CHUUK STATE HEALTH CARE PLAN
BOARD OF TRUSTEES
REGULATIONS CHAPTER V
ELIGIBILITY FOR ENROLLMENT IN THE PLAN

Part 1.0         General Provision

Part 1.0.1       Authority.  These Regulations have been promulgated by the Chuuk State Health Care Plan, Board of trustees for the establishment of eligibility of every qualified resident of Chuuk State to be enrolled in the Plan and shall  be eligible to receive benefits as provided by the act and these regulations.  These regulations and any further amendments thereto shall have the force and effects of law, and be binding, upon persons performing any specified  activities regarding the eligibility under the Plan to receive benefits.

Part 1.0.2        Purpose.  The purpose of these regulations is for the Board to establish  eligibility of every qualified resident of the Chuuk State to be enrolled  under the Plan to receive benefits as provided by the act and these  regulations.

Part 1.0.3       Eligibility
 
1.   All qualified residents of Chuuk State shall be enrolled in the
Plan nd shall be eligible to receive benefits as provided under
the act and this regulation,

2.   Except for unemployed non-citizens who are not dependents of
enrollees; further excepting those qualified under Part 1.05 of
this regulation.

3.   Citizens residing outside of Chuuk may be covered under the
Plan upon arrival in Chuuk except that they will not be eligible
for out of state medical referrals until they have established
permanent residency in Chuuk, in accordance with Section 1.4
(15) of the act.
 
4.   Dependent children studying outside of Chuuk are covered
under the Plan as provided for under Part 2.0.5 of this
regulation.

5.   Dependents covered under the Plan will be natural born
children, legally adopted children, stepchildren and legally
married spouses (including church and civil marriage).
 
To qualify as a dependent child, the child must be:

a.         unmarried and under the age of 19 or
 
b.         unmarried and physically  or mentally incapable of earning a living or
 
c.        unmarried and a full time student under age 23 who is primarily dependent on his or her parents support.
Part 1.0.4     Enrollment

1.   All eligible person are automatically enrolled in the basic
coverage; (or Essential coverage), and may enroll in the
additional coverage (optional)
 
2.  Persons may enroll within 30days of first becoming eligible,
 
3.   Subsequent enrollment changes may only be made during an
open season which will be held annually during the month of
August for an October 1 effective date. In other words, once a
person enroll, in August coverage he or she may not disenroll
himself/herself or his/her dependents until the next open
season. Likewise if a person does not enroll himself/herself or
his/her newly acquired dependents within 30 days of first
becoming eligible, he/she may not enroll himself/ herself or
such dependents until the next open season. Except that for
the first PLAN Year, the open season will be month of April
2001 for a June 2001 effective date.

4.   Identification cards will be given to the enrollees with their
name, social security number, and date of birth, and
signatures. New identification card will be issued every year.

Part 1.0.5       Agreement for Eligibility of others

The Board is authorized to enter into agreement with the National Government, international organizations, or other entities to extend the benefits of the act and this regulation to persons within Chuuk not otherwise eligible. 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.
 
Part 2.0          Benefits

Part 2.0.1      Description of benefits
 
1.    CSHCP offers two (2) levels of coverage. Basic coverage
which is mandatory and additional coverage which is optional.

Part 2.0.2       Basic Coverage or Essential Coverage
 
1.         Basic Coverage or Essential Coverage includes all health care services not specifically excluded under Part 3.0.3 of these rules and regulations Benefits Exclusion.

2.         The following services are covered only if provided at the Chuuk State Hospital or a Chuuk State Dispensary

(a)     Physical exams and wellness advice

(b)     Pre-natal care

(c)     Family Planning

(d)     Immunizations

(e)     Dental exams, X-ray cleaning, and extractions

(f)      Vision tests

(g)     Hearing tests

3.         All health care services, which can be provided at the Chuuk State Hospital must be provided there or at a Chuuk State Dispensary and are not covered elsewhere. All services, which cannot be provided at the Chuuk. State Hospital but can be provided at a hospital or dispensary within FSM, must be provided there and are not covered elsewhere. Except in an emergency, no service is covered outside the FSM unless the patient has been referred by the medical referral committee and the service is rendered by an Approved Basic Coverage Provider.

