376.986. Pool to offer medical coverage--premiums, how established--standard risk rate, how calculated--director to approve rates--exclusions--benefits reduced by other insurance or workers' compe
Pool to offer medical coverage--premiums, how established--standardrisk rate, how calculated--director to approverates--exclusions--benefits reduced by other insurance orworkers' compensation--medical expense to include prayer forspiritual healing.
376.986. 1. The pool shall offer major medical expense coverage toevery person eligible for coverage under section 376.966. The coverage tobe issued by the pool and its schedule of benefits, exclusions and otherlimitations, shall be established by the board with the advice andrecommendations of the pool members, and such plan of pool coverage shallbe submitted to the director for approval. The pool shall also offercoverage for drugs and supplies requiring a medical prescription andcoverage for patient education services, to be provided at the direction ofa physician, encompassing the provision of information, therapy, programs,or other services on an inpatient or outpatient basis, designed torestrict, control, or otherwise cause remission of the covered condition,illness or defect.
2. In establishing the pool coverage the board shall take intoconsideration the levels of health insurance provided in this state andmedical economic factors as may be deemed appropriate, and shall promulgatebenefit levels, deductibles, coinsurance factors, exclusions andlimitations determined to be generally reflective of and commensurate withhealth insurance provided through a representative number of insurers inthis state.
3. The pool shall establish premium rates for pool coverage asprovided in subsection 4 of this section. Separate schedules of premiumrates based on age, sex and geographical location may apply for individualrisks. Premium rates and schedules shall be submitted to the director forapproval prior to use.
4. The pool, with the assistance of the director, shall determine thestandard risk rate by considering the premium rates charged by otherinsurers offering health insurance coverage to individuals. The standardrisk rate shall be established using reasonable actuarial techniques andshall reflect anticipated experience and expenses for such coverage.Initial rates for pool coverage shall not be less than one hundredtwenty-five percent of rates established as applicable for individualstandard risks. Subject to the limits provided in this subsection,subsequent rates shall be established to provide fully for the expectedcosts of claims including recovery of prior losses, expenses of operation,investment income of claim reserves, and any other cost factors subject tothe limitations described herein. In no event shall pool rates exceed thefollowing:
(1) For federally defined eligible individuals and trade act eligibleindividuals, rates shall be equal to the percent of rates applicable toindividual standard risks actuarially determined to be sufficient torecover the sum of the cost of benefits paid under the pool for federallydefined and trade act eligible individuals plus the proportion of thepool's administrative expense applicable to federally defined and trade acteligible individuals enrolled for pool coverage, provided that such ratesshall not exceed one hundred fifty percent of rates applicable toindividual standard risks; and
(2) For all other individuals covered under the pool, one hundredfifty percent of rates applicable to individual standard risks.
5. Pool coverage established pursuant to this section shall providean appropriate high and low deductible to be selected by the poolapplicant. The deductibles and coinsurance factors may be adjustedannually in accordance with the medical component of the consumer priceindex.
6. Pool coverage shall exclude charges or expenses incurred duringthe first twelve months following the effective date of coverage as to anycondition for which medical advice, care or treatment was recommended orreceived as to such condition during the six-month period immediatelypreceding the effective date of coverage. Such preexisting conditionexclusions shall be waived to the extent to which similar exclusions, ifany, have been satisfied under any prior health insurance coverage whichwas involuntarily terminated, if application for pool coverage is made notlater than sixty-three days following such involuntary termination and, insuch case, coverage in the pool shall be effective from the date on whichsuch prior coverage was terminated.
7. No preexisting condition exclusion shall be applied to thefollowing:
(1) A federally defined eligible individual who has not experienced asignificant gap in coverage; or
(2) A trade act eligible individual who maintained creditable healthinsurance coverage for an aggregate period of three months prior to loss ofemployment and who has not experienced a significant gap in coverage sincethat time.
8. Benefits otherwise payable under pool coverage shall be reduced byall amounts paid or payable through any other health insurance, orinsurance arrangement, and by all hospital and medical expense benefitspaid or payable under any workers' compensation coverage, automobilemedical payment or liability insurance whether provided on the basis offault or nonfault, and by any hospital or medical benefits paid or payableunder or provided pursuant to any state or federal law or program exceptMedicaid. The insurer or the pool shall have a cause of action against aneligible person for the recovery of the amount of benefits paid which arenot for covered expenses. Benefits due from the pool may be reduced orrefused as a setoff against any amount recoverable under this subsection.
9. Medical expenses shall include expenses for comparable benefitsfor those who rely solely on spiritual means through prayer for healing.
(L. 1990 H.B. 998 § 6, A.L. 2007 H.B. 818)Effective 1-01-08