20-77-1503. Program administration — Member agreements — Definition.

20-77-1503. Program administration — Member agreements — Definition. (a) A community-based health cooperative shall administer a community-based healthcare access program in a manner that: (1) Defines the population that may receive subsidized services provided through the community-based healthcare access program by limiting program eligibility to adults between eighteen (18) years of age and sixty-five (65) years of age who: (A) Are residing in or working in the community being served by the community-based healthcare access program; (B) Are without healthcare 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 community-based healthcare access program by limiting community-based healthcare access program eligibility to adults between eighteen (18) years of age and sixty-five (65) years of age and their dependent children who: (A) Are residing in or working in the community being served by the community-based healthcare access program; (B) Are without healthcare 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 community-based health 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 community-based healthcare access program to the community-based health cooperative as a condition of eligibility; (4) Defines the services to be covered under the community-based healthcare access program; and (5) Establishes copayments for services received by client members of the community-based healthcare access program. (b) To promote the most efficient use of resources, community-based health 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 community-based health cooperative shall file with the Insurance Commissioner the community-based healthcare access 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 community-based healthcare access program is actuarially sound based upon the person's examination, including a review of the appropriate records and methods utilized by the community-based health cooperative in establishing premium rates for the community-based healthcare access program.