4.        Approved Essential Coverage Providers are:

a.    Tripler Hospital in Hawaii

b.    Straub Hospital in Hawaii

c.    Guam Memorial Hospital in Guam

d.    Makati Medical Center in Manila

e.    Medical City in Manila
 
f.     Philippine Heart Center in Manila

g.    SDA Clinic in Guam

h.    Good Samaritan Clinic - Guam

5.        The third party administrator (TPA) may select any provider on Guam or Hawaii if the care cannot be rendered by any of the providers mentioned above.

6.         Referrals for the patient and any family member or medical attendant necessitated by the disability of the patient, to a maximum of three persons (3) including the patient. For details refer to regulation Chapter IV Parts 1.3.13, 1.3.14, 1.3.15 and 1.3.16

a.    Lodging

Patients must stay in rooms with negotiated discounts. No payment is made for lodging except through stipends.

b.    Stipends

1.         Stipends are not paid for inpatient days

2.         Stipends are not paid for care in the Philippines; because patients and attendants can stay in the Hospitals.

3.         For care outside of FSM, the TPA pays stipends, from off-islands trust account, for outpatient days certified by the medical referral committee as medically necessary.
            The amount of the stipend is $ 40 per day for the patient. If, because of the disability of the patient, a family member and or medical attendant is needed, the TPA will pay the patient an additional $ 30 per day for each additional person to a maximum of 2 additional persons.

Part 2.0.3       Additional Coverage or Supplemental Coverage
 
1.        The benefits for Additional Coverage are the same as for Essential Coverage except that enrollees have to pay $100.00 co-payment up front as self-refer to Approved Additional Coverage Providers for eligible off-island care and off-island physical exams. Enrollees canchoose to be treated off-island, but if the treatment sought is excluded under Part 3.0.3 below, CSHCP will not pay for it. No airfares or stipends are paid for self-referrals. No service is covered outside the FSM unless rendered by an Approved Additional Coverage Provider except for Emergency case.

2.        Approved Additional Coverage Providers are:

a.   Tripler Hospital in Hawaii

b.   Guam Memorial Hospital

c.   Makati Medical Center in Manila

d.   Medical City in Manila

e.   Philippine Heart Center in Manila

f.    Straub Hospital in Hawaii

g.   Kaiser permanent's Moanalua Medical Center, Hawaii

h.   Castle Health group

i.    Any provider selected by the TPA if the care cannot be rendered by any of the above providers.

j.    Good Samaritan Clinic- Guam

k.   Guam Seventh Day Adventist Clinic

Note:  The patient may select the specific providers. If any of the above providers does not have a participating provider contract with the TPA, the provider ceases to be an Approved Essential Coverage Provider.

3.        The monthly premiums for Additional Coverage are:

Subscriber only
$25.00
Subscriber and 5 or less dependents
$35.00
Subscriber and between 6 and 19 dependents, inclusive
$45.00
Subscriber and 20 or more dependents
$75.00

4.         Employers of subscriber in additional coverage upon request of the employee must deduct from payroll the amount of the employees additional coverage premiums and pay bi-weekly the same to the CSHCP Executive Director to be deposited in the Trust Fund Account.

5.         Both enrollees in essential coverage and additional coverage will receive identification cards including their names, date of birth (DOB), social security numbers and signature, which must be surrendered upon disenrollment. New identification cards will be issued every year. Anyone found attempting to access additional coverage benefits who is not so entitled or otherwise attempting to defraud the CSHCP will have no amount paid for that care, will be disenrolled from additional coverage and will be ineligible to re-enroll in additional coverage for at least five years from the date of the discovery.

