§ 23-79-510 - Outline of benefits.
23-79-510. Outline of benefits.
(a) (1) Subject to the contractual policy form language adopted by the Board of Directors of the Arkansas Comprehensive Health Insurance Pool, expenses for the following services, supplies, drugs, or articles when prescribed by a physician and determined by the plan to be medically necessary shall be covered, subject to provisions of subsection (b) of this section:
(A) Hospital services;
(B) Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental, that are rendered by a physician or by other licensed professionals at his or her direction;
(C) Drugs requiring a physician's prescription;
(D) Skilled nursing services of a licensed skilled nursing facility for not more than one hundred twenty (120) days during a policy year;
(E) Services of a home health agency up to a maximum of two hundred seventy (270) services per year;
(F) Use of radium or other radioactive materials;
(G) Oxygen;
(H) Prostheses other than dental;
(I) Rental of durable medical equipment, other than eyeglasses and hearing aids, for which there is no personal use in the absence of the conditions for which such equipment is prescribed;
(J) Diagnostic X rays and laboratory tests;
(K) Oral surgery for excision of partially or completed unerupted, impacted teeth or the gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth;
(L) Services of a physical therapist;
(M) Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat a covered condition;
(N) Services for diagnosis and treatment of mental and nervous disorders or chemical and drug dependency, provided that a covered person shall be required to make a fifty percent (50%) copayment and that the plan's payment shall not exceed four thousand dollars ($4,000) annually; and
(O) Such additional benefits deemed appropriate by the board in accordance with the provisions of subsection (b) of this section.
(2) Exclusions. Unless the contractual policy form language adopted by the board provides otherwise, the following services, supplies, drugs, or articles whether or not prescribed by a physician shall not be covered:
(A) Any charge for treatment for cosmetic purposes other than surgery for the repair or treatment of an injury or a congenital bodily defect to restore normal bodily functions;
(B) Care that is primarily for custodial or domiciliary purposes;
(C) Any charge for confinement in a private room to the extent it is in excess of the institution's charge for its most common semiprivate room unless a private room is medically necessary;
(D) That part of any charge for services rendered or articles prescribed by a physician, dentist, or other health care personnel that exceeds the prevailing charge in the locality or for any charge not medically necessary;
(E) Any charge for services or articles the provision of which is not within the scope of authorized practice of the institution or individual providing the services or articles;
(F) Any expense incurred prior to the effective date of coverage by the plan for the person on whose behalf the expense is incurred;
(G) Dental care except as provided in subdivision (a)(1)(K) of this section;
(H) Eyeglasses and hearing aids;
(I) Illness or injury due to acts of war;
(J) Services of blood donors and any fee for failure to replace the first three (3) pints of blood provided to a covered person each policy year;
(K) Personal supplies or services provided by a hospital or nursing home or any other nonmedical or nonprescribed supply or service;
(L) Any expense or charge for services, articles, drugs, or supplies that are not provided in accord with generally accepted standards of current medical practice;
(M) Any expense for which a charge is not made in the absence of insurance or for which there is no legal obligation on the part of the patient to pay;
(N) Any expense incurred for benefits provided under the laws of the United States and the State of Arkansas, including Medicare and Medicaid and other medical assistance, military service-connected disability payments, medical services provided for members of the armed forces and their dependents or employees of the armed forces of the United States, and medical services financed on behalf of all citizens by the United States;
(O) Any expense or charge for in vitro fertilization, artificial insemination, or any other artificial means used to cause pregnancy;
(P) Any expense or charge for oral contraceptives used for birth control or any other temporary birth control measures;
(Q) Any expense or charge for sterilization or sterilization reversals;
(R) Any expense or charge for weight-loss programs, exercise equipment, or treatment of obesity except when certified by a physician as morbid obesity, i.e., at least two (2) times normal body weight;
(S) Any expense or charge for acupuncture treatment unless used as an anesthetic agent for a covered surgery;
(T) Any expense or charge for organ or bone marrow transplants other than those performed at a hospital with a board-approved organ transplant program that has been designated by the board as a preferred provider organization for that specific organ or bone marrow transplant;
(U) Any expense or charge for procedures, treatments, equipment, or services that are provided in special settings for research purposes or in a controlled environment, are being studied for safety, efficiency, and effectiveness, and are awaiting endorsement by the appropriate national medical specialty college for general use within the medical community;
(V) Such additional exclusions deemed appropriate by the board in accordance with the provisions of subsection (b) of this section; and
(W) (i) Any benefits that exceed the maximum lifetime benefit for plan coverage established by the board under 23-79-506(a)(1)(N).
