H 3688 Session 111 (1995-1996)
H 3688 General Bill, By Harvin
A Bill to amend Title 38, Code of Laws of South Carolina, 1976, relating to
insurance, by adding Chapter 91 so as to enact provisions for health care
purchasing alliances, and provide for related matters.
02/23/95 House Introduced and read first time HJ-29
02/23/95 House Referred to Committee on Labor, Commerce and
Industry HJ-29
A BILL
TO AMEND TITLE 38, CODE OF LAWS OF SOUTH
CAROLINA, 1976, RELATING TO INSURANCE, BY ADDING
CHAPTER 91 SO AS TO ENACT PROVISIONS FOR HEALTH
CARE PURCHASING ALLIANCES, AND PROVIDE FOR
RELATED MATTERS.
Be it enacted by the General Assembly of the State of South
Carolina:
SECTION 1. Title 38 of the 1976 Code is amended by adding:
"CHAPTER 91
Health Care Purchasing Alliance Act
Section 38-91-10. The purpose and intent of this chapter is to
increase the affordability, efficiency, and fairness of health care
coverage for small employers.
The chapter promotes the development of voluntary purchasing
alliances to provide affordable health care coverage for
self-employed individuals and employees of participating small
employers in the manner of large employer groups. The alliances
will allow members to benefit from the contracting expertise and
the administrative savings that can result from the pooling of small
employers and self-employed individuals.
These alliances will make available through their contracting
processes a choice of accountable health carriers that arrange for
quality health services in a cost-effective manner. The chapter
establishes rules for fair competition among competing accountable
health carriers. These rules include the offering of comparable
benefits by competing accountable health carriers, risk assessment,
and risk adjustment to assure competition based on a fair allocation
of risk among accountable health carriers, and the providing of data
that measures clinical outcomes and other valid areas of accountable
health carrier performance.
Carriers throughout the health care coverage market for small
employers are required to use adjusted community rating, guarantee
the continuity of coverage, adhere to limitations on the use of
preexisting conditions, abolish individual medical underwriting, and
follow rules limiting the use of participation requirements.
Section 38-91-20. As used in this chapter:
(1) `Accountable health carrier' means a carrier registered with
the board pursuant to Section 38-91-60.
(2) `Adjusted community rating' means a method used to de-
velop carrier premiums which spreads financial risk across a large
population and allows adjustments only for the following
demographic factors: age, gender, number of family members
covered, and geographic areas.
(3) `Alliance' means a state-chartered, nonprofit organization
that provides health insurance purchasing services to member small
employers in a market area regarding qualified health care plans
offered by accountable health carriers established pursuant to
Section 38-91-90.
(4) `Alliance board' means the alliance board of directors for a
market area established pursuant to Section 38-91-70.
(5) `Antitrust laws' means federal and state laws intended to
protect commerce from unlawful restraints, monopolies, and unfair
business practices.
(6) `Board' means the State Health Plan Purchasing Alliance
Board.
(7) `Community sponsor' means an organization that assumes
responsibility for serving as the host for an alliance in a market
area.
(8) `Employee enrollee' means an eligible employee or depen-
dent of an eligible employee who is enrolled in a qualified health
care plan.
(9) `Fund' means the State Health Plan Purchasing Alliance
Fund established under Section 38-91-150.
(10) `Grievance procedure' means an established set of rules that
specify a process for appeal of an organizational decision.
(11) `Late enrollee' means an eligible employee or a dependent
of an eligible employee who requests enrollment in a qualified
health care plan after the initial enrollment period for a member
small employer, provided the enrollment is consistent with the
alliance's rules for initial enrollment and provided that the initial
enrollment period shall extend for at least thirty consecutive
calendar days. However, an eligible employee or dependent shall
not be considered a late enrollee if:
(a) The individual was covered under a public or private
health benefit plan that provided at least the minimum level of
benefits in qualified health care plans at the time the individual was
eligible to enroll and either:
(i) lost coverage under another health plan as a result of
termination of employment, the termination of coverage under
another health plan, or the death of a spouse or divorce and requests
enrollment in a qualified health care plan within thirty days after
termination of coverage, or
(ii) stated, in writing, during the enrollment period that
coverage under another employer's health benefit plan was the
reason for declining coverage;
(b) The individual elects a different health plan offered
through an alliance during an open enrollment period;
(c) An eligible employee requests enrollment within thirty
days of becoming an employee of a member small employer;
(d) A court has ordered that coverage be provided for a
spouse or minor child under a covered employee's health benefit
plan and the request for enrollment is made within thirty days after
issuance of the court order; or
(e) The individual or employee enrollee makes a request for
enrollment of the spouse or child within thirty days of his
or her marriage or the birth or adoption of a child.
