§ 401. Short title.
§ 402. Definitions.
§ 403. Eligibility.
§ 404. Establishment of Employees’ Health Insurance Fund.
§ 405. Premium contributions.
§ 406. Disposition of fund.
§ 407. Health Insurance Plan Board of Directors and Administrator.
§ 408. Reporting.
§ 409. Promulgation of regulations.
§ 410. Off-island medical referral.
(1) “Administrator” means the National Government Employees’ Health Insurance Plan Administrator established by the provisions of this chapter.
(2) “Agency” means any municipal, State or National Government public agency, institution or entity.
(3) “Board” or “Board of Directors” means the National Government Employees’ Health Insurance Plan Board of Directors established under the provisions of this chapter.
(4) “Business” means any quasi-public or private business entity which is duly licensed to do business under, and doing business under, the laws of the Federated States of Micronesia or its political subdivisions, which is also a participant in the Social Security system of the Federated States of Micronesia, and which has been qualified to participate in the plan pursuant to the regulations promulgated by the Director under section 409 of this chapter.
(5) “Costs of administration” means the following costs of administering the plan:
(a) wages or salaries for personnel engaged in administering the plan;
(b) necessary travel for personnel engaged in administering the plan;
(c) costs and expenses for training of personnel engaged in administering the plan;
(d) the costs of processing claims;
(e) the costs of printing informational booklets, claim forms, and other necessary materials;
(f) the costs of necessary supplies and equipment;
(g) the costs of communications necessary to the operation of the plan;
(h) the costs of professional services necessary to the operation of the plan.
(6) “Dependents” means the members of an employee’s immediate family, including grandchildren, dependent parents, and dependent parents-in-law.
(7) “Employee” means an employee of the National Government of the Federated States of Micronesia, an employee of a participating agency, or an employee of a participating business.
(8) “Full-time employee” means an employee who works at least 32 hours of the regular and scheduled workweek.
(9) “Full-time student” means a student who currently enrolled in classes totaling 12 or more semester units at an accredited post-secondary educational institution.
(10) “Participating agency” or “participating agencies” means any public agency, public institution or other public entity, either municipal, State or National, participating in the plan pursuant to section 403 of this chapter.
(11) “Participating business” or “participating businesses” means any business entity, whether quasi-public or privately owned, participating in the plan pursuant to section 403 of this chapter.
(12) “Plan” means the National Government Employees’ Health Insurance Plan.
Editor’s note: Subsection (6) of this section includes a lone paragraph (a) which has been omitted and made a part of subsection (6) itself to comport with standard code formatting.
(1) All full-time employees of the National Government of the Federated States of Micronesia shall participate in the plan.
(2) Other persons who may participate in the plan are:
(a) The full-time employees of each participating agency and business which has entered into a contract with the Director, as administrator of the plan, whereby such agencies or businesses have agreed to participate in the plan.
(b) The dependents of full-time employees of the National Government, participating agencies and participating businesses;
(c) Members of an employee’s household who are dependent upon the employee, but are not otherwise defined as “dependents” under the provisions of this Act, if the employee pays 100 percent of the premiums for such persons to the plan;
(d) Government employees whose State or agency does not participate in the plan, and their dependents, if they pay 100 percent of the premiums for themselves and the dependents to the plan;
(e) Former enrollees in the plan, and their dependents, if they pay 100 percent of the premiums for themselves and their dependents to the plan; and
(f) Full-time students enrolled at any postsecondary institution in the FSM, if the postsecondary institution has entered into a contract of participation with the plan and the students pay 100 percent of the premium for themselves to the plan.
Editor’s note: PL 14-49 § 1 added subsubsection (2)(f) of this section, without moving the “and” from subsubsection (2)(d) to subsubsection (2)(e) of this section. This change has been made. In subsection (f) of this section, the two words “post secondary” have been changed to the one word “postsecondary” to correct a typographical error. These changes has been made for format consistency.
Pursuant to section 3 of PL 15-52, subsection (1) of this Act became effective on October 1, 2009.
(1) There is established a National Government Employees’ Health Insurance Fund, (hereinafter ‘Employees’ Health Insurance Fund) which shall be separate from the General Fund or other funds. All sums appropriated by Congress representing contributions of the National Government to the plan, all sums representing contributions of participating agencies to the plan, and all employee contributions to the plan, shall be deposited in the Employees’ Health Insurance Fund. Any unexpended money in the Employees’ Health Insurance Fund shall not revert to the General Fund or lapse at the end of the fiscal year, but shall remain in the Employees’ Health Insurance Fund.
