POHNPEI STATE HEALTH CARE PLAN
Tirow...anybody familiar with this ? sorry I only read it was passed by the PSL about four days ago.
Legislature is just implementing something already in the Constitution.
This is Article 8, Section 4. It says:
(1) The Government of Pohnpei shall provide health care services for the public.
(2) The Government of Pohnpei shall establish and faithfully execute comprehensive plans for the continual improvement in health care services.
(3) The Government of Pohnpei shall provide for the regulation of health care services.
HEALTH CARE PLAN
4-101 Short title
4-103 Plan established
4-105 Board of Trustees
4-106 Organizational meeting
4-107 Terms of office and reappointment
4-113 Election of Chairman
4-114 Election of Vice-Chairman
4-115 Compensation of Board members
4-116 Exclusion from employment
4-118 Personnel and procurement
4-120 Corporate powers
4-122 Basic eligibility
4-123 Agreements for eligibility of others
4-124 Payment for services
4-125 Medical referral committee
4-127 Covered services
4-128 Benefit amounts
4-129 Qualified providers
4-130 Universal coverage
4-131 Optional benefits
4-132 Other coverage
4-133 Claims procedures
4-134 Assessment and premium amounts
4-135 Billed amounts
4-136 Responsibility for benefit offerings
4-137 Liability for premium payment
4-138 Supplemental revenues
4-139 Premium collection
4-142 Trust Fund
4-143 Management of fund
4-144 Authorization for appropriation; administration
4-145 Consultation requirements
4-146 Fiscal and operational integrity
4-147 Third-party administrators and consultants
4-148 Determinations and appeals
4-149 Budget preparation
4-150 Tax exemption
4-151 Corporate debts and obligations
4-152 Immunity from liability
4-153 Records and reporting
4-156 Health care premium fund
4-157 Appropriation requests
4-158 Authorization for appropriation from health care premium fund; administration
4-159 Periodic financial review
4-160 Government assistance to the Plan
4-161 Initial administration
4-162 Authorization for initial financing
4-163 Effective date
17 PC 4-101. Short title. This chapter is known and may be cited as the “Pohnpei Health Care Act of 1993.”
Source: S.L. No. 3L-39-93 §1-1, 7/29/93
17 PC 4-102. Purpose. The purpose of this chapter is to improve the provision and quality of health services to residents of the state of Pohnpei, 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 chapter establishes a means to control the costs, improve the quality, and assure the availability of medically necessary services of health care providers within and outside of Pohnpei.
Source: S.L. No. 3L-39-93 §1-2, 7/29/93
17 PC 4-103. Plan established. The Pohnpei Health Care Plan is hereby established as a public corporation under the laws of Pohnpei.
Source: S.L. No. 3L-39-93 §1-3, 7/29/93
17 PC 4-104. Definitions. As used in this chapter:
(1) “Board” means the Board of Trustees of the Pohnpei Health Care Plan.
(2) “Bylaws” means the bylaws of the Pohnpei Health Care Plan, in effect from time to time.
(3) “Dependent” means the spouse and child(ren) of an enrollee for additional coverage under this 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 within Pohnpei and who is primarily supported by his or her enrollee parents; and unemployed dependent parents who are members of the enrollee’s household, are over the age of 60 years, and are citizens of Pohnpei residing in Pohnpei.
(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 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 chapter and such regulations as may be issued pursuant hereto.
(7) “Executive Director” means the Executive Director of the Pohnpei Health Care Plan.
(8) “Fund” means the trust fund to be established by the Board pursuant to 17 PC 4-142.
(9) “Off-island health care facility” means any facility providing covered services as defined in 17 PC 4-127 that is located outside of Pohnpei and that is determined by the Board to be a qualified provider as defined in 17 PC 4-129.
(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 Pohnpei Health Care Plan.
(12) “Provider” means any person furnishing any covered service as defined in 17 PC 4-127.
(13) “Referral” means a referral of an enrollee to an out-of-state health care facility granted pursuant to 17 PC 4-125.
(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 Pohnpei for whom Pohnpei is his principal residence, or any noncitizen who has established an ongoing physical presence in Pohnpei and whose presence is sanctioned by law and is not merely transitory in nature.
(16) “State” or “Pohnpei” means the state of Pohnpei.
(17) “Third-party administrator” means the individual or firm within or outside of Pohnpei that contracts to perform administrative services in the operation of the Plan.