(12) `Lowest cost plan' means the lowest cost qualified health
care plan selected by a member small employer and offered to the
employer's employee enrollees.
(13) `Market area' means a clearly defined, nonoverlapping, and
exclusive geographical area determined by the board for the purpose
of defining the region in which an alliance shall operate.
(14) `Member small employer' means a small employer who
enrolls in an alliance.
(15) `Qualified health care plans' means the basic or standard
health care plans offered by an accountable health carrier to
member small employers.
(16) `Risk adjustment mechanism' means the process established
pursuant to Section 38-91-130.
(17) `Service area' means a geographic region in which a carrier
is licensed to operate.
(18) `Small employer' means any individual actively engaged in
business that, on at least fifty percent of its working days during the
preceding calendar quarter, employed no more than forty-nine
eligible employees, the majority of whom are employed within this
State, and is not formed primarily for purposes of buying health
insurance and in which a bona fide employer-employee relationship
exists. In determining the number of eligible employees, companies
that are affiliated companies, or that are eligible to file a combined
tax return for purposes of taxation by this State, are considered one
employer. Subsequent to the issuance of a health benefit plan to a
small employer and for the purpose of determining eligibility, the
size of a small employer shall be determined annually. Except as
otherwise specifically provided, the provisions of this chapter that
apply to a small employer shall continue to apply until the plan
anniversary following the date the small employer no longer meets
the requirements of this definition. For purposes of this chapter,
the term small employer includes self-employed individuals.
Section 38-91-30. A health benefit plan is subject to this
chapter if it provides health benefits for small employers and if any
of the following conditions are met:
(1) any part of the premiums or benefits is paid by a small
employer, or any covered individual is reimbursed, whether through
wage or adjustments or otherwise, by a small employer for any
portion of the premium;
(2) the health benefit plan is treated by the employer or any of
the covered self-employed individuals as part of a plan or program
for the purposes of Sections 106, 125, or 162 of the United States
Internal Revenue Code; or
(3) the small employer has permitted payroll deductions for the
eligible enrollees for the health benefit plans.
Section 38-91-40. Nothing in this chapter is considered to be in
conflict with or in limitation of the duties and powers granted to the
Director of the Department of Insurance. The board and alliances
established under this chapter shall bring to the attention of the
Department of Insurance any suspected or alleged violations of this
chapter.
Section 38-91-50. (A) There is established the State Health
Plan Purchasing Alliance Board. The board shall be established
within the Department of Insurance for administrative,
organizational, and budgetary purposes only. The Department of
Insurance shall pro vide administrative and staff support to the
board. The Department of Insurance shall provide technical
assistance as requested by the board.
(B) The board shall consist of eleven members as follows:
(1) three appointed by the Governor, at least one of whom
shall be an owner or manager of a member small employer of an
alliance operating in South Carolina, and at least one of whom shall
be an employee enrollee of an alliance operating in South Carolina;
(2) three appointed by the General Assembly upon the
recommendation of the Speaker of the House of Representatives, at
least one of whom shall be an owner or manager of a member small
employer of an alliance operating in South Carolina, and at least
one of whom shall be an employee enrollee of an alliance operating
in South Carolina;
(3) three appointed by the General Assembly upon the
recommendation of the President Pro Tempore of the Senate, at
least one of whom shall be an owner or manager of a member small
employer of an alliance operating in South Carolina, and at least
one of whom shall be an employee enrollee of an alliance operating
in South Carolina;
(4) the designee of the Lieutenant Governor; and
(5) the Director of the Department of Insurance or his
designee.
