Health Insurance

Chapter 4: Health Insurance Plan

§ 401. Short title.

§ 402. Definitions.

§ 403. Eligibility.

§ 404. Establishment of Employees' Health Insurance Fund.

§ 405. Premium contributions.

§ 406. Disposition of fund.

§ 407. Administration of the plan.

§ 408. Reporting.

§ 409. Promulgation of regulations.

§ 410. Off-island medical referral.

§ 401. Short title.

This chapter shall be known as the "National Government Employees' Health Insurance Plan Act of 1984."

Source: PL 3-82 § 1.

§ 402. Definitions.

As used in this chapter:

(1) "Agency" means any municipal, State or National Government public agency, institution or entity.

(2) "Business" means any quasi-public or private business entity which is duly licensed to do business under, and doing business under, the laws of the Federated States of Micronesia or its political subdivisions, which is also a participant in the Social Security system of the Federated States of Micronesia, and which has been qualified to participate in the plan pursuant to the regulations promulgated by the Director under section 409 of this chapter.

(3) "Costs of administration" means the following costs of administering the plan:

(a) wages or salaries for personnel engaged in administering the plan;

(b) necessary travel for personnel engaged in administering the plan;

(d) the costs of processing claims;

(e) the costs of printing informational booklets, claim forms, and other necessary materials;

(f) the costs of necessary supplies and equipment;

(g) the costs of communications necessary to the operation of the plan;

(h) the costs of professional services necessary to the operation of the plan.

(4) "Dependents" means:

(a) the members of an employee's immediate family, including grandchildren, dependent parents, and dependent parents-in-law.

(5) "Director" means the Director of the Office of Administrative Services of the Federated States of Micronesia.

(6) "Employee" means an employee of the National Government of the Federated States of Micronesia, an employee of a participating agency, or an employee of a participating business.

(7) "Full-time employee" means an employee who works at least 32 hours of the regular and scheduled workweek.

(8) "Full-time student" means a student who currently enrolled in classes totaling 12 or more semester units at an accredited post-secondary educational institution.

(9) "Participating agency" or "participating agencies" means any public agency, public institution or other public entity, either municipal, State or National, participating in the plan pursuant to section 403 of this chapter.

(10) "Participating business" or "participating businesses" means any business entity, whether quasi-public or privately owned, participating in the plan pursuant to section 403 of this chapter.

(11) "Plan" means the National Government Employees' Health Insurance Plan.

Source: PL 3-82 § 2; PL 7-16 § 1; PL 8-53 § 1; PL 8-133 § 1.

§ 403. Eligibility.

(1) All full-time employees of the National Government of the Federated States of Micronesia may participate in the plan.

(2) Other persons who may participate in the plan are:

(a) The full-time employees of each participating agency and business which has entered into a contract with the Director, as administrator of the plan, whereby such agencies or businesses have agreed to participate in the plan.

(b) The dependents of full-time employees of the National Government, participating agencies and participating businesses;

(c) Members of an employee's household who are dependent upon the employee, but are not otherwise defined as "dependents" under the provisions of this act, if the employee pays 100 percent of the premiums for such persons to the plan;

(d) Government employees whose State or agency does not participate in the plan, and their dependents, if they pay 100 percent of the premiums for themselves and the dependents to the plan; and

(e) Former enrollees in the plan, and their dependents, if they pay 100 percent of the premiums for themselves and their dependents to the plan.

Source: PL 3-82 § 3; PL 8-53 § 2; PL 8-133 § 2.

§ 404. Establishment of Employees' Health Insurance Fund.

(1) There is established a National Government Employees' Health Insurance Fund, (hereinafter "Employees' Health Insurance Fund") which shall be separate from the General Fund or other funds. All sums appropriated by Congress representing contributions of the National Government to the plan, all sums representing contributions of participating agencies to the plan, and all employee contributions to the plan, shall be deposited in the Employees' Health Insurance Fund. Any unexpended money in the Employees' Health Insurance Fund shall not revert to the General Fund or lapse at the end of the fiscal year, but shall remain in the Employees' Health Insurance Fund.

(2) The Director shall have the sole authority to administer the Employees' Health Insurance Fund in accordance with regulations promulgated under this act. The Director shall maintain this Employees' Health Insurance Fund in a separate custodial trust account and may, from time to time, invest such moneys that are in excess of the amount deemed necessary for the operation of the plan during the reasonable future. Such investments shall be low-risk and made in consultation with the Secretary of the Department of Finance. The investments shall at all times be made so that all of the assets of the Employees' Health Insurance Fund shall be readily convertible into cash when needed for the purpose of this act. All income earned on these investments shall be deposited into the Employees' Health Insurance Fund.