Source: S.L. No. 3L-39-93 §1-4, 7/29/93
17 PC 4-105. Board of Trustees.
(1) The governing and administrative powers of the Plan shall be vested in a Board of Trustees, which Board shall consist of five voting members and the Executive Director, who shall serve as an ex-officio, nonvoting member of the Board.
(2) The Governor shall appoint the five voting members of the Board, with the advice and consent of the Pohnpei Legislature, and may remove each such member in case of incompetency, neglect of duty or malfeasance in office. The Board shall be composed of members experienced in financing, health care administration, medical 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 Legislature draft legislation to provide for the periodic popular selection of Board members by citizen enrollees of the Plan.
Source: S.L. No. 3L-39-93 §2-1, 7/29/93
17 PC 4-106. Organizational meeting. The first meeting of the Board shall be held not later than 45 days after appointments of all five voting members of the Board have become effective.
Source: S.L. No. 3L-39-93 §2-2, 7/29/93
17 PC 4-107. Terms of office and reappointment. 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: S.L. No. 3L-39-93 §2-3, 7/29/93
17 PC 4-108. Vacancies. 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: S.L. No. 3L-39-93 §2-4, 7/29/93
17 PC 4-109. Removal. In addition to the removal of a Board member pursuant to 17 PC 4-105, any Board member may be removed from office on such grounds as specified in 17 PC 4-105 by the affirmative vote of four voting Board members.
Source: S.L. No. 3L-39-93 §2-5, 7/29/93
17 PC 4-110. Meetings.
(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.
(4) Full and accurate minutes of all Board meetings shall be kept in such manner as shall be provided in the bylaws.
Source: S.L. No. 3L-39-93 §2-6, 7/29/93
17 PC 4-111. Quorum. 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: S.L. No. 3L-39-93 §2-7, 7/29/93
17 PC 4-112. Deadlock. 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: S.L. No. 3L-39-93 §2-8, 7/29/93
17 PC 4-113. Election of Chairman. 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: S.L. No. 3L-39-93 §2-9, 7/29/93
17 PC 4-114. Election of Vice-Chairman. 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: S.L. No. 3L-39-93 §2-10, 7/29/93
17 PC 4-115. Compensation of Board members. Board members who are employees of the Pohnpei 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 Pohnpei Government or of any other cooperating entities shall be entitled to compensation at rates established by the Government Officers’ Salary Act, Title 9 Chapter 4, as amended or superseded, (9 PC 4-*), when actually performing the functions of the Board, at the direction of the Chairman. 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 Pohnpei Government employees.
Source: S.L. No. 3L-39-93 §2-11, 7/29/93; S.L. No. 4L-25-96 §11, 7/1/97
17 PC 4-116. Exclusion from employment. 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: S.L. No. 3L-39-93 §2-12, 7/29/93
17 PC 4-117. Bylaws. 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: S.L. No. 3L-39-93 §2-13, 7/29/93
17 PC 4-118. Personnel and procurement.
(1) Officers and employees of the Plan shall be exempt from the Public Service System Act, Title 9 Chapter 2, (9 PC 2-*), and the state’s compensation plan, Title 9 Chapter 4, (9 PC 4-*); PROVIDED that, within 120 days following its first organizational 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 maintains in its bylaws a contracting and procurement code certified by the Director of the Department of Treasury and Administration to be sufficient to meet United States of America 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: S.L. No. 3L-39-93 §2-14, 7/29/93
17 PC 4-119. Officers.
(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 chapter, the bylaws or by the Board. Except as provided in 17 PC 4-112, 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.
(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: S.L. No. 3L-39-93 §2-15, 7/29/93
17 PC 4-120. Corporate powers. In addition to any other authority granted under this 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 this chapter;
(9) To conduct its business, carry on its operations, have offices, and 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 Pohnpei; 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: S.L. No. 3L-39-93 §2-16, 7/29/93
17 PC 4-121. Regulations. The Board shall, with the approval of the Governor, adopt, amend or repeal regulations for the administration of the Plan pursuant to the procedures for adoption of regulations as set out in the Administrative Procedures Act, Title 8 Chapter 1, or its successor. Such regulations shall determine, among other things, assessments for universal coverage, premium amounts, professional service standards, and standards and procedures for referrals, collections, disbursement, 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 17 PC 4-148.
Source: S.L. No. 3L-39-93 §2-17, 7/29/93
17 PC 4-122. Basic eligibility. Every resident of Pohnpei shall be enrolled in and shall be eligible to receive benefits as provided under this chapter, except that unemployed noncitizens residing in the state who are not dependents of enrollees are not eligible, except as provided in 17 PC 4-123.