(C) Members of the board who are not officers or employees of
the State shall receive compensation of two hundred dollars for
each day or part of a day of service plus reimbursement for travel
and subsistence expenses at the rates allowed by law. Members of
the board who are officers or employees of the State shall receive
reimbursement for travel and subsistence at the rates allowed by
law.
(D) Appointed members shall serve for four-year terms except
that the initial terms of:
(1) two members appointed by the Governor, two members
appointed by the General Assembly upon the recommendation of
the President Pro Tempore of the Senate, and one member
appointed by the General Assembly upon the recommendation of
the Speaker of the House of Representatives shall expire July 1,
1997; and
(2) one member appointed by the Governor, one member
appointed by the General Assembly upon the recommendation of
the President Pro Tempore of the Senate, and two members
appointed by the General Assembly upon the recommendation of
the Speaker of the House of Representatives shall expire July 1,
1999.
(E) At the end of a term, a member shall continue to serve until
a successor is appointed. A member who is appointed after a term
has begun serves only for the remainder of the term and until a
successor is appointed. A member who serves two consecutive full
four-year terms shall not be reappointed until four years after
completion of those terms. A vacancy in a legislative appointment
shall be filled in the same manner as original appointment.
(F) The board shall elect officers biennially. Officers shall
serve no more than two consecutive terms in an office.
(G) The board shall appoint an executive director who shall
serve at the pleasure of the board. The executive director shall
administer the affairs of the board. The executive director may
employ and direct staff necessary to carry out the provisions of this
chapter.
(H) The board shall meet as needed at the times and places it
determines. A majority of the fully authorized membership of the
board is a quorum.
(I) No board members or their spouses shall be employed by,
affiliated with an agent of, or otherwise a representative of any
carrier or health care provider.
(J) No individual shall be appointed to or remain a member of
the board if the individual, the individual's spouse, or the individual
and spouse together, held securities or are otherwise the
beneficiaries of securities worth ten thousand dollars or more at fair
market value as of December 31 of the preceding year in a single
health care business or aggregated among multiple health care
businesses. For the purposes of this subsection, the term, `health
care business':
(1) includes an association, corporation, enterprise, joint
venture, organization, partnership, proprietorship, trust, and every
other business interest that provides or insures human health care;
and
(2) does not include a widely held investment fund, regulated
investment company, or pension or deferred compensation plan if
neither the individual nor the individual's spouse has the ability to
exercise control over the financial interests held by the fund.
Section 38-91-60. The board shall:
(1) establish no less than four and no more than twelve market
areas in this State. In establishing such market areas, the board
shall ensure that every location is a part of a market area. To the
largest extent possible, the board should consider metropolitan
standard areas and other existing markets. The board may redefine
market areas where it determines there will be insufficient numbers
of enrollees, health care providers, or qualifying accountable health
carriers to make such requirements feasible. Any such
modifications are subject to annual review by the board;
(2) accept applications by carriers to qualify as accountable
health carriers, determine the eligibility of carriers to become
accountable health carriers according to criteria described in Section
38-91-90, and designate carriers as accountable health carriers;
(3) establish alliances with community sponsors pursuant to
Section 38-91-70 for each market area determined by the board;
(4) conduct annual reviews of the performance of each alliance
to ensure that the alliance is in compliance with this chapter. To
assist the board in its review, each alliance shall submit data to the
board quarterly including, but not limited to, employer enrollment
by employer size; industry sector, previous insurance status and
number of employees within each insurance status; number of total
eligible employers in the market area participating in the alliance;
number of insured lives by county and insured category, including
employees, dependents and other insured categories, represented by
alliance members; profiles of potential employer membership by
county; premium ranges for each qualified health care plan for
alliance member categories; type and resolution of member
grievances; surcharges; and alliance financial statements. A
summary of this annual review shall be provided to the General
Assembly and each alliance;
(5) develop standard enrollment procedures to be used in
enrolling small employers and their eligible employees;
(6) establish conditions of participation for small employers
and self-employed individuals which shall conform to the
requirements of this chapter and include, but not be limited to, the
following:
