§ 20-77-1503 - Program administration -- Member agreements.
20-77-1503. Program administration -- Member agreements.
(a) A community-based health cooperative shall administer a community-based health care access program in a manner that:
(1) Defines the population that may receive subsidized services provided through the program by limiting program eligibility to adults between the ages of eighteen (18) and sixty-five (65) who:
(A) Are residing in or working in the community being served by the program;
(B) Are without health care coverage;
(C) Are not eligible for Medicare, Medicaid, or other similar government programs;
(D) Have an income not exceeding two hundred percent (200%) of the federal poverty level, as in effect January 1, 2003; and
(E) Meet any other requirements that, consistent with the purposes of this subchapter, are established by the board of directors of the community-based health cooperative;
(2) Defines the population that may receive unsubsidized services provided through the program by limiting program eligibility to adults between the ages of eighteen (18) and sixty-five (65) and their dependent children who:
(A) Are residing in or working in the community being served by the program;
(B) Are without health care coverage;
(C) Are not eligible for Medicare, Medicaid, ARKids First, or similar government programs;
(D) Have an income not exceeding three hundred percent (300%) of the federal poverty guidelines or are full-time employees of the cooperative; and
(E) Meet any other requirements that, consistent with the purposes of this subchapter, are established by the board;
(3) Provides for the automatic assignment of medical payments due the client member of the program to the cooperative as a condition of eligibility;
(4) Defines the services to be covered under the program; and
(5) Establishes copayments for services received by client members of the program.
(b) To promote the most efficient use of resources, cooperatives shall emphasize in client member agreements and provider member agreements:
(1) Disease prevention;
(2) Early diagnosis and treatment of medical problems; and
(3) Community care alternatives for individuals who would otherwise be at risk to be institutionalized.
(c) (1) A cooperative shall file with the Insurance Commissioner the program it develops.
(2) The filing with the commissioner shall be for review purposes only and shall neither require approval or disapproval by the commissioner.
(3) The information filed with the commissioner shall include an actuarial certification.
(4) For the purposes of this subsection, "actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individuals acceptable to the commissioner that the program is actuarially sound based upon the person's examination, including a review of the appropriate records and methods utilized by the cooperative in establishing premium rates for the program.