Source: PL 3-82 § 4; PL 8-53 § 3.

§ 405. Premium contributions.

Employees participating in the plan shall contribute the percentage of the premium not paid by their employer for insurance under the plan. The National Government of the Federated States of Micronesia shall contribute at least 52 percent of the premium for eligible employees of the National Government participating in the plan. Any participating agency or participating business shall contribute at least 52 percent of the premium for their employees participating in the plan, or may at their request contract with the Director to contribute more than 52 percent.

Source: PL 3-82 § 5; PL 8-53 § 4; PL 8-133 § 3.

§ 406. Disposition of fund.

(1) All money deposited in the Employees' Health Insurance Fund shall be used to pay claims, except that a sum representing not more than ten percent of the estimated income for that year from contributions and income on investments may be expended for costs of administration.

(2) The Employees' Health Insurance Fund shall maintain a separate account for each of the States, which shall include all contributions from that State, plus interest, minus administrative costs. A State's account may not be charged for any services rendered to a member who resides in any other State, unless, in the case of a state-wide emergency, both States transmit their agreement in writing to the Plan Director.

(3) If a State's premium payments are current, the Plan may use any amount which remains in a State's account at the end of the fiscal year, and which exceeds 25 percent of the total premium paid by that State in that fiscal year, to purchase hospital supplies, equipment or medicines for that State's hospital.

Source: PL 3-82 § 6; PL 6-114 § 1; PL 8-53 § 5.

§ 407. Administration of the plan.

The plan shall be administered by the Director.

Source: PL 3-82 § 7; PL 8-53 § 6.

§ 408. Reporting.

The Director shall prepare and submit an annual report on the status of the plan prior to the commencement of each regular May session of Congress. This report shall include a statement of the amount of money on deposit in the Employees' Health Insurance Fund as of the date of the annual report, the amount of premiums collected and interest earned during the preceding fiscal year, the amount of money disbursed for claims during the preceding fiscal year, the number of claims paid during the preceding fiscal year, the costs of administration, and such other information as the Director may deem appropriate.

Source: PL 3-82 § 8; PL 8-53 § 7.

§ 409. Promulgation of regulations.

(1) The Director, with the approval of the President, shall promulgate regulations, pursuant to chapter 1 of title 17 of this code, governing the amount of the premium for insurance under the plan, the procedure for making claims under the plan, the amount and type of benefits under the plan, the policy limits under the plan, and such other matters as may be consistent with the contents and purpose of this chapter, including the implementation of those provisions of this chapter pertaining to participating agencies and participating businesses.

(a) The Director shall promulgate no regulation allowing a claim for benefits under the plan to be denied on the grounds that the medical condition giving rise to the claim existed before the person making the claim began participating in the plan. Any such existing regulation is hereby retroactively repealed for a period of six months from the date this act becomes law.

(a) provide, arrange for, pay for, or reimburse the costs of medical, dental and vision treatment and care, hospitalization, surgery, prescription drugs, medicine, prosthetic appliances, out-patient care, and other medical care benefits, in cash or the equivalent in medicines and supplies;

(b) provide life insurance benefits;

(d) contract for other services as needed.

Source: PL 3-82 § 9; PL 8-53 § 8; PL 8-133 § 4.

Cross-reference: Chapter 1 of title 17 of this code is on FSM Administrative Procedures.

§ 410. Off-island medical referral.

(1) No payment shall issue for any off-island medical referral unless:

(a) The procedure is one which must or may be performed off-island under the standard medical referral criteria, or cannot be effectively performed at the referring hospital, and the referral conforms to all referral procedures set forth in the regulations; or

(b) The Director determines that a medical emergency existed, the necessary surgery or treatment could not have been performed effectively at the referring hospital, and the delay necessary to follow proper procedures would have resulted in death or permanent serious damage to the health of the patient; or

(c) The patient is outside of the Federated States of Micronesia when a medical emergency arises, or is covered by a supplemental or non-resident plan, as set forth in the regulations.

(2) The Director shall consult with the Directors of the member States' Health Services, and shall develop standard medical referral criteria within six months of the date this act becomes law, to be applied to all off-island medical referrals.