Source: S.L. No. 3L-39-93 §3-1, 7/29/93
17 PC 4-123. Agreements for eligibility of others. The Board is authorized to enter into agreements with the national government, international organizations or other entities to extend the benefits of this chapter to persons within Pohnpei 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: S.L. No. 3L-39-93 §3-2, 7/29/93
17 PC 4-124. Payment for services.
(1) The Plan shall pay the benefit amount for any covered service that is furnished to an enrollee by a qualified provider outside of Pohnpei if such covered service is authorized in a referral granted under 17 PC 4-125.
(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 Pohnpei and for assessment and collection of additional premiums.
(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 Pohnpei.
Source: S.L. No. 3L-39-93 §4-1, 7/29/93
17 PC 4-125. Medical referral committee.
(1) The Pohnpei Department of Health Services shall establish a medical referral committee that shall be composed of, at a minimum, three physicians or medical officers who regularly practice in Pohnpei. 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 Pohnpei medical referral committee. The Pohnpei 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 17 PC 4-127 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 Pohnpei 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 alternate means for the authorization of medical referrals in the event of serious and immediate medical emergencies involving situations in which the medical referral committee is unable to meet for the purposes prescribed in Subsection (2) of this section.
Source: S.L. No. 3L-39-93 §4-2, 7/29/93
17 PC 4-126. Supervision. The Board, by regulation, shall establish policies and procedures to supervise provision of covered services at health care facilities.
Source: S.L. No. 3L-39-93 §4-3, 7/29/93
17 PC 4-127. Covered services. 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, that 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 Pohnpei 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 when authorized by the Plan as provided in its regulations issued pursuant to 17 PC 4-121; and
(6) Preventative health care programs sponsored by the Plan on its own initiative or in conjunction with the Pohnpei Department of Health Services.
Source: S.L. No. 3L-39-93 §4-4, 7/29/93
17 PC 4-128. Benefit amounts. Benefit amounts are the amounts that 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: S.L. No. 3L-39-93 §4-5, 7/29/93
17 PC 4-129. Qualified providers. 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 Pohnpei. The Board shall maintain a list of qualified providers.
Source: S.L. No. 3L-39-93 §4-6, 7/29/93
17 PC 4-130. Universal coverage. The Board, by regulation, shall provide for an essential level of health coverage to be financed in accordance with 17 PC 4-154 through 17 PC 4-159, which coverage shall extend to all eligible enrollees.
Source: S.L. No. 3L-39-93 §4-7, 7/29/93
17 PC 4-131. Optional benefits. 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 17 PC 4-127 or higher benefit amounts than those set pursuant to 17 PC 4-128, and 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: S.L. No. 3L-39-93 §4-8, 7/29/93
17 PC 4-132. Other coverage. The obligations of the Plan to make payment for benefits under this 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 chapter and any other sources, which policies and procedures shall establish the secondary nature of benefits under this chapter. Any overpayments of benefits made under this chapter may be recovered by the Plan from any person to or for whom the payment was made or from any company or organization that is obligated to pay for such services.
Source: S.L. No. 3L-39-93 §4-9, 7/29/93
17 PC 4-133. Claims procedures. The Board, by regulation, shall establish policies and procedures for the identification of enrollees by providers, filing of claims, and disbursement of payment for covered services.
Source: S.L. No. 3L-39-93 §4-10, 7/29/93
17 PC 4-134. Assessment and premium amounts.
(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 whom 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;
(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: S.L. No. 3L-39-93 §5-1, 7/29/93
17 PC 4-135. Billed amounts.
(1) The Board by regulation may, subject to 17 PC 4-137, 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 chapter.
(2) The Plan shall bill the amounts determined under this section.
Source: S.L. No. 3L-39-93 §5-2, 7/29/93
17 PC 4-136. Responsibility for benefit offerings.
(1) All employers shall offer to their employees the opportunity to accept first level optional coverage as prescribed by 17 PC 4-131.
(2) Employers may, at their discretion, offer to their employees additional coverage beyond the first level of optional coverage.
(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 17 PC 4-137(4).
Source: S.L. No. 3L-39-93 §5-3, 7/29/93
17 PC 4-137. Liability for premium payment.
(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.
(4) Any person required to pay a premium amount for whom a collection procedure is not otherwise provided in this chapter or the regulations shall pay such premium amount to the Plan with such report or returns as specified by the Board.
Source: S.L. No. 3L-39-93 §5-4, 7/29/93
17 PC 4-138. Supplemental revenues. The Plan shall seek appropriations from the Pohnpei 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 of the total amount of assessments and premiums collected or that are otherwise deemed to be beneficial to the financial status of this Plan.