(a) assurances that the member small employer is a valid
small employer group and is not formed for the purpose of securing
health benefits coverage. This assurance must include requirements
that sole proprietors and self-employed individuals have been in
business for a reasonable period of time as established by the board,
have provided filings to verify employment status, and have
provided other evidence, in the board's discretion, to ensure that the
individual is working;
(b) a member small employer who opts to pay seventy
percent or more of the cost of coverage may choose to offer a
single qualified health care plan to its eligible employees. Eligible
employees of other member small employers shall have the choice
of at least two qualified health care plans. All member small
employers may offer the qualified health care plans of more than
one accountable health carrier. The board and alliances shall
encourage all member small employers to consider offering more
than one accountable health carrier;
(c) minimum employer contribution requirements that shall
be an amount not less than fifty percent of the premium for an
employee's coverage of the lowest cost plan. The alliance shall
require that the employer contribute the same dollar amount for
each employee regardless of the qualified health care plan chosen
by the employee;
(d) a mechanism that will provide for participation if an
employer chooses not to participate but one hundred percent of the
eligible employees who are not covered under a health benefit plan
elect to purchase their coverage through the alliance; and
(e) prepayment of premiums or other mechanisms to assure
that payment will be made for coverage;
(7) ensure that any small employer or any employee of a small
employer who meets the requirements established by the board
pursuant to subdivision (6) of this section may purchase health care
coverage through an alliance;
(8) assure compliance with this chapter by alliances, small
employers, and employee enrollees;
(9) have the authority to request carrier information about the
financial condition of the carrier consistent with the financial
information required to be submitted by the carrier to the
Department of Insurance;
(10) assure fair and affirmative marketing of the qualified health
care plans consistent with standards established by the Department
of Insurance and Section 38-91-120;
(11) appoint advisory committees that shall include persons with
expertise in health benefits management and representatives of
accountable health carriers;
(12) develop uniform standards for the data that alliances collect
from accountable health carriers. In formulating such standards, the
board shall strive for consistency with health care data collection
activities underway in South Carolina and nationally. Any data
collection requirements promulgated by the board shall be based on
a study of their feasibility and cost-effectiveness, including their
consistency with national standards for electronic data interchange,
and their necessity for supporting the evaluation of accountable
health carriers and their provider networks with respect to cost
containment, quality, control of expensive technology, and customer
satisfaction. All enrollee satisfaction surveys employed by alliances
shall be in a standardized format promulgated by the board;
(13) have the authority to sue or be sued, including taking action
necessary for securing legal remedies on behalf of, or against
alliances, member small employers, or employee enrollees and
dependents of those employees;
(14) have the authority to receive and accept grants or funds
from any public or private agency and receive and accept
contributions from any source of money, property, labor, or any
other thing of value;
(15) develop and implement standardized forms for use by
accountable health carriers in conformance with applicable national
standards;
(16) review, and limit if necessary, surcharges charged by each
alliance for administrative costs;
(17) develop guidelines for any authorized marketing materials to
be used in providing member small employers and their eligible
employees with information regarding accountable health carriers
and their respective qualified health care plans in accordance with
Section 38-91-120. Such guidelines shall be consistent with
standards established by the Department of Insurance;
(18) develop grievance procedures to be used in resolving dis-
putes between member small employers and alliances. A member
small employer alliance or accountable health carrier may appeal to
the board any grievance that is not resolved;
(19) receive, review, and act on appeals of grievances not
resolved;
(20) analyze information collected from accountable health
carriers and other sources and report findings that assist consumers,
alliances, accountable health carriers, or health care providers in
improving the delivery or purchase of cost-effective health care;
(21) report annually on the operation of the board to the General
Assembly and the Governor.
Section 38-91-70. (A) The board is authorized to create a
single alliance within each designated market area for the benefit of
its member small employers. Each alliance shall be operated as a
state-chartered, nonprofit private organization.
(B) Each alliance shall operate under the supervision of an
alliance board of directors, which shall consist of eleven members.
