covered services.
Source: CSL
2-94-06, § 4-10.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
Assessments and
Premiums
§
1050. Assessment and Premium Amounts.
§
1051. Billed Amounts.
§
1052. Responsibility for Benefit
Offerings.
§
1053. Liability for premium payment.
§
1054. Supplemental Revenues.
§
1055. Premium Collection.
§
1056. Sanctions.
§
1057. Remedies.
(1) By regulation, the
Board shall assess the requisite amounts and sources for universal
coverage for essential care in accordance with State law, and shall
determine the premium amounts to be charged by the Plan for additional
levels of coverage. The aggregate of all universal coverage payments
and premium amounts, along with other sources of income for the Plan,
shall be sufficient to pay all costs of benefits under the Plan, the
costs of administering the Plan, and reasonable reserves for
uncollectible debts to the plan and unexpected demands on the plan for
payment and other purposes;
(2) The Board in its
regulations establishing premium amounts, may prescribe differing amounts
for enrollees who have no dependents and for enrollees with differing
numbers of dependents.
(3) The Board, by
regulation, may establish additional classifications for enrollees for
which different premiums will be determined, based on one or more of the
following:
(a) Covered services
for which the enrollee is eligible or is likely to use;
(b)
Location;
(c) Risk of or
exposure to injury or illness; or
(d) Other factors
normally considered by the health and hospitalization programs and the
health maintenance organization industry in the determination of
premiums.
Source: CSL
2-94-06, § 5-1.
Cross-reference:
The constitutional provisions on health are found in Art. X,
Sections 6 and 7 of the Chuuk State Constitution. Sections 6 and 7
state as follows:
Section 6. The State Government shall
provide for the protection and promotion of health, and shall ensure,
within the limits of its resources, that no person is discriminated
against in the distribution of medical care, or is refused medical care
because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
(1) The Board be
regulation may, subject to Section 5-4 1053 of this
Act Chapter, establish classifications for the
portion of the premium amounts to be billed to an enrollee, employer,
State Government, National Government or other entity or person.
Such classifications shall be based on one or more of the
following:
(a) Payments on behalf
of the enrollees or employers by a State Government of the Federated
States of Micronesia, the National Government, the Government of the
United States of America, or any other source;
(b) Time of payment;
and
(c) Any other factor
reasonably related to the purposes of this Act Chapter.
(2) The Plan shall
bill the amounts determined under this Section.
Source: CSL
2-94-06, § 5-2.
(1) All employers
shall offer to their employees the opportunity to accept first level
optional coverage as prescribed by Section 4-8 1045 of this
Act Chapter;
(2) Employers may at
their discretion offer to their employees additional coverage beyond the
first level of optional coverage; and
(3) Notwithstanding
Subsections (1) and (2) of this Section, enrollees who are not employed
and enrollees desiring additional coverage beyond the first level when it
is not offered by the employer, may attain such coverage by making full
payment of the premium to the Plan in the manner prescribed by Section
5-4 1053(4) of this Act Chapter.
Source: CSL
2-94-06, § 5-3, modified.
(1) An employer of an
enrollee with respect to whom a premium amount is billed shall be
responsible for payment of one-half of such premium amount. The
employer may, by written agreement filed with the Plan, assume
responsibility to pay more than one-half of the premium
amount;
(2) The employer shall
collect the balance of the premium by deducting and withholding such
amount from the enrollee's compensation with respect to pay periods as
specified by the Board's regulation. Every employer required to
deduct and withhold a premium amount shall be liable for the payment of
such amount as well as the employer's share of the premium amount and
shall pay such premium amounts to the Plan with reports or returns as
specified by the Board by regulation;
(3) The Board by
regulation shall establish policies and procedures to equitably allocate
the employer's portion of the premium amount among employers if an
enrollee is employed by more than one employer during a premium payment
period; and
(4) Any person
required to pay a premium amount for whom a collection procedures is not
otherwise provided in this Act Chapter or the regulations shall pay such premium
amount of the Plan with report or returns as specified by the
Board.
Source: CSL
2-94-06, § 5-4.