Part 2.0.4       Third Party Administrator (TPA)
 
1.         At least one TPA will be contracted to administer all referrals and Self-referrals outside of Chuuk. The TPA will manage care, provides utilization review including concurrent review, and pay health care costs and stipends. The TPA will be selected through a competitive bidding process

2.         Prior to the effective date of CSHCP, the selected TPA, at its own expense will send a medical expert and an administrative expert to Chuuk to tour the Chuuk State Hospital, meet with medical and administrative staff, and otherwise make best efforts to ensure the smooth operation of the off-island referral program

3.         The Executive Director at the approval of the Board will establish an off-island trust account in the location of the TPA. The TPA will be authorized to draw against it for payment of off-island health care, stipends and its own administrative fees.

4.        The Executive Director will initially seed the off-island trust account with $300,000 from the CSHCP Trust Fund. Thereafter, the Executive Director will make quarterly deposits to the off-island trust account. The deposits will replenish the Prior months actual expenses.

5.        The TPA must estimate the cost of each referral in advance and keep the Board advised through the Executive Director of the balance in the off-island trust accounts, less the estimated cost of referrals pending less a reserve amount for self-referrals, higher than expected costs, and administrative fees.

6.         Before the patient departure from Chuuk Hospital, the TPA will veto any referral if there is insufficient money in the off-island trust account to cover the ,expected cost of the care. The TPA will provide no service with respect to that referral until there is sufficient money in the off-island trust account, except for bono fide emergency.
 
7.        Except for self-referral the medical referral committee selects the location where the patient can receive the most cost effective care. The TPA then directs the patient to the appropriate provider and monitors the care.

8.         In advance of the patient's departure, the medical referral committee must fax the TPA a copy of the official referral form, signed by an authorized person, and narrative or history of the patient describing the patient conditions and the services approved for payment.

9.        The TPA must advise its contracted providers that no payment will be made without pre-certification by the TPA. Therefore, enrollees, whether referred or self-referred may not receive treatment until the TPA pre-certifies their eligibility to provider

10.      The TPA must pays 100% of the cost of eligible medical referred patients and self-referred patients from the off-island trust account.

11.      The only off-island expenses that are paid for directly by the Executive Director are:

1.    Medical Services received within the FSM,

2.    Stipends for care received within the FSM, and

3.    Airfare

12.       If health care provider outside of Chuuk request a follow up visit after the patient has returned to Chuuk, such request must be approved by the medical referral committee using the criteria as for an initial referral. However, the CSHCP will not be responsible for any costs incurred by such patient prior to the effective date of the plan.

13.      The TPA will not pay for unauthorized referrals or ineligible self referral or if there is insufficient money in the off-island trust account. Bi-weekly, the Executive Director must provide the TPA with updated lists of enrollees in additional Coverage.

1)    Medical Management
 
The Third Party Administrator and the Executive Director shall ensure that the medical management forms are dealt with including the following:

(a)       The first is administrative monitoring on members access to treatment; the Board of Trustees' approval must be obtained for certain treatment, procedures or drugs,
 
(b)       The second requires identification of those members or enrollees most at risk of incurring significant costs, and actively treating them. This is very important because health care spending is remarkably concentrated with 10% of patients' accounting for about 3/4 of all medical costs,

(c)       The third aspect or form of medical management requires monitoring of doctors practice, identifying those who consistently prescribe unnecessary or expensive treatments and bring them in line with standard practice,

(d)       The key to effective medical management is information, such essential information including health care utilization focused on hospital inpatient data, tracking hospital admission, and hospital bed days, and case management of the members or enrollees on and off-island.

Part 2.0.5        Maximum Benefits
 
a)        The following maximum plan payments for off-island care apply whether the patient was referred or self-referred, and include airfares and stipends. Airfares and Stipends paid for a patient's companions or medical attendants are also charged against the patient's annual and lifetime maximums. No airfares or stipends are paid for self-referrals.