The majority of members on each alliance board shall be small
employers.
(1) The board shall initially appoint six members for a term
of two years. The community sponsor shall initially appoint five
members for a term of two years. In so doing, the board and
community sponsor shall consider, among other things, whether all
member small employers are fairly represented and assure that a
majority of the alliance board shall be small employers.
(2) Subsequent members of the alliance board of directors
shall be elected pursuant to the alliance board's bylaws.
(C) Each alliance board shall adopt bylaws that shall include a
procedure for the election of alliance board members by the
alliance's member small employers.
(D) Of the initially elected members of each alliance board, six
members shall be designated to serve two-year terms and the
remaining five members shall serve four-year terms. Thereafter, the
term of an elected member shall be four years.
(E) Vacancies on an alliance board shall be filled for the
remaining period of the term by a majority vote of the remaining
board members. A member appointed to fill a vacancy may serve
for the remainder of the term and until a qualified successor is
elected for a new term.
(F) A member who serves two consecutive full four-year terms
shall not be reelected for four years after completion of those terms.
(G) Members of the alliance board shall be bound by the
financial interest restrictions set forth for board members in Section
38-91-50(I) and (J).
(H) The alliance board shall elect officers from among its
members every two years. Officers shall not serve more than two
consecutive terms in an office.
(I) The alliance board shall meet at times and places as it
determines necessary to operate the alliance in accordance with this
section and Section 38-91-80. Such meetings shall be governed by
the procedures and policies set forth by the South Carolina Freedom
of Information Act.
(J) There shall be no liability on the part of, and no cause of
action of any nature shall arise against any member of the alliance
board, or its employees or agents, for any action taken in good faith
by them in the performance of their powers and duties as defined
under Section 38-91-80.
(K) The alliance board shall have the powers and duties regard-
ing operation of the alliance set forth in Section 38-91-60.
Section 38-91-80. An alliance shall have the following powers
and duties:
(1) enter into contracts with accountable health carriers for the
provision of qualified health care plans for members of the alliance
pursuant to Section 38-91-90. Each alliance shall contract with all
accountable health carriers which offer qualified health care plans
operating in its market area and apply to serve member small
employers;
(2) enter into contracts with small employers pursuant to
Section 38-91-100;
(3) maintain eligibility records as appropriate to carry out the
functions of this chapter;
(4) transmit enrollment and eligibility information to ac-
countable health carriers on a timely basis;
(5) establish procedures for collection of premiums from mem-
ber small employers, including the share of premiums paid by
employee enrollees pursuant to Section 38-91-100;
(6) pay contracted rates to accountable health carriers on a
monthly basis or as otherwise mutually agreed pursuant to Section
38-91-110;
(7) impose annual surcharges established at the beginning of the
fiscal year to be paid monthly by member small employers for
necessary costs incurred in connection with the operation of the
alliance. The amount of annual surcharges shall cover any default
on insurer premium payments by member small employers;
(8) provide that in the event a member small employer termi-
nates coverage purchased through the alliance, the former member
small employer shall be ineligible to purchase a qualified health
care plan through the alliance for a period of two years, except as
permitted by the alliance board and the board for good cause;
(9) contract, as authorized by the alliance board of directors,
with a qualified third party for any service necessary to carry out
the powers and duties as defined in this section, including contracts
with agents to assist in contracting with accountable health carriers
and small employers and to assist the alliance in undertaking
activities necessary to administer the alliance, such as marketing and
publicizing the availability of the qualified health care plans;
(10) provide to member small employers clear, standardized
information on each accountable health carrier and qualified health
care plans offered by each accountable health carrier, including
information on price, enrollee costs quality, patient satisfaction,
enrollment, and enrollee responsibilities and obligations, and
provide qualified health care plan comparison sheets in accordance
with board rules to be used in providing members and their
employees with information regarding coverage that may be
obtained through the accountable health carriers;
(11) appoint an executive director to serve as the chief operating
officer of the alliance, who may employ other staff as needed to
administer the alliance. The executive director shall serve at the
pleasure of the alliance board;
(12) establish advisory boards as necessary to assist with carrying
out the duties established pursuant to this section;
(13) establish administrative and accounting procedures for
operating the alliance, providing services to member small
employers and employee enrollees, and preparing an annual budget;
(14) prepare annual reports on the operations of the alliance
including program and financial operations as required by the
board, and provide for annual internal and independent audits;
(15) sue or be sued, including taking any legal actions necessary
or proper for recovering any penalties for or on behalf of the
alliance;
(16) maintain records and submit reports to the board as re-
quired; and
(17) accept and expend funds received through grants,
appropriations, or other appropriate and lawful means.