The Plan shall seek
appropriations from the Chuuk State
Legislature, the National Congress and from other sources, for such
additional revenues as it is reasonably anticipated will be necessary to
compensate for any reduction the total amount of assessments and premiums
collected or that are otherwise deemed to be beneficial to the financial
status of this Plan.
Source: CSL
2-94-06, § 5-5, modified.
The Board by regulation
shall establish and implement procedures to regularly collect premium
amounts from government appropriations, enrollees, employers and other
sources.
Source: CSL
2-94-06, § 5-6.
(1) If any premium
amount imposed by this Act Chapter or regulations is not paid by an employer
or enrollee on or before the date prescribed for such payment, there shall
be collected, in addition to such premium amount and penalties, interest
on the unpaid balance of the premium amount at the rate of 10 percent per
annum from its due date until the date it is paid;
(2) An employer who
has failed to make premium payments when required under this Act Chapter
shall be liable to the Plan for the reasonable coasts incurred by the Plan
and/or employee or covered dependent(s) for medical services required by
the employee or covered dependent(s); provided, that such liability shall
not exceed the costs of such services allowable under the Plan at the
level for which the premiums were to be made; and
(3) Any employer found
to carry on any employment practice directly or indirectly designed to
discourage or prevent employees from exercising the option to accept the
first level of voluntary coverage shall be subject to a penalty of not
more than ten times the amount due to the Plan by the employer for each
employee so affected by such practice. Receipts from the penalty shall
first go to payment of the affected employees' premium payments. The
remainder shall be deposited in the Trust Fund of the Plan as the
realization of general revenue.
Source: CSL
2-94-06, § 5-7, modified.
(1) The Board is
authorized to take civil action and impose liens, if necessary, to collect
overdue premiums or any amount imposed or authorized under this Act Chapter;
and
(2) If any person
liable to pay any amount under this Act Chapter
neglects or refuses to pay the same after demand, the amount including any
fine or interest assessed pursuant to Section 5-7 1056 of this
Act Chapter, together with any costs that may accrue
in addition thereto shall be a lien in favor of the Plan upon all property
and rights to property, whether real or personal, belonging to such person
and may be collected by levy upon such property in the same manner as the
levy of an execution.
Source: CSL
2-94-06, § 5-8, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
Trust
Fund
§
1060. Remedies.
§
1061. Management of Fund.
§
1062. Authorization.
The Board shall
establish a Trust Fund, which shall be administered exclusively for the
purpose of this Act Chapter. All payments or benefits under
this Act Chapter shall be paid from the Fund. The
Fund shall consist of:
(1) All assessments
for universal coverage as provided under this Act Chapter;
(2) All premiums
collected from enrollees and employers;
(3) All money received
as subsidies to the Plan from the Chuuk State
Government, the National Government, or any other source for payment to
the Fund; and
(4) All co-payments,
fines, penalties and interest payments collected pursuant to this Act Chapter.
Source: CSL
2-94-06, § 6-1, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X,
Sections 6 and 7 of the Chuuk State Constitution. Sections 6 and 7
state as follows:
Section 6. The State Government shall
provide for the protection and promotion of health, and shall ensure,
within the limits of its resources, that no person is discriminated
against in the distribution of medical care, or is refused medical care
because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
The Executive Director
shall be the custodian of the Fund and shall administer the Fund in
accordance with the rules and regulations established by the Board.
All monies in the Fund shall be held in trust solely for the
purposes of this Act Chapter. With the approval and under the
direction of the Board, the Executive Director may, from time to time,
invest such monies in the Fund as are in excess of the amount deemed
necessary for a reasonable future period. The investments shall at
all times be so made that all the assets of the fund shall be readily
convertible into cash when needed for the purposes of this Act Chapter.
Source: CSL
2-94-06, § 6-2, modified.
There is hereby
authorized for appropriation such sums from such Fund of the Chuuk State Treasury as may be determined annually to
pay assessments required thereof by Section 5-1 1050 of this
Act Chapter and to assist in the financing of the
Trust Fund to be established pursuant to Section 6-1 1060 of this
Act Chapter. All sums appropriated shall remain
available until fully expended.