Maximum Per Year
25,000
Maximum Per Lifetime
50,000

b)         There is no maximum benefit for care received at Chuuk State Hospital or a State dispensary, and the cost of care received within Chuuk does not count towards the above maximums. However, the cost of care received at other FSM Hospitals does count.

c)         Once the Plan has paid out the total amount of the annual maximum for an enrollee will not be entitled to coverage under the Plan for, the remainder of the Plan year.

Part 2.0.6       Emergency Care
 
a)         For enrollees traveling or studying outside Chuuk, CSHCP pay 100l0 of off-island emergency care to a minimum of $1,500,
 
b)         An emergency means the sudden and unexpected onset of a severe medical condition which, if not treated immediately would be in the opinion of a physician, life threatening or result in a permanent disability, e.g. a heart attack, severe hemorrhaging, poisoning; loss of consciousness or respiration, broken bones and convulsions are considered emergencies,

c)         In serious cases, and emergency can be classified as referral by the medical referral committee. However, as soon as possible, the patient must be transferred to an approved Basic Coverage Provider.

d)        As it is not possible to contract with every Hospital that an enrollee may need for emergency coverage outside of FSM, Guam, Hawaii, and Manila, enrollees may have to pay such Hospitals for their medical care and file for reimbursement from CSHCP later. Therefore, enrollees traveling or studying outside of Chuuk should advise to enroll in student health plans or travel health plans otherwise enrollees must contact the medical referral committee or the TPA to approve the emergency and pay the Hospital as quickly as possible through the off island trust account.

e)        If the emergency is not reclassified as a referral by the medical referral committee, but patient is enrolled in additional coverage, CSHCP does not pay for unnecessary days or treatments at the emergency provider, and does not pay more than $1,500. However the patients may go, at his/her own expense, to an approved additional coverage provider, but TPA will not pay for ineligible care

f)         Citizens living outside Chuuk, and desiring health insurance, should be advised to purchase it in the area they reside.
 
Part 3.0          Consulting Physicians
 
If cost effective CSHCP will pay for consulting specialist physicians to come to Chuuk to treat patients. However, if a patient misses an appointment with such physician without compelling reason, that patient will not be referred off-island for the same condition. Visiting specialist should be able to initiate referrals after cosigned by Chuuk State Hospital Physician.

Part 3.0.1       Coordination of Benefits
 
If an enrollee is covered by other insurance or other agreement under which health care benefits are provided, CSHCP will provide benefits in full but will be entitled to receive payment for the services provided, to the extent that they are recovered through the other insurance or agreement.

Part 3.0.2       It is a condition of enrollment in CSHCP that the enrollee agrees that he/ she, his/ her guardian, his/ her survivors, or his/ her estate shall file all allowable claims under such other insurance or agreement and shall remit all payments made under such other insurance or agreement to CSHCP up to the amount of the payments received or the actual cost of the benefits provided by CSHCP whichever is less.

Part 3.0.3      Benefit Exclusions
 
With the above constraints, all health care services (including treatments, products and supplies) are covered under Essential and Additional Coverages, both in and out of Chuuk, except for the following:

1.  Any services rendered by a private physician or at a private medical clinic or pharmacy within the FSM, provided that a written agreement between the Plan and the person is signed.

2.  Any service rendered outside of Chuuk State without a referral approved by the Medical Referral Committee, unless the patient is enrolled in Additional Coverage.

3.  Any service if a medical statement made on an enrollment form, claim form, etc. is false and would otherwise have rendered the service ineligible
 
4.  Any service not provided by, or directly supervised by, a hospital or physician duly licensed to provide that service in the geographical area where the service was provided

5.  Any service which is not medically necessary, unless specifically covered

Any service if the patient is unlikely to recover or he significantly improved, unless provided at the Chuuk State Hospital or a state dispensary

Any service, including hospital, surgical, medical, laboratory, and xray services, related to a non-covered service

Any service rendered by the patient's spouse, parent, child, or sibling.