Section 38-91-90. (A) By July 1, 1997, the board shall
establish a process whereby a carrier that fulfills the qualifications
of subsection (B) of this section shall be designated as an
accountable health carrier.
(B) In order to be eligible to be designated as an accountable
health carrier, a carrier must be able to demonstrate the following
operating characteristics to the board:
(1) licensure and in good standing with the Department of
Insurance;
(2) capacity to administer the qualified health care plans;
(3) in the case of a carrier with a contractual obligation to
provide or arrange for the covered health services, the ability to
provide enrollees with adequate access to covered services within
the carrier's service area;
(4) grievance procedures, including the ability to respond to
enrollees' calls, questions, and complaints;
(5) established utilization management procedures;
(6) ability to arrange and pay for the appropriate level and
type of health care services;
(7) ability to monitor and evaluate the quality and
cost-effectiveness of care;
(8) ability to assure enrollees with adequate numbers and
types of health care providers;
(9) ability to provide information on enrollee satisfaction
based on standard surveys prescribed by the board; and
(10) ability to provide information on the types of treatments
and outcomes with respect to the clinical health, functional status,
and well-being of the enrollees based on standard data elements
prescribed by the board.
Carriers receiving accreditation by nationally recognized
accreditation organizations including, but not limited to, the
National Committee on Quality Assurance (NCQA) the Utilization
Review Accreditation Commission (URAC), Joint Commission on
Accreditation of Health Care Organizations (JCAHO), or
qualification by federal agencies, is considered to be in compliance
with the requirements of subdivisions (2) through (10) of this
subsection as they pertain to the relevant accreditation activities of
the organization.
(C) After notice and hearing, the board may suspend or revoke
the designation as an accountable health carrier of any carrier that
fails to maintain compliance with the requirements listed in
subsections (B), (D), or (E) of this section.
(D) Each accountable health carrier shall:
(1) offer qualified health care plans;
(2) provide for the collection and reporting to the board and
to the appropriate alliance of information on the performance of
accountable health carriers regarding the effectiveness and outcomes
in providing selected services; provided, however, that data
reporting requirements adopted by the board shall be consistent with
the method of operation of accountable health carriers, shall be
consistent with national standards where available, and shall not
impose an unreasonable cost for compliance;
(3) not deny, limit, or condition coverage under qualified
health care plans based on health status, claims experience, receipt
of health care, medical history, or lack of evidence of insurability
of an eligible employee or dependent pursuant to the provisions of
this chapter;
(4) establish premium rates for each qualified health care plan
pursuant to the adjusted community rating method;
(5) comply with all rules regarding rating, underwriting
claims handling, sales, solicitation, licensing, unfair trade practices,
and other provisions in this chapter and Title 38;
(6) issue a qualified health care plan to any member small
employer that elects to be covered under a qualified health care plan
offered by an accountable health carrier during the open enrollment
period established pursuant to subsection (E) of this section;
(7) renew each qualified health care plan with respect to any
member small employer except in the following cases:
(a) nonpayment of the required premiums;
(b) fraud or material misrepresentation of the member
small employer, or the employee enrollee, or a dependent of the
member small employer or the employee enrollee;
(c) noncompliance by a small employer with requirements
regarding employer contribution or participation as required by the
board;
(d) repeated misuse of a provider network provision
including, but not limited to, unreasonable refusal of the enrollee to
follow a prescribed course of treatment, or violation of reasonable
policies of an accountable health carrier;
(e) election by the accountable health carrier to terminate
its contract with an alliance. In such a case, the accountable health
carrier shall:
(i) provide advance notice of its decision in accordance
with this sub-subdivision to the alliance and to the board;
(ii) provide notice of the decision at least one hundred
eighty days before the nonrenewal of any qualified health care plan
to the enrollees. Except as provided in sub-subdivision (f) of this
subdivision an accountable health carrier that elects not to renew a
qualified health care plan with an alliance shall be prohibited from
writing new business with the alliance for a period of three years
from the date of notice to the alliance or until the alliance invites
the carrier to renew participation, whichever is sooner; and
(f) determination by an alliance, subject to review by the
board, that continuation of coverage would not be in the best
interest of the employee enrollees and member small employers or
would impair the accountable health carrier's ability to meet its
contractual obligations. In this instance, the alliance shall assist
affected employee enrollees in finding replacement coverage; and
(8) provide a procedure for addressing grievances that arise
between the accountable health carrier and the alliance, member
small employers, or employee enrollees.
