SCS CSHB 538(HES): "An Act relating to uniform claims forms, uniform standards, and uniform procedures for processing data relating to billing and payment of health care services; relating to the Comprehensive Health Insurance Association and to health insurance provided to residents of the state who are high risks; and providing for an effective date."

00SENATE CS FOR CS FOR HOUSE BILL NO. 538(HES) 01 "An Act relating to uniform claims forms, uniform standards, and uniform 02 procedures for processing data relating to billing and payment of health care 03 services; relating to the Comprehensive Health Insurance Association and to health 04 insurance provided to residents of the state who are high risks; and providing 05 for an effective date." 06 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 07 * Section 1. AS 21.06 is amended by adding a new section to read: 08  Sec. 21.06.085. UNIFORM DATA AND PROCEDURES FOR HEALTH 09 CLAIMS. (a) The director shall adopt by regulation uniform claims forms, uniform 10 standards, and uniform procedures for the processing of data relating to billing for and 11 payment of health care services provided to state residents. A health insurer shall use 12 the uniform claims forms and comply with the uniform standards and procedures 13 established under this section. 14  (b) In this section,

01  (1) "health care services" has the meaning given in AS 21.86.900; 02  (2) "health insurance" has the meaning given "disability insurance" in 03 AS 21.12.050; 04  (3) "health insurer" means an insurer transacting the business of health 05 insurance, a health maintenance organization under AS 21.86, a hospital service 06 corporation under AS 21.87, a medical service corporation under AS 21.87, or a 07 combined medical service and hospital service corporation under AS 21.87. 08 * Sec. 2. AS 21.55.010 is amended to read: 09  Sec. 21.55.010. CREATION; MEMBERSHIP. There is established a nonprofit 10 incorporated legal entity to be known as the Comprehensive Health Insurance 11 Association. Membership consists of all licensed hospital or medical service 12 corporations in the state that offer subscriber contracts for major medical coverage, all 13 health maintenance organizations or other managed care arrangements approved 14 by the director, and all insurers licensed to transact health insurance in the state that 15 offer policies for major medical coverage on an expense incurred basis. All members 16 shall maintain membership in the association as a condition of doing health insurance 17 business, or being able to offer subscriber contracts or enrollment in a health 18 maintenance organization or managed care arrangement, in the state. 19 * Sec. 3. AS 21.55.100 is amended by adding a new subsection to read: 20  (d) The association may make available to residents who are high risks 21 coverage through a health maintenance organization or other managed care 22 arrangement as approved by the director. 23 * Sec. 4. AS 21.55.120(c) is amended to read: 24  (c) Except as provided in (e) of this section, the [THE] sum of the 25 deductible and copayments required in any calendar year under a plan may not exceed 26 a maximum limit of $2,000 per covered individual. Covered expenses incurred after 27 the applicable maximum limit has been reached shall be paid at the rate of 100 percent 28 of usual, customary, reasonable, or prevailing charges, except that expenses incurred 29 for treatment of mental and nervous conditions shall be paid at the rate of 50 percent. 30 The $2,000 maximum shall be adjusted yearly to correspond with the change in the 31 medical care component of the Consumer Price Index as adjusted by the director.

01 * Sec. 5. AS 21.55.120 is amended by adding a new subsection to read: 02  (e) In addition to the deductible, copayment, and applicable maximums 03 described in this section, other deductible, copayment, or maximum limits may be 04 offered if approved by the director. 05 * Sec. 6. AS 21.55.150(b) is amended to read: 06  (b) The association shall use separate scales of premium rates based on age 07 and geographic location of the insured. The association may use separate scales of 08 premium rates based on other factors, including use or nonuse of tobacco, if 09 approved by the director. 10 * Sec. 7. AS 21.55.300 is repealed and reenacted to read: 11  Sec. 21.55.300. ELIGIBILITY FOR STATE HEALTH INSURANCE. (a) 12 Except as provided in this section, a state resident who is a high risk is eligible to 13 enroll in a state plan described in AS 21.55.100. 14  (b) A person may not be covered by the state plan 15  (1) while covered by another health insurance policy or subscriber 16 contract; or 17  (2) if the person is eligible to be covered by a plan subject to the 18 requirements of AS 21.56.110 - 21.56.250. 19  (c) Upon ceasing to be a resident, a person is not eligible to purchase or renew 20 coverage under a state plan, but previously purchased coverage remains in effect for 21 the period covered by payments made while a resident. 22  (d) Additional eligibility requirements for enrollment in a state plan may be 23 imposed if approved by the director. 24 * Sec. 8. AS 21.55.310 is amended to read: 25  Sec. 21.55.310. ENROLLMENT BY AN ELIGIBLE PERSON. A person may 26 enroll in a state plan by applying to the writing carrier. The application must include 27 the following: 28  (1) name, address, age, and length of residency of the applicant; 29  (2) a designation of the plan desired, including deductible option 30 chosen; 31  (3) information relevant to whether the person is a high risk; and

01  (4) payment of the first premium. 02 * Sec. 9. AS 21.55.320 is amended to read: 03  Sec. 21.55.320. WRITING CARRIER'S RESPONSE. Within 30 days after 04 receiving the certificate described in AS 21.55.310, the writing carrier shall either 05 reject the application for failing to comply with the requirements of AS 21.55.300 and 06 21.55.310 or forward the eligible person a notice of acceptance [AND BILLING 07 INFORMATION]. 08 * Sec. 10. AS 21.55.400 is amended to read: 09  Sec. 21.55.400. DUTIES OF DIRECTOR. The director may 10  (1) approve the selection of the writing carrier by the association and 11 approve the association's contract with the writing carrier, including the coverages and 12 premiums to be charged; 13  (2) contract with the federal government or another unit of government 14 to ensure coordination of the state plans with other governmental assistance programs; 15  (3) undertake directly or through contracts with other persons studies 16 or demonstration programs to develop awareness of the benefits of this chapter; and 17  (4) formulate general policy, adopt regulations that are reasonably 18 necessary to administer this chapter. 19 * Sec. 11. AS 21.55 is amended by adding a new section to read: 20  Sec. 21.55.420. BOARD MEMBER CIVIL AND CRIMINAL IMMUNITY. 21 A member of the board of directors of the association may not be held civilly or 22 criminally liable for an act or omission if the act or omission was in good faith and 23 within the scope of the director's duties under this chapter. 24 * Sec. 12. AS 21.55.500(10) is amended to read: 25  (10) "residents who are high risks" means residents who 26  (A) have been rejected for medical reasons after applying for 27 a subscriber contract, a policy of health insurance, or a Medicare supplement 28 policy by at least two association members within the six months immediately 29 preceding the date of application for a state plan; medical reasons may include 30 preexisting medical conditions, a family history that predicts future medical 31 conditions, or an occupation that generates a frequency or severity of injury or

01 disease that results in coverage not being generally available; [OR] 02  (B) have had a restrictive rider placed on a subscriber contract, 03 a health insurance policy, or a Medicare supplement policy that substantially 04 reduces coverage; or 05  (C) meet other requirements adopted by regulation by the 06 director that are consistent with this chapter and that indicate that a 07 person is unable to obtain coverage substantially similar to that which may 08 be obtained by a person who is considered a standard risk; 09 * Sec. 13. By July 1, 1995, the director of the division of insurance shall adopt regulations 10 necessary to implement the uniform claim form required under AS 21.06.085, added by sec. 1 11 of this Act. 12 * Sec. 14. This Act takes effect July 1, 1994.