(2) The Board of Directors shall have the sole authority to administer the Employees’ Health Insurance Fund in accordance with regulations promulgated under this Act. The Board shall maintain this Employees’ Health Insurance Fund in a separate custodial trust account and may, from time to time, invest such moneys that are in excess of the amount deemed necessary for the operation of the plan during the reasonable future. Such investments shall be low-risk and made in consultation with the Secretary of the Department of Finance. The investments shall at all times be made so that all of the assets of the Employees’ Health Insurance Fund shall be readily convertible into cash when needed for the purpose of this Act. All income earned on these investments shall be deposited into the Employees’ Health Insurance Fund.
Source: PL 3-82 § 4; PL 8-53 § 3; PL 12-77 § 2.
Cross-reference: The statutory provisions on the President and the Executive are found in title 2 of this code. The statutory provisions on the FSM Congress are found in title 3 of this code.
Employees participating in the plan shall contribute the percentage of the premium not paid by their employer for insurance under the plan. The National Government of the Federated States of Micronesia shall contribute at least 52 percent of the premium for eligible employees of the National Government participating in the plan. Any participating agency or participating business shall contribute at least 50 percent of the premium for their employees participating in the plan, or may at their request contract with the Board to contribute more than 50 percent.
All money deposited in the Employees’ Health Insurance Fund shall be used to pay claims, except that a sum representing not more than ten percent of the estimated income for that year from contributions and income on investments may be expended for costs of administration.
Editor’s note: In amending section 406 to remove former subsections (2) and (3), which dealt with maintaining separate accounts for each state, PL 15-52 did not remove the subsection number from subsection (1). The subsection (1) designation has been removed to comport with standard code formatting.
(1) Creation. There is hereby established a National Government Employees’ Health Insurance Plan Board of Directors to oversee the Plan and the assets of the Employee’s Health Insurance Fund. There is also hereby established a new full-time position of National Government Employees’ Health Insurance Plan Administrator. The Administrator shall be appointed by the Board. The Administrator shall serve at the pleasure of the Board of Directors and shall be exempt from the provisions of the National Public Service System Act.
(2) Composition. The National Government Employees’ Health Insurance Plan Board of Directors shall consist of not less than seven members, including one representative from each State of the Federated Sates of Micronesia, who shall be recommended by the Governor of the relevant State; one representative from the National Government of the Federated States of Micronesia; one representative from the private healthcare sector; and the Administrator. Each appointed member of the Board shall be appointed by the President with the advice and consent of the Congress. The Administrator shall serve as ex officio member of the Board. All members of the Board shall be voting members of the Board.
(3) Terms. Each appointed member of the Board shall serve for a period of three years, except that initial appointments to the Board shall be made as follows: two members for a period of one year; two members for the period of two years; and two members for a period of three years. Successor to the first appointees hereunder shall be appointed for terms of three years each. Vacancies other than by expiration of term shall be filled by the President by appointment, in the same manner as the original appointment was made, for the unexpired term. Appointed members shall not hold-over at the expiration of their terms, but may be reappointed to consecutive terms in the manner set forth in this section.
(4) Organization. The Board shall provide for its own organization and procedure, except that the Board shall, at a minimum, designate a Chairman and a Secretary. The Secretary shall keep all records of, and actions taken by, the Board. These records shall be open to the public for public inspection. The Secretary of Justice of the Federated States of Micronesia shall act as legal advisor to the Board.
(5) Meetings. The board shall meet at least once every six months. Meetings may be held at any time or place within the FSM to be determined by the Board upon the call of the Chairman or upon written request of any four members. All meetings shall be open to the public and public notice of the time and place of such meetings shall be posted in public places and shall be announced on radio and television throughout the FSM and in newspapers of general circulation in the FSM. Four members of the Board shall constitute a quorum for the transaction of business.
(6) Compensation. Members of the Board shall be paid at a rate established by the Board when actually performing their duties under this chapter; provided that officials and employees of the State governments or the Government of the Federated States of Micronesia who are members of the Board shall not receive any compensation. All members shall be entitled to receive travel costs and per diem at standard National Government rates when actually attending Board meetings or engaged in the performance of duties authorized by the Board. Any employee of the National Government shall be granted leave with pay when actually attending Board meetings or engaged in the performance of duties authorized by the Board.
(7) General powers and duties.