(ii) The maximum lifetime benefit shall not be less than one million dollars ($1,000,000) and shall not exceed three million dollars ($3,000,000).
(b) In establishing the plan coverage, the board shall take into consideration the levels of health insurance provided in the state and medical economic factors as may be deemed appropriate and promulgate benefits, deductibles, copayments, coinsurance factors, exclusions, and limitations determined to be generally reflective of and commensurate with health insurance provided through a representative number of large employers in the state.
(c) The board may adjust any deductibles, copayments, and coinsurance factors annually according to the medical component of the Consumer Price Index.
(d) Nonduplication of Benefits. (1) (A) The pool shall be payer of last resort of benefits whenever any other benefit or source of third-party payment is available.
(B) Benefits otherwise payable under plan coverage shall be reduced by all amounts paid or payable through any other health insurance or any other source providing benefits because of a sickness or injury and by all hospital and medical expense benefits paid or payable under any workers' compensation coverage, automobile medical payment, or liability insurance whether provided on the basis of fault or nonfault and by any hospital or medical benefits paid or payable under or provided pursuant to any state or federal law or program.
(2) The pool shall have a cause of action against a covered person for the recovery of the amount of benefits paid that are not covered by the pool. Benefits due from the pool may be reduced or refused as a set-off against any amount recoverable under this subdivision (d)(2).
(e) Right of Subrogation -- Recoveries. (1) (A) Whenever the pool has paid benefits because of sickness or an injury to any covered person resulting from a third party's wrongful act or negligence or for which an insurance company or self-insured entity is liable in accordance with the provisions of any policy of insurance, and the covered person has recovered or may recover damages from a third party that is liable for damages, the pool shall have the right to recover the benefits it paid from any amounts that the covered person has received or may receive regardless of the date of the sickness or injury or the date of any settlement, judgment, or award resulting from the sickness or injury.
(B) The pool shall be subrogated to any right of recovery the covered person may have under the terms of any private or public health care coverage or liability coverage including coverage under a workers' compensation act without the necessity of assignment of claim or other authorization to secure the right of recovery.
(C) To enforce its subrogation right, the pool may:
(i) Intervene or join in an action or proceeding brought by the covered person or his or her personal representative, including his or her guardian, conservator, estate, dependents, or survivors, against any third party or the third party's insurance carrier or self-insured entity that may be liable; or
(ii) Institute and prosecute legal proceedings against any third party or the third party's insurance carrier or self-insured entity that may be liable for the sickness or injury in an appropriate court either in the name of the pool or in the name of the covered person or his or her personal representative including his or her guardian, conservator, estate, dependents, or survivors.
(2) (A) (i) If any action or claim is brought by or on behalf of a covered person against a third party or the third party's insurance carrier or self-insured entity, the covered person or his or her personal representative, including his or her guardian, conservator, estate, dependents, or survivors, shall notify the pool by personal service or registered mail of the action or claim and of the name of the court in which the action or claim is brought, filing proof thereof in the action or claim.
(ii) The pool may, at any time thereafter, join in the action or claim upon its motion so that all orders of court after hearing and judgment shall be made for its protection.
(B) No release or settlement of a claim for damages and no satisfaction of judgment in the action shall be valid without the written consent of the pool to the extent of its interest in the settlement or judgment and of the covered person or his or her personal representative.
(3) (A) In the event that the covered person or his or her personal representative fails to institute a proceeding against any appropriate third party before the fifth month before the action would be barred, the pool, in its own name or in the name of the covered person or personal representative, may commence a proceeding against any appropriate third party for the recovery of damages on account of any sickness, injury, or death to the covered person.
(B) The covered person shall cooperate in doing what is reasonably necessary to assist the pool in any recovery and shall not take any action that would prejudice the pool's right to recovery.