Source: S.L. No. 3L-39-93 §5-5, 7/29/93
17 PC 4-139. Premium collection. The Board, by regulation, shall establish and implement procedures to regularly collect premium amounts from government appropriations, enrollees, employers, and other sources.
Source: S.L. No. 3L-39-93 §5-6, 7/29/93
17 PC 4-140. Sanctions.
(1) If any premium amount imposed by this 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 ten percent (10%) 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 chapter shall be liable to the Plan for the reasonable costs 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.
(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: S.L. No. 3L-39-93 §5-7, 7/29/93
17 PC 4-141. Remedies.
(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 chapter.
(2) If any person liable to pay any amount under this chapter neglects or refuses to pay the same after demand, the amount including any fine or interest assessed pursuant to 17 PC 4-140, 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: S.L. No. 3L-39-93 §5-8, 7/29/93
17 PC 4-142. Trust Fund. The Board shall establish a trust fund that shall be administered exclusively for the purpose of this chapter. All payments for benefits under this chapter shall be paid from the fund. The fund shall consist of:
(1) All assessments for universal coverage as provided under this chapter;
(2) All premiums collected from enrollees and employers;
(3) All money received as subsidies to the Plan from the Pohnpei 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 chapter.
Source: S.L. No. 3L-39-93 §6-1, 7/29/93
17 PC 4-143. Management of fund. 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 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 chapter.
Source: S.L. No. 3L-39-93 §6-2, 7/29/93
17 PC 4-144. Authorization for appropriation; administration. There is hereby authorized for appropriation such sums from such funds of the Pohnpei Treasury as may be determined annually to pay assessments required thereof by 17 PC 4-134 and to assist in the financing of the trust fund to be established pursuant to 17 PC 4-142. All sums appropriated shall remain available until fully expended.
Source: S.L. No. 3L-39-93 §6-3, 7/29/93
17 PC 4-145. Consultation requirements. 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: S.L. No. 3L-39-93 §7-1, 7/29/93
17 PC 4-146. Fiscal and operational integrity. 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. Reviews 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 Pohnpei;
(2) Payments for benefits do not exceed revenues to the fund; and
(3) Only payments for benefits that the Plan is obligated to provide are made.
Source: S.L. No. 3L-39-93 §7-2, 7/29/93
17 PC 4-147. Third-party administrators and consultants. 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: S.L. No. 3L-39-93 §7-3, 7/29/93
17 PC 4-148. Determinations and appeals. Except as otherwise provided in this chapter, determinations of eligibility, covered services, qualified providers, benefit amounts, premium amounts to be billed, and all other matters arising in the implementation of the Plan shall be made by the Executive Director in accordance with regulations. Appeals from determinations of the Executive Director may be made to the Board in accordance with procedures specified in the regulations.
Source: S.L. No. 3L-39-93 §7-4, 7/29/93
17 PC 4-149. Budget preparation.
(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 Pohnpei Government. The budget shall indicate the operating capital and maintenance requirements of the Plan that will be met with the anticipated revenues of the Plan and such essential requirements as cannot be met without increase in revenues or outside financial assistance. The annual budget shall be reviewed and approved by the Board.
(2) The estimated administrative costs budgeted for any fiscal year of the Plan shall not exceed an expenditure maximum equal to ten percent (10%) 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 Pohnpei 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 expenditure; 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: S.L. No. 3L-39-93 §7-5, 7/29/93
17 PC 4-150. Tax exemption. 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: S.L. No. 3L-39-93 §7-6, 7/29/93
17 PC 4-151. Corporate debts and obligations. Unless otherwise expressly provided by law, the Pohnpei Government shall not be liable or responsible for any debts or obligations of the Plan.
Source: S.L. No. 3L-39-93 §7-7, 7/29/93
17 PC 4-152. Immunity from liability. 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 Pohnpei Government and officers, directing boards and employees of the Pohnpei Government with respect to government service.
Source: S.L. No. 3L-39-93 §7-8, 7/29/93
17 PC 4-153. Records and reporting.
(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, that 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 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, 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 Public Auditor annually.
Source: S.L. No. 3L-39-93 §7-9, 7/29/93
17 PC 4-154. Intent. The Legislature is of the mind that all persons eligible for enrollment in the Plan will in fact be enrolled. To this end, the Legislature anticipates creating a source of public financing, that along with other mandated sources of financing, will ensure that all such persons are accorded the essential level of coverage under the Plan.