Source: CSL
2-94-06, § 6-3, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
Administration
§
1068. Consultation Requirements.
§
1069. Fiscal and Operational Integrity.
§
1070. Third-party Administrators and
Consultants.
§
1071. Determination and appeals.
§
1072. Budget Preparation.
§
1073. Tax Exemption.
§
1074. Corporate Debts and Obligations.
§
1075. Immunity from Liability.
§
1076. Records and Reporting.
The Board shall
establish appropriate measures to assure that it consults with enrollees
and providers on a regular basis and is advised of the impact of its
policies and procedures on such individuals.
Source: CSL
2-94-06, § 7-1.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
The Board shall take
all measures necessary to assure the fiscal and operational integrity of
the Plan and shall review the Plan no less often than quarterly for such
purposes. Review shall include utilization reviews, reviews of
financial statements, reviews of premium and benefit schedules, and
reviews of operational policies and procedures. In particular, the
Board shall take all measures necessary to assure that:
(1) Its policies and
procedures support the health care objectives of Chuuk State;
(2) Payments for
benefits do not exceed revenues to the fund; and
(3) Only payments for
benefits which the Plan is obligated to provide are made.
Source: CSL
2-94-06, § 7-2, modified.
The Board may retain
the services of third-party administrators or qualified health care or
business consultants, as it deems necessary for the successful operation
of the Plan.
Source: CSL
2-94-06, § 7-3.
Except as otherwise
provided in this act Chapter, determinations of eligibility, covered
services, qualified providers, benefit amount, premium amounts to be
billed, and all other matters arising in the implementation of the Plan
shall be made by the Executive Director may be made to the Board in
accordance with procedures specified in the regulations.
Source: CSL
2-94-06, § 7-4, modified.
(1) The Executive
Director shall prepare in advance of each fiscal year an annual budget for
the Plan, taking into consideration anticipated capital and operating
expenditures and anticipated revenues. The Plan shall use the same
fiscal year as that of the Chuuk State
Government. The budget shall indicate the operating capital, and
maintenance requirements of the Plan that will be met with
anticipated revenues of the Plan, and such essential requirements as
cannot be met without increase in revenues of outside financial
assistance. The annual budget shall be reviewed and approved by the
Board; and
(2) The estimated
administrative costs budgeted for any fiscal year of the Plan shall not
exceed an expenditure maximum equal to ten percent of the Plan's estimated
income for such year. For purposes of this
Section, "administrative costs" include the costs of salaries and
wages, maintenance of branch offices, patient and physician care
coordination, third-party administrator contractual service fees, office
supplies and equipment, as well as actuarial, auditing, legal, computer,
financial management, accounting, and similar services. For purposes
of this Section, "income" includes universal coverage payments made,
premiums collected, investment income, fines, penalties and interest
collected. "Income" also includes such subsidiary funds
received from the Chuuk State Government, the
National Government, or any other sources for payment to the Fund that are
not allocated to any particular or specific use or category of
expenditures; provided that the specific approval of the Board must be
obtained for any budgeted administrative cost from such particular or
special use of category funds in excess of the expenditure maximum
prescribed in this Section.
Source: CSL
2-94-06, § 7-5, modified.
The plan shall exist
and operate solely for the benefit of the public and shall to the extent
allowed by law be exempt from any taxes or assessments on any of its
property, operations, or activities. Nothing herein shall be deemed
to exempt employees and independent contractors of the plan from tax
liability for income received from the plan.
Source: CSL
2-94-06, § 7-6.
Unless otherwise
expressly provided by law, the Chuuk State
Government shall not be liable or responsible for any debts or obligations
of the Plan.
Source: CSL
2-94-06, § 7-7, modified.
The Plan and officers,
employees and Board members of the Plan shall be immune from liability for
acts or omissions with respect to service for the Plan to the same extent
as the Chuuk State Government and officers,
directing boards and employees of the Chuuk State Government with respect to Government
service.
Source: CSL
2-94-06, § 7-8, modified.
(1) The Executive
Director shall keep accurate records of the Plan's business transactions.