Any service received while not enrolled under the plan

Any service resulting from complications of a non-covered service

Any service for which no charge would be made in the absence of plan coverage

Any service for which the patient has any other coverage through any other plan or program

Any service necessitated by an injury or illness recovered while in the commission of a criminal act, unless provided at the Chuuk State Hospital or a state dispensary

Any service necessitated by a self-inflicted injury received while sane or insane, unless provided at the Chuuk State Hospital or a state dispensary

Acupuncture

Air ambulance outside the State of Chuuk. The cost of medivac within the State of Chuuk to the Chuuk Hospital is covered provided the patient is hospitalized as an inpatient for at least 12 hours thereafter.

Allergy testing and treatment

Alcohol and drug dependence services

Cases that only require palliative treatment

Chiropractic care

Contact lenses, eye exercises and refractive surgery to correct visual problems

Cosmetic surgery or treatment
 
Custodial domiciliary, nursing home, or convalescent care

Dental care, except for exams, cleanings, x-rays, amalgam fillings, composite resin fillings, and extractions provided at the Chuuk State Hospital or a state dispensary

Durable medical equipment (outpatient); for example, wheelchairs, crutches, hospital beds, commodes, walkers, suction machines, oxygen and accessories

Elective abortions

Experimental treatments, including any clinical visits, in-patient stays, drugs, laboratory testing, x-rays, etc. related to such experimental treatments (Any treatment or procedure not approved for payment by U.S. Medicare will be considered experimental.)

Eye exams and glasses, unless provided at the Chuuk State Hospital or a state dispensary

Family planning, unless provided at the Chuuk State Hospital or a state dispensary

Fertility procedures or fertilization by artificial means

Hearing aids and hearing tests, unless provided at a state hospital or state dispensary within the FSM

Heat lamp treatments

Hospice care

Hospital inpatient doctor visits in excess of one per day and one consultation visit per confinement

Liposuction

Living expenses, except as otherwise specifically covered herein

Mental health care, including mental retardation and mental deficiency treatments

Military service incurred injury or disability

Normal deliveries, including normal multiple births, and normal maternity care unless provided at the Chuuk State Hospital or a state dispensary

Occupational therapy

Organ transplants

Personal comfort and convenience items
 
Physical exams and health appraisals unless provided at the Chuuk State Hospital or a state dispensary, except that physical exams at Approved Additional Coverage Providers will be covered for enrollees in Additional Coverage

Physical therapy, unless provided at the Chuuk State Hospital or a state dispensary

Private duty nursing

Prosthetic appliances except for artificial limbs provided at the state hospital or dispensary within the FSM

Rest cures

Reversal of sterilization

Sexual dysfunction

Speech therapy

Substance abuse treatments

Telephone calls

Temporomandibular joint (TMJ) treatments

Transportation, except as otherwise specifically covered herein

Transsexual surgery

Tuberculosis

Weight control or weight loss programs, products, or procedures

Well child care, unless provided at the Chuuk State Hospital or a state
dispensary

Whole blood and blood derivatives

Part 3.0.4       Subrogation of Rights
If an enrollee is injured or infected through the act or omission
of another person, as defined in the Act, and recovers
damages from the other person, the enrollee shall reimburse
CSHCP for the cost of the benefits provided by CSHCP in
treating such condition. Reimbursement shall be in the amount
of the recovery or the actual cost of the health care benefits,
whichever is less.

If there is no recovery of damages, CSHCP shall be
subrogated to the enrollee's rights against the wrongdoer to
the extent of the cost of the benefits provided by CSHCP,
including the right to bring  suit in the enrollee's name and to
compromise the  claim, in order to indemnify CSHCP for amounts
paid
 
Part 4.0.1       If there is no recovery of damages, CSHCP shall be subro.gated to the enrollee's rights against the wrongdoer to the extent of the cost of the benefits provided by CSHCP, including the right to bring suit in the enrollee's name and to compromise the claim, in order to indemnify CSHCP for amount paid.