(E) Each accountable health carrier shall offer an open
enrollment period to small employers at the anniversary date of the
member small employers qualified health care plan. The open
enrollment period shall be at least thirty consecutive calendar days.
Member small employers may choose from the accountable health
carriers selected from the qualified health care plans that are offered
in the market area in which they reside. An accountable health
carrier shall not be required to offer coverage or accept enrollments
if:
(1) the eligible employee or dependent does not reside within
the accountable health carrier's approved service area;
(2) an accountable health carrier provides ninety days' prior
notice that lt will not have the capacity to deliver service adequately
in a market area to additional enrollees because of its obligations to
existing groups and enrollees; or
(3) the Director of the Department of Insurance determines
that the acceptance of an application or applications would place an
accountable health carrier in a financially impaired condition.
(F) An accountable health carrier that cannot offer coverage
pursuant to subdivision (2) of subsection (E) of this section shall
not offer coverage to or accept applications from a new employer
group or an individual until the later of ninety days following such
refusal or the date on which the accountable health carrier notifies
the alliance and the board that it has regained capacity to deliver
services to eligible employees and their dependents in the service
area. An accountable health carrier that cannot offer coverage
pursuant to subdivision (3) of subsection (E) of this section shall
not offer coverage or accept applications for any individual or
employer group until a determination by the Director of the
Department of Insurance that acceptance of an application will not
put the accountable health carrier in a financially impaired
condition.
(G) Nothing in this chapter or any other provision of the Code
of Laws shall prohibit an accountable health carrier from providing
a qualified health care plan in an alliance through a managed-care
system, and from contracting with particular health care providers
or types, classes, or categories of health care providers.
Section 38-91-100. The contracts between alliances and member
small employers and between accountable health carriers and
alliances shall provide that payment of all premiums shall be
transmitted by member small employers on their behalf and on
behalf of the employee enrollee, directly to the alliance for the
benefit of the accountable health carrier. Premiums shall be
payable on a monthly basis. Alliances may provide for penalties
and grace periods for late payment. Nonpayment of premiums by a
member small employer or employee enrollee shall constitute a
breach of contract and a breach of the insurance policy.
Section 38-91-110. (A) Under a contract between an accountable
health carrier and an alliance, the alliance shall forward to each
accountable health carrier with enrollees under a qualified health
care plan an amount equal to:
(1) premiums determined by the accountable health carrier's
contracted rates, and
(2) adjustments in payments, if any, resulting from a risk
adjustment mechanism determined in accordance with Section
38-91-130.
(B) The alliances shall pay the accountable health carrier on a
monthly basis.
Section 38-91-120. (A) Each alliance shall use efficient and
standardized means to notify small employers of the availability of
sponsored health coverage through the alliance.
(B) Each alliance shall make available to member small
employers marketing materials accurately summarizing the benefit
plans, rates, cost, and accreditation information that its accountable
health carriers offer through the alliance.
(C) If authorized by the board, an accountable health carrier
may provide, directly or through an agent, broker, or contractor
marketing material relating to health plans offered through the
alliance. Accountable health carriers shall not need authorization
from an alliance for advertisement to the public at large through the
means of mass media.