Source: PL 8-53 § 9.

	FSMC, TITLE 52. PUBLIC EMPLOYMENT
	Chapter 4: Health Insurance Plan § 401. Short title. § 402. Definitions. § 403. Eligibility. § 404. Establishment of Employees' Health Insurance Fund. § 405. Premium contributions. § 406. Disposition of fund. § 407. Administration of the plan. § 408. Reporting. § 409. Promulgation of regulations. § 410. Off-island medical referral. § 401. Short title. This chapter shall be known as the "National Government Employees' Health Insurance Plan Act of 1984." Source: PL 3-82 § 1. § 402. Definitions. As used in this chapter: (1) "Agency" means any municipal, State or National Government public agency, institution or entity. (2) "Business" means any quasi-public or private business entity which is duly licensed to do business under, and doing business under, the laws of the Federated States of Micronesia or its political subdivisions, which is also a participant in the Social Security system of the Federated States of Micronesia, and which has been qualified to participate in the plan pursuant to the regulations promulgated by the Director under section 409 of this chapter. (3) "Costs of administration" means the following costs of administering the plan: (a) wages or salaries for personnel engaged in administering the plan; (b) necessary travel for personnel engaged in administering the plan; (c) costs and expenses for training of personnel engaged in administering the plan; (d) the costs of processing claims; (e) the costs of printing informational booklets, claim forms, and other necessary materials; (f) the costs of necessary supplies and equipment; (g) the costs of communications necessary to the operation of the plan; (h) the costs of professional services necessary to the operation of the plan. (4) "Dependents" means: (a) the members of an employee's immediate family, including grandchildren, dependent parents, and dependent parents-in-law. (5) "Director" means the Director of the Office of Administrative Services of the Federated States of Micronesia. (6) "Employee" means an employee of the National Government of the Federated States of Micronesia, an employee of a participating agency, or an employee of a participating business. (7) "Full-time employee" means an employee who works at least 32 hours of the regular and scheduled workweek. (8) "Full-time student" means a student who currently enrolled in classes totaling 12 or more semester units at an accredited post-secondary educational institution. (9) "Participating agency" or "participating agencies" means any public agency, public institution or other public entity, either municipal, State or National, participating in the plan pursuant to section 403 of this chapter. (10) "Participating business" or "participating businesses" means any business entity, whether quasi-public or privately owned, participating in the plan pursuant to section 403 of this chapter. (11) "Plan" means the National Government Employees' Health Insurance Plan. Source: PL 3-82 § 2; PL 7-16 § 1; PL 8-53 § 1; PL 8-133 § 1. § 403. Eligibility. (1) All full-time employees of the National Government of the Federated States of Micronesia may participate in the plan. (2) Other persons who may participate in the plan are: (a) The full-time employees of each participating agency and business which has entered into a contract with the Director, as administrator of the plan, whereby such agencies or businesses have agreed to participate in the plan. (b) The dependents of full-time employees of the National Government, participating agencies and participating businesses; (c) Members of an employee's household who are dependent upon the employee, but are not otherwise defined as "dependents" under the provisions of this act, if the employee pays 100 percent of the premiums for such persons to the plan; (d) Government employees whose State or agency does not participate in the plan, and their dependents, if they pay 100 percent of the premiums for themselves and the dependents to the plan; and (e) Former enrollees in the plan, and their dependents, if they pay 100 percent of the premiums for themselves and their dependents to the plan. Source: PL 3-82 § 3; PL 8-53 § 2; PL 8-133 § 2. § 404. Establishment of Employees' Health Insurance Fund. (1) There is established a National Government Employees' Health Insurance Fund, (hereinafter "Employees' Health Insurance Fund") which shall be separate from the General Fund or other funds. All sums appropriated by Congress representing contributions of the National Government to the plan, all sums representing contributions of participating agencies to the plan, and all employee contributions to the plan, shall be deposited in the Employees' Health Insurance Fund. Any unexpended money in the Employees' Health Insurance Fund shall not revert to the General Fund or lapse at the end of the fiscal year, but shall remain in the Employees' Health Insurance Fund. (2) The Director shall have the sole authority to administer the Employees' Health Insurance Fund in accordance with regulations promulgated under this act. The Director shall maintain this Employees' Health Insurance Fund in a separate custodial trust account and may, from time to time, invest such moneys that are in excess of the amount deemed necessary for the operation of the plan during the reasonable future. Such investments shall be low-risk and made in consultation with the Secretary of the Department of Finance. The investments shall