Such records shall include, but not be limited to, accounting of all
income and expenditures, assets (both tangible and intangible), and
liabilities of the Plan. The Executive Director shall prepare and
submit to the Board a monthly report, which shall include the monthly
financial report. The Board, not later than 90 days after the close
of each fiscal year, shall submit to the Governor and the Chuuk State Legislature, a complete report showing the
activities of the Plan during the fiscal year, the present financial
condition of the Plan, and such other matters as the Board shall deem
appropriate;
(2) The personal
records of the Plan shall be confidential. No officer, employee, or
Board member of the Plan shall disclose any personal records obtained by
him in any manner in connection with his service as such officer,
employee, or Board member, or otherwise. For purposes of this
Section, the term "officer, employee, or Board member" includes a
former officer, employee or Board member. "Personal records"
means any records concerning any individual enrollee or
employer;
(3) The books of
account of the Plan shall be audited by the Chuuk State Public Auditor annually.
Source: CSL
2-94-06, § 7-9, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
Support for the Essential
Level
of Health Insurance
Coverage
§
1080. Intent.
§
1081. Financing.
§
1082. Health Care Premium Fund.
§
1083. Appropriation Requests.
§
1084. Authorization.
§
1085. Review.
The Chuuk State Legislature is of the mind that all persons
eligible for enrollment in the Plan will in fact be enrolled. To
this end, the Chuuk State Legislature
anticipates creating a source of public financing, which along with other
mandated sources of financing, will ensure that all such persons are
accorded the essential level coverage under the Plan.
Source: CSL
2-94-06, § 8-1, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X,
Sections 6 and 7 of the Chuuk State Constitution. Sections 6 and 7
state as follows:
Section 6. The State Government shall
provide for the protection and promotion of health, and shall ensure,
within the limits of its resources, that no person is discriminated
against in the distribution of medical care, or is refused medical care
because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
Not later than July 1,
1994, the Board of the Plan shall submit to the Legislature a detailed
proposal for the financing of the essential level of coverage under the
Plan. Such proposal shall include the sources, levels and expected
revenues to be collected and shall include such draft legislation to amend
this Title Chapter as the Plan deems necessary to secure
financing.
Source: CSL
2-94-06, § 8-2, modified.
There is hereby created
within the Chuuk State Treasury a Health Care
Premium Fund to which all collections imposed by this Title Chapter,
along with all civil penalties and interest with respect thereto, shall be
deposited.
Source: CSL
2-94-06, § 8-3, modified.
The Plan shall,
following consultation with appropriate officials of the State and
National Governments, present an annual request to the Chuuk State Legislature for appropriation from the Fund
to provide the State Government's share of payments necessary to finance
the essential level of health care coverage for all eligible enrollees.
Such request shall include information as to the level of support
being requested of the National Government and other sources for financing
the essential level of coverage provided by the Plan.
Source: CSL
2-94-06, § 8-4, modified.
There is hereby
authorized for appropriation from the Health Care Premium Fund such
amounts as may be determined annually in the Comprehensive Budget Act for
the sole purpose of assisting in the financing of an essential level of
health care coverage for all persons eligible therefor under this act Chapter.
Sums so appropriated shall be administered and expended by the Plan in
accordance with this act Chapter and shall remain available until fully
expended.
Source: CSL
2-94-06, § 8-5, modified.
The Plan shall
periodically undertake a comprehensive review of the financial demands of
maintaining an essential level of health care coverage as provided by this
act Chapter and the revenue generation capacities of
this Title Chapter along with National Government assistance
and other means of support for this coverage; and shall thereafter make
recommendations to the Chuuk State Legislature
as to modifications to the financing systems of this Title Chapter
and other methods and sources of support.
Source: CSL
2-94-06, § 8-6, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
Government
Assistance
§
1090. Government Assistance to the Plan.
§
1091. Initial Administration.
§
1092. Authorization for Initial
Financing.