(D) Nothing in this section shall be construed to or explicitly
prohibit an alliance or accountable health carrier from using the
services of an agent or broker in order to assist in marketing. An
accountable health carrier shall not vary compensation or
commissions to such agents or brokers based, directly or indirectly,
on the anticipated or actual claims experience or health status
associated with particular small employers to which each plan is
sold.
(E) No accountable health carrier, agent of an accountable health
carrier or independent insurance agent shall engage, directly or
indirectly, in any activity of marketing practices that would
encourage member small employers or eligible employees to:
(1) refrain from enrolling in the accountable health carrier
because of their health status or claim experience; or
(2) seek coverage from other accountable health carriers
because of their health status or claim experience.
(F) An alliance shall notify the board of any marketing practices
or materials that it finds contrary to the fair and affirmative mar-
keting requirements of this chapter. Furthermore, the board shall
monitor compliance with this section, including the conduct of ac-
countable health carriers and their agents, brokers, or contractors
and shall report to the Department of Insurance any unfair trade
practices and misleading or unfair conduct that has been reported to
the board by alliances, agents consumers, or any other individual.
The Department of Insurance shall investigate all reports and, upon
a finding of noncompliance with this section or of unfair and
misleading practices, shall take action against violators as permitted
under Title 38 or this chapter. The board shall forward all reports
of cases of abuse to the Department of Insurance for investigation.
Section 38-91-130. (A) The board shall establish a payment
mechanism to adjust for the amount of risk covered by each
qualified health care plan offered by an accountable health carrier.
Risk adjustment shall be based on prospectively determined factors
that predict utilization of health care services.
(B) On an annual basis, the board shall establish a factor that
represents the difference between the average risk of persons
covered through the alliance and the risk covered by each qualified
health care plan offered by each accountable health carrier through
the alliance. The board shall apply that factor in determining
amounts received by accountable health carriers. This may be done
directly or it may be done indirectly by adjusting quoted premiums.
The mechanism by which the adjustment is made shall be
established after consultation with a technical advisory committee.
(C) In addition to the risk adjustment mechanism described in
subsections (A) and (B) of this section, the board may develop a list
of a limited number of high cost diagnoses. The board may
develop a mechanism to protect an accountable health carrier that
has a disproportionate share of one or more of the listed diagnoses.
(D) Any payments to accountable health carriers under this sec-
tion shall be determined on an annual basis. No payments under
this section shall be based on claims or the health care costs of an
accountable health carrier.
Section 38-91-140. In addition to the duties described in Section
38-91-60, the board shall actively supervise the alliances to ensure
that actions affecting market competition are not for private
interests, but accomplish the legislative intent of this chapter. The
board shall also monitor conduct throughout the small employer
market to ensure that the legislative intent of this chapter to
improve the competitiveness of the small employer health coverage
market is not impeded.
Section 38-91-150. (A) There is established in the Office of the
State Treasurer the State Health Plan Purchasing Alliance Fund.
The Fund shall be placed in an interest-bearing account and any
interest or other income derived from the Fund shall be credited to
the Fund. Moneys in the Fund shall be spent only in accordance
with subsection (B) of this section. The Fund shall be administered
in accordance with the directives of the Budget and Control Board.
(B) All money credited to the Fund shall be used as set forth by
the board.
(C) Moneys appropriated by the General Assembly shall be
deposited in the Fund and shall become part of the budget of the
Department of Insurance.
Section 38-91-160. (A) For member small employers not
covered by Subtitle B of Title III, Public Law 100-647 (26 U.S.C.
Section 4980B), enrollees who lose their health care coverage due
to loss of employment shall be offered the option of continuing
health care coverage for one year, provided such enrollee pays the
entire required premium charged to the enrollee's former employer
and remains a resident of the State. An enrollee shall transmit
payment of premium payments through the enrollee's former
employer, who shall submit it to the respective alliance.
(B) At the end of one year of continuation coverage, such
enrollees shall be offered a conversion option if such option, where
available, is available for former group enrollees."
SECTION 2. Except as otherwise specifically provided in this
act, this act takes effect July 1, 1996.
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