Source: S.L. No. 3L-39-93 §8-1, 7/29/93
17 PC 4-155. Financing. 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 17 PC 4-154 through 17 PC 4-159 as the Plan deems necessary to secure financing.
Source: S.L. No. 3L-39-93 §8-2, 7/29/93
17 PC 4-156. Health care premium fund. There is hereby created within the Treasury a health care premium fund to which all collections imposed by 17 PC 4-154 through 17 PC 4-159 along with all civil penalties and interest with respect thereto, shall be deposited.
Source: S.L. No. 3L-39-93 §8-3, 7/29/93
17 PC 4-157. Appropriation requests. The Plan shall, following consultation with appropriate officials of the state and national governments, present an annual request to the Legislature for appropriation from the health care premium 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: S.L. No. 3L-39-93 §8-4, 7/29/93
17 PC 4-158. Authorization for appropriation from health care premium fund; administration. 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 chapter. Sums so appropriated shall be administered and expended by the Plan in accordance with this chapter and shall remain available until fully expended.
Source: S.L. No. 3L-39-93 §8-5, 7/29/93
17 PC 4-159. Periodic financial review. 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 chapter and the revenue generation capacities of 17 PC 4-154 through 17 PC 4-159 along with national government assistance and other means of support for this coverage; and shall thereafter make recommendations to the Legislature as to modifications to the financing systems of 17 PC 4-154 through 17 PC 4-159 and other methods and sources of support.
Source: S.L. No. 3L-39-93 §8-6, 7/29/93
17 PC 4-160. Government assistance to the Plan. For the purpose of planning, undertaking, and carrying out this chapter and the subsequent operation of the Plan established hereunder, and where permissible under law, the Pohnpei 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: S.L. No. 3L-39-93 §9-1, 7/29/93
17 PC 4-161. Initial administration. In addition to such assistance as may be provided under 17 PC 4-160, the Governor shall provide the initial Board of Trustees appointed under this chapter with office space and administrative assistance for the first 12 months of its operations, unless such space and assistance is otherwise acquired by the Board.
Source: S.L. No. 3L-39-93 §9-2, 7/29/93
17 PC 4-162. Authorization for initial financing. There is hereby authorized for appropriation from the general fund of the Pohnpei 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 chapter, for the development of the detailed proposal for the financing of the Plan as required by 17 PC 4-155, and for the complete review of the contents of this statute as required by 17 PC 4-163. Prior to the organization of the first Board of Trustees of the Plan under this chapter, not more than thirty-five percent (35%) 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 17 PC 4-142. 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 17 PC 4-153, 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: S.L. No. 3L-39-93 §9-3, 7/29/93
Note: S.L. No. 3L-39-93 §9-4 appropriation provision has been omitted.
17 PC 4-163. Effective date. This 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 17 PC 4-154 through 17 PC 4-159; PROVIDED FURTHER that in addition to the requirements of 17 PC 4-155, the Board of the Plan shall, within six months following its initial organization, conduct a complete review of the contents of this 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 chapter to fully realize the purpose of this chapter and to ensure compliance of the Plan with all existing laws and regulations.
Source: S.L. No. 3L-39-93 §10-1, 7/29/93
edited September 2018
As you can see, in 1993, S.L. No. 3L-39-93 implemented the promises of the Pohnpei Constitution with a hold on everything. Since MiCare is being run like a Nazi camp, I guess Pohnpei Leadership is now looking to implement that 1993 statute.
Thank you so much, microspring2014, for providing the background and the full rendition of the legislation....lot of amendments need to be in place as it'll be 26 years by Micare's open season next year.
"Every resident of Pohnpei shall be enrolled in and shall be eligible to receive benefits..." Sounds very noble, most appropriate for our people, and ambitious, not to mention it needs some sharp and creative brains to overcome the financial hurdles. Something very interesting to follow into 2023 and beyond.
This reminds me of Palau's high ranking Reklai of Melekeok, in his farewell speech to participants of the Pacific Festival held in Koror few years back, said something like - when the government leaders informed me Palau plans to host the Festival, I asked them if we can, and be ready to host the Festival, and when they said yes, starting from that day, every Palauan, men and women, young and old, our children, even the birds started to prepare to welcome you.....
And brings back memories of our late Nanmwarkis who were so able in all aspects of Pohnpeian life...oh, how they would support this Health Plan.
Extremely thoughtful of our leaders in 1993.
i think it's good health system
Pushing relevant & Important topics up on the board list.