Part 4.0.2       It is a condition of enrollment in CSHCP that the enrollee agrees that he/she, his/her guardian, his/her survivors, or his/her estate shall execute and deliver an assignment of claim form, and any other necessary forms, to CSHCP, upon request, and shall render all necessary assistance, other than pecuniary, to enable CSHCP to secure these rights.

Part 4.0.3       Appeals Procedures
Appeals for denials of eligibility enrollment, or benefits maybe presented in writing and/or in person to the CSHCP Board of Trustees. Such appeals will be duly considered by the Board outside the presence of the appellant. The board may request additional information and documentation from the appellant. Decision will be made based on majority vote by secret ballot. The Board will provide the appellant in writing with its decision, and the reasons therefore within 30 days of receipt of all requested information and documentation. The Decision of the Board of Trustees will be final.

Part 4.0.4       Communication, and Information Policies and Procedures,
The Executive Director shall ensure that information
requirements are identified and systems are put in
place to provide the needed information so that
CSHCP will be well communicated to residents, and
leaders on the terms and conditions of CSHCP through
out the community down, across and upward.

Communicating the principle that health insurance is for the
social good is critical, because,
 
Many people evaluate the worth of a health insurance plan by
comparing the amount they paid for it to the amount they get
back.

In fact, the primary purpose of a health plan is to provide a
specified amount of financial assistance in case of
catastrophic illness,

The Plan should educate the enrollees to understand that more
care and more expensive care is not necessarily better care,
and that great sums of money can be wasted on unnecessary
and inappropriate care

One of the objectives of the Plan is to provide good coverage
for all residents, but that it cannot afford to cover extremely
expensive treatments as doing so would drain CSHCP's funds
to the determent of the majority of enrollees, and

CSHCP has been specifically designed to allow all residents
equal access to health care but that tight controls are
necessary to ensure that CSHCP remains financially stable,

The Executive Director's office should also serve as a source
of CSHCP information.

A video should be made explaining the terms and conditions
of CSHCP played daily in the hospital waiting room, perhaps
along with another video instructing persons how to avoid
becoming sick or injured and how to diagnose and care for
minor conditions, These videos could also be played in
government departments (including schools), at dispensaries,
and as part of the existing program to bring the government to
the people of outer islands through monthly boat field trips. The
use of videos is very important as the information to be
communicated can be thought through in advance, videos will
save the time and effort of CSHCP administrators and void
needless repetition, and videos will ensure that all persons are
given the same information.
 
Television and radio broadcasts are essential. These
broadcasts could be presented in question and answer
formats for ease of understanding and should be continued for
the life of CSHCP. As questions regarding CSHCP are
brought to the attention of members of the CSHCP Board of
Trustees, the board will develop answers to these questions.
Both the question and answer could be broadcast. During the
2 months prior to the effective date of CSHCP and during the 2
months thereafter, these broadcasts should be made daily.
After that, weekly broadcasts should suffice. Videos could be
shown on television.

An informational brochure should be made available to all
residents at least one month prior to the effective date of
CSHCP. After the effective date, new residents should be
given a copy of this brochure upon arrival in Chuuk. Videos
could also be shown.

The written rules and regulations of CSHCP should be made
available to any enrollee requesting them. For illiterate
enrollees, the Executive Director should ensure that a reader is
available.

Community meetings should be held to explain CSHCP and to
give people a chance to ask questions and voice their
comments and concerns. Such meetings should be directed
by community leaders in strong support of the Plan. Videos
could be shown.

All communications should be available in at least Chuukese
and English.

Part 4.0.5       Effective Date:
These regulations shall become effective upon the approval of the Governor of the State of Chuuk.
 

                         Adopted by:          /s/                    Approved by:     /s/     
5/16/01                                  Chairman                                        Governor
                                               Board of Trustees                          State of Chuuk