For the purpose of
planning, undertaking and carrying out the provisions of this Act Chapter and
the subsequent operation of the Plan established hereunder, and where
permissible under law, the Chuuk State
Government, or any agency or political subdivision thereof, may if the
Chief Executive Officer of the respective Governmental Branch or political
subdivision determines that the project is of importance and benefit to
that branch or political subdivision and be of advantage to the people of
this State:
(1) Dedicate, sell,
convey or lease interests in real or personal properties, rights or
privileges that it may have to the Plan;
(2) Incur expenses on
behalf of the plan subject to reimbursement under such conditions as may
be agreed upon with the Board of the Plan;
(3) Do any and all
things necessary to aid or cooperate in the planning or carrying out the
duties, powers and obligations of the Plan;
(4) Lend, advance,
grant or contribute funds to the Plan and provide for or waive the
repayment of any such funds loaned or advanced; and
(5) Contract with or furnish services
to the Plan upon conditions and terms as may be agreed
upon.
Source: CSL
2-94-06, § 9-1, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X,
Sections 6 and 7 of the Chuuk State Constitution. Sections 6 and 7
state as follows:
Section 6. The State Government shall
provide for the protection and promotion of health, and shall ensure,
within the limits of its resources, that no person is discriminated
against in the distribution of medical care, or is refused medical care
because of that person's inability to pay.
Section 7. The State Government shall
provide for the establishment and administration of a comprehensive system
of medical or health insurance which is mandatory for all employed
residents of the State of Chuuk while present in the State. All
revenues received under this system of medical or health insurance, and
all other revenues received by the Health Department as payment for
medicine and medical services, shall be separated from any general fund
established by the Legislature and used only for medical
purposes.
In
addition to such assistance as may be provided under Section 9-1 1090 of this
Title Chapter, the Governor shall provide the initial
Board of Trustees appointed under this act Chapter with
office space and administrative assistance for the first 12 twelve
months of its operations, unless such space and assistance is otherwise
acquired by the Board.
Source: CSL
2-94-06, § 9-2, modified.
There is hereby
authorized for appropriation from the General Fund of the Chuuk State Treasury the sum of $10,000, or so much
thereof as may be appropriated and necessary for the start-up and initial
administration of the Plan established by this act Chapter, for
the development of the detailed proposal for the financing of the Plan as
required by Section 8-2 1081 of this act Chapter, and
for the complete review of the contents of this statute as required by
Section 10-1 1098 of this Act Chapter.
Prior to the organization of the first Board of Trustees of the Plan
under this Act Chapter, not more than 35 percent of the monies
appropriated under the authorization of this Section may be administered
and expended by the Governor solely for the purposes specified in this
Section. Following the organization of the Board, the Governor shall
cause the remainder of monies appropriated hereunder and not expended or
obligated for expenditure by the Governor to be deposited in the Trust
Fund established by the Board pursuant to Section 6-1 1060 of this
Act Chapter. Monies so deposited in the Trust
Fund may only be expended by the Plan for the purposes specified in this
Section, and shall remain available therein until fully expended. The
Board, in its annual report to the Governor and the Legislature as
provided by Section 7-9 1076 of this Act Chapter,
shall provide a full accounting of the use of monies appropriated under
the authorization of this Section, inclusive of such uses and expenditures
by the Office of the Governor prior to the transfer of the appropriation
to the Trust Fund.
Source: CSL
2-94-06, § 9-3, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
Effective
Date
§
1098. Effective Date.
This Act Chapter
shall take effect upon the approval of the Governor, or upon its becoming
law without such approval; provided, however, that no level of coverage
may be extended, no mandatory premiums may be imposed, nor obligation to
provide benefits deriving therefrom may be undertaken prior to the
enactment of a financing system for coverage of persons under the
essential level of care pursuant to Title
VII Subchapter G of this act Chapter;
provided further, that in addition to the requirements of Section 8-2 1081 of this
act Chapter, the Board of the Plan shall within six
months following its initial organization, conduct a complete review of
the contents of this act Chapter and shall thereafter present to the
Legislature a full report as to its proposed implementation of the Plan
along with such draft legislation as the Board deems necessary to amend
this act Chapter to fully realize the purpose of this
act Chapter and to ensure compliance of the Plan with
all existing laws and regulations.
Source: CSL
2-94-06, § 10-1, modified.
Cross-reference:
The constitutional provisions on health are found in Art. X, Sections 6 and 7
of the Chuuk State Constitution.
Editor's note:
CSL 2-94-06 was signed into law by the Governor on April 24,
1994.