(C) The pool shall pay to the covered person or his or her personal representative all sums collected from any third party by judgment or otherwise in excess of amounts paid in benefits under the pool and amounts paid or to be paid as costs, attorney's fees, and reasonable expenses incurred by the pool in making the collection or enforcing the judgment.
(4) (A) (i) In the event of judgment or award in either a suit or claim against a third party, the court shall first order paid from any judgment or award the reasonable litigation expenses incurred in preparation and prosecution of the action or claim, together with reasonable attorney's fees.
(ii) After payment of those expenses and attorney's fees, the court shall apply out of the balance of the judgment or award an amount sufficient to reimburse the pool the full amount of benefits paid on behalf of the covered person under this subchapter, provided that the court may reduce and apportion the pool's portion of the judgment proportionately to the recovery of the covered person.
(B) (i) The burden of producing sufficient evidence to support the exercise by the court of its discretion to reduce the amount of a proven charge sought to be enforced against the recovery shall rest with the party seeking the reduction.
(ii) The court may consider the nature and extent of the injury, economic and noneconomic loss, settlement offers, comparative or contributory negligence as it applies to the case at hand, hospital costs, physician costs, and all other appropriate costs.
(C) The pool shall pay its pro rata share of the attorney's fees based on the pool's recovery as it compares to the total judgment.
(D) Any reimbursement rights of the pool shall take priority over all other liens and charges existing under the laws of the State of Arkansas.
(5) The pool may compromise or settle and release any claim for benefits provided under this subchapter or waive any claims for benefits, in whole or in part, for the convenience of the pool or if the pool determines that collection will result in undue hardship upon the covered person.
(f) Preexisting Conditions. (1) Except for federally eligible individuals or qualified trade adjustment assistance eligible persons qualifying for plan coverage under 23-79-509(b) or resident eligible persons or trade adjustment assistance eligible persons who qualify for and elect to purchase the waiver authorized in subdivision (f)(2) of this section, plan coverage shall exclude charges or expenses incurred during the first six (6) months following the effective date of coverage as to any condition if:
(A) The condition has manifested itself within the six-month period immediately preceding the effective date of coverage in such a manner as would cause an ordinary prudent person to seek diagnosis, care, or treatment; or
(B) Medical advice, care, or treatment was recommended or received within the six-month period immediately preceding the effective date of the coverage.
(2) Waiver. The preexisting condition exclusions as set forth in subdivision (f)(1) of this section will be waived to the extent to which the resident eligible person or trade adjustment assistance eligible person:
(A) Has satisfied similar exclusions under any prior individual health insurance coverage that was involuntarily terminated; and
(B) (i) Has applied for plan coverage not later than thirty (30) days following the involuntary termination.
(ii) For each resident eligible person or trade adjustment assistance eligible person who qualifies for and elects this waiver, there shall be added on a prorated basis to each payment of premium a surcharge of up to ten percent (10%) of the otherwise applicable annual premium for as long as that individual's coverage under the plan remains in effect or sixty (60) months, whichever is less.
(3) (A) Whenever benefits are due from the plan because of sickness or an injury to a covered person resulting from a third party's wrongful act or negligence and the covered person has recovered or may recover damages from a third party or its insurance carrier or self-insured entity, the plan shall have the right to reduce benefits or to refuse to pay benefits that otherwise may be payable in the amount of damages that the covered person has recovered or may recover regardless of the date of the sickness or injury or the date of any settlement, judgment, or award resulting from that sickness or injury.
(B) (i) During the pendency of any action or claim that is brought by or on behalf of a covered person against a third party or its insurance carrier or self-insured entity, any benefits that would otherwise be payable except for the provisions of this subsection shall be paid if payment by or for the third party has not yet been made and the covered person or, if capable, that person's legal representative agrees in writing to pay back properly the benefits paid as a result of the sickness or injury to the extent of any future payments made by or for the third party for the sickness or injury.
(ii) This agreement is to apply whether or not liability for the payments is established or admitted by the third party or whether those payments are itemized.
(C) Any amounts due the plan to repay benefits may be deducted from other benefits payable by the plan after payments by or for the third party are made.
(4) Benefits due from the plan may be reduced or refused as an offset against any amount otherwise recoverable under this section.