(a) It shall be the responsibility of the Board to promote the soundness, stability, growth and development of the National Government Employees’ Health Insurance Plan and the National Government Employees’ Health Insurance Fund. To that end, the Board shall have overall responsibility for administration of the Plan, PROVIDED, however, that day-to-day operations of the Plan shall be the responsibility of Administrator. The Board shall have such other powers and duties as may be necessary to carry out the purpose of this chapter.
(b) Responsibility for the proper day-to-day operation of the Plan shall be vested in Administrator who shall have power to delegate duties and responsibilities to such employees of the Plan as the Administrator deems feasible and desirable to carry out the provisions of this chapter.
(c) The Board shall periodically consult with, and seek the advice of, interested members of the public in each respective State of the Federated States of Micronesia regarding the operation of the Plan and shall endeavor to ensure that such consultations are done with persons broadly representative of actual and potential participants in the Plan, including representatives of the medical profession and participating businesses.
(8) Time for Implementation.
(a) All nominations for all positions on the Board shall be transmitted to Congress within 90 days of the date this Act becomes law.
(b) The Board shall appoint an Administrator within 90 days of the date all Board members have been appointed by Congress. If no Administrator is appointed within this time, the Board shall submit to Congress a detailed account of the steps it is taking to appoint an Administrator and the reasons why it has not done so.
(c) Immediately upon the appointment of the Administrator, all employees of the Plan who hold a job title containing the word “Chief” shall be given a new job title and the word “Chief” shall be deleted from the job title.
Cross-reference: The statutory provisions on the President and the Executive are found in title 2 of this code. The statutory provisions on the FSM Congress are found in title 3 of this code.
Prior to the commencement of each regular May session of Congress, the Board, through the Administrator, shall prepare and submit to the President of the Federated States of Micronesia and to the Speaker of the Congress an annual report on the status of the plan. This report shall include a statement of the amount of money on deposit in the Employees’ Health Insurance Fund as of the date of the annual report, the amount of premiums collected and interest earned during the preceding fiscal year, the amount of money disbursed for claims during the preceding fiscal year, the number of claims paid during the preceding fiscal year, the costs of administration, and such other information as the Board may deem appropriate.
Source: PL 3-82 § 8; PL 8-53 § 7; PL 12-77 § 5.
Cross-reference: The statutory provisions on the President and the Executive are found in title 2 of this code. The statutory provisions on the FSM Congress are found in title 3 of this code.
(1) The Board, with the approval of the President, shall promulgate regulations, pursuant to chapter 1 of title 17 of this code, governing the amount of the premium for insurance under the plan, the procedure for making claims under the plan, the amount and type of benefits under the plan, the policy limits under the plan, and such other matters as may be consistent with the contents and purpose of this chapter, including the implementation of those provisions of this chapter pertaining to participating agencies and participating businesses.
(a) The Board shall promulgate no regulation allowing a claim for benefits under the plan to be denied on the grounds that the medical condition giving rise to the claim existed before the person making the claim began participating in the plan. Any such existing regulation is hereby retroactively repealed for a period of six months from the date this Act becomes law.
(2) The plan may:
(a) provide, arrange for, pay for, or reimburse the costs of medical, dental and vision treatment and care, hospitalization, surgery, prescription drugs, medicine, prosthetic appliances, out-patient care, and other medical care benefits, in cash or the equivalent in medicines and supplies;
(b) provide life insurance benefits;
(c) contract with private sector insurance companies to provide benefits; and
Cross-reference: Chapter 1 of title 17 of this code is on FSM Administrative Procedures. The statutory provisions on the President and the Executive are found in title 2 of this code.
(1) No payment shall issue for any off-island medical referral unless:
(a) The procedure is one which must or may be performed off-island under the standard medical referral criteria, or cannot be effectively performed at the referring hospital, and the referral conforms to all referral procedures set forth in the regulations; or
(b) The Administrator determines that a medical emergency existed, the necessary surgery or treatment could not have been performed effectively at the referring hospital, and the delay necessary to follow proper procedures would have resulted in death or permanent serious damage to the health of the patient; or
(c) The patient is outside of the Federated States of Micronesia when a medical emergency arises, or is covered by a supplemental or non-resident plan, as set forth in the regulations.
Source: PL 8-53 § 9; PL 12-77 § 7.
Editor’s notes: PL 12-77 § 7 omitted the word “determines” after “Administrator”. The word “determines” has been left in subsubsection (1)(b) to correct an obvious omission and typographical error. PL 12-77 § 7 also omitted subsection (2). Subsection (1) and its subsubsections have not been renumbered.