at all times be made so that all of the assets of the Employees' Health Insurance Fund shall be readily convertible into cash when needed for the purpose of this act. All income earned on these investments shall be deposited into the Employees' Health Insurance Fund. Source: PL 3-82 § 4; PL 8-53 § 3. § 405. Premium contributions. Employees participating in the plan shall contribute the percentage of the premium not paid by their employer for insurance under the plan. The National Government of the Federated States of Micronesia shall contribute at least 52 percent of the premium for eligible employees of the National Government participating in the plan. Any participating agency or participating business shall contribute at least 52 percent of the premium for their employees participating in the plan, or may at their request contract with the Director to contribute more than 52 percent. Source: PL 3-82 § 5; PL 8-53 § 4; PL 8-133 § 3. § 406. Disposition of fund. (1) All money deposited in the Employees' Health Insurance Fund shall be used to pay claims, except that a sum representing not more than ten percent of the estimated income for that year from contributions and income on investments may be expended for costs of administration. (2) The Employees' Health Insurance Fund shall maintain a separate account for each of the States, which shall include all contributions from that State, plus interest, minus administrative costs. A State's account may not be charged for any services rendered to a member who resides in any other State, unless, in the case of a state-wide emergency, both States transmit their agreement in writing to the Plan Director. (3) If a State's premium payments are current, the Plan may use any amount which remains in a State's account at the end of the fiscal year, and which exceeds 25 percent of the total premium paid by that State in that fiscal year, to purchase hospital supplies, equipment or medicines for that State's hospital. Source: PL 3-82 § 6; PL 6-114 § 1; PL 8-53 § 5. § 407. Administration of the plan. The plan shall be administered by the Director. Source: PL 3-82 § 7; PL 8-53 § 6. § 408. Reporting. The Director shall prepare and submit an annual report on the status of the plan prior to the commencement of each regular May session of Congress. This report shall include a statement of the amount of money on deposit in the Employees' Health Insurance Fund as of the date of the annual report, the amount of premiums collected and interest earned during the preceding fiscal year, the amount of money disbursed for claims during the preceding fiscal year, the number of claims paid during the preceding fiscal year, the costs of administration, and such other information as the Director may deem appropriate. Source: PL 3-82 § 8; PL 8-53 § 7. § 409. Promulgation of regulations. (1) The Director, with the approval of the President, shall promulgate regulations, pursuant to chapter 1 of title 17 of this code, governing the amount of the premium for insurance under the plan, the procedure for making claims under the plan, the amount and type of benefits under the plan, the policy limits under the plan, and such other matters as may be consistent with the contents and purpose of this chapter, including the implementation of those provisions of this chapter pertaining to participating agencies and participating businesses. (a) The Director shall promulgate no regulation allowing a claim for benefits under the plan to be denied on the grounds that the medical condition giving rise to the claim existed before the person making the claim began participating in the plan. Any such existing regulation is hereby retroactively repealed for a period of six months from the date this act becomes law. (2) The plan may: (a) provide, arrange for, pay for, or reimburse the costs of medical, dental and vision treatment and care, hospitalization, surgery, prescription drugs, medicine, prosthetic appliances, out-patient care, and other medical care benefits, in cash or the equivalent in medicines and supplies; (b) provide life insurance benefits; (c) contract with private sector insurance companies to provide benefits; and (d) contract for other services as needed. Source: PL 3-82 § 9; PL 8-53 § 8; PL 8-133 § 4. Cross-reference: Chapter 1 of title 17 of this code is on FSM Administrative Procedures. § 410. Off-island medical referral. (1) No payment shall issue for any off-island medical referral unless: (a) The procedure is one which must or may be performed off-island under the standard medical referral criteria, or cannot be effectively performed at the referring hospital, and the referral conforms to all referral procedures set forth in the regulations; or (b) The Director determines that a medical emergency existed, the necessary surgery or treatment could not have been performed effectively at the referring hospital, and the delay necessary to follow proper procedures would have resulted in death or permanent serious damage to the health of the patient; or (c) The patient is outside of the Federated States of Micronesia when a medical emergency arises, or is covered by a supplemental or non-resident plan, as set forth in the regulations. (2) The Director shall consult with the Directors of the member States' Health Services, and shall develop standard medical referral criteria within six months of the date this act becomes law, to be applied to all off-island medical referrals. Source: PL 8-53 § 9.