2012 Arkansas Code
Title 23 - Public Utilities and Regulated Industries
Subtitle 3 - Insurance
Chapter 79 - Insurance Policies Generally
Subchapter 5 - -- Comprehensive Health Insurance Pool Act
§ 23-79-509 - Plan eligibility.

(a) General Eligibility Requirements. The following requirements apply to a resident eligible person or a trade adjustment assistance eligible person in order for the person to be eligible for plan coverage:

(1) Except as provided in subdivision (a)(2) of this section or subsection (b) of this section, any individual person who meets the definition of resident eligible person as defined by § 23-79-503 or a trade adjustment assistance eligible person as defined by § 23-79-503 and is either a citizen of the United States or an alien lawfully admitted for permanent residence who continues to be a resident of this state shall be eligible for plan coverage if evidence is provided of:

(A) A notice of rejection or refusal by an insurer to issue substantially similar individual health insurance coverage by reason of the existence or history of a medical condition or upon such other evidence that the Board of Directors of the Arkansas Comprehensive Health Insurance Pool deems sufficient in order to verify that the applicant is unable to obtain the coverage from an insurer due to the existence or history of a medical condition;

(B) (i) A refusal by an insurer to issue individual health insurance coverage except at a rate that the board determines is substantially in excess of the applicable plan rate.

(ii) A rejection or refusal by a group health plan or insurer offering only stop-loss or excess-of-loss insurance or contracts, agreements, or other arrangements for reinsurance coverage with respect to the applicant shall not be sufficient evidence under this subsection;

(C) (i) Until September 30, 2011, a refusal by an insurer to issue individual health insurance coverage to a child under nineteen (19) years of age.

(ii) After September 30, 2011, the eligibility of a child under nineteen (19) years of age for individual health insurance coverage shall be determined by the board; or

(D) Evidence that the applicant was covered under a qualified high risk pool of another state, provided that the coverage terminated no more than sixty-three (63) days prior to the date the pool receives the applicant's application for coverage and the other state's qualified high risk pool did not terminate the person's coverage for fraud;

(2) A person shall not be eligible for coverage under the plan if:

(A) The person has or obtains health insurance coverage substantially similar to or more comprehensive than a plan policy or would be eligible to have coverage if the person elected to obtain it except that:

(i) A person may maintain other coverage for the period of time the person is satisfying any waiting period for a preexisting condition under a plan policy; and

(ii) A person may maintain plan coverage for the period of time the person is satisfying a waiting period for a preexisting condition under another health insurance policy intended to replace the plan policy;

(B) The person is determined to be eligible for health care benefits under Title XIX of the Social Security Act;

(C) The person has previously terminated plan coverage unless twelve (12) months have elapsed since termination of coverage;

(D) The person fails to pay the required premium under the covered person's terms of enrollment and participation, in which event the liability of the plan shall be limited to benefits incurred under the plan for the same period for which premiums had been paid and the covered person remained eligible for plan coverage;

(E) The plan has paid on behalf of the covered person the maximum lifetime benefit established by the board in accordance with § 23-79-510(a)(2)(W);

(F) The person is a resident of a public institution;

(G) All or part of the person's premium is paid for or reimbursed:

(i) By one (1) of the following in connection with a group health plan:

(a) The person's current employer;

(b) If the person is retired, by the person's former employer; or

(c) If the person is a dependent of an employee or retiree, by the current or former employer of the employee or retiree; or

(ii) Under any government-sponsored program or by any government agency, foundation, health care facility, or health care provider except for premiums paid on behalf of:

(a) A trade adjustment assistance eligible person or a qualified trade adjustment assistance eligible person in accordance with section 35 of the Internal Revenue Code; or

(b) An otherwise qualifying full-time employee or dependent of a qualifying full-time employee of a government agency, foundation, health care facility, or health care provider; or

(H) The person commits a fraudulent insurance act as defined in § 23-66-501(4) against the Arkansas Comprehensive Health Insurance Pool;

(3) The board or the plan administrator shall require verification of residency and may require any additional information, documentation, or statements under oath whenever necessary to determine plan eligibility or residency;

(4) Coverage shall cease:

(A) On the date a person is no longer a resident of the State of Arkansas;

(B) On the date a person requests coverage to end;

(C) On the death of the covered person;

(D) On the date state law requires cancellation of the policy; or

(E) At the plan's option, thirty (30) days after the plan makes any written inquiry concerning a person's eligibility or place of residence to which the person does not reply; and

(5) Except under the conditions set forth in subdivision (a)(4) of this section, the coverage of any person who ceases to meet the eligibility requirements of this section terminates at the end of the month that the person ceases to meet the eligibility requirements of this section.

(b) Persons Eligible for Guaranteed Issuance of Coverage. The following requirements apply to a federally eligible individual or a qualified trade adjustment assistance eligible person in order for such an individual to be eligible for plan coverage:

(1) Notwithstanding the requirements of subsection (a) of this section, any federally eligible individual or a qualified trade adjustment assistance eligible person for whom a plan application and such enclosures and supporting documentation as the board may require is received by the board within sixty-three (63) days after the termination of prior creditable coverage for reasons other than nonpayment of premium or fraud that covered the applicant shall qualify to enroll in the plan under the portability provisions of this subsection;

(2) Any individual seeking plan coverage under this subsection must submit with his or her application evidence, including acceptable written certification of previous creditable coverage, that will establish to the board's satisfaction that he or she meets all of the requirements to be a federally eligible individual or a qualified trade adjustment assistance eligible person and is currently and permanently residing in the State of Arkansas as of the date his or her application was received by the board;

(3) A period of creditable coverage shall not be counted, with respect to qualifying an applicant for plan coverage as an individual under this subsection, if after such a period and before the application for plan coverage was received by the board, there was at least a sixty-three-day period during all of which the individual was not covered under any creditable coverage;

(4) Any individual who the board determines qualifies for plan coverage under this subsection shall be offered his or her choice of enrolling in one (1) of the alternative portability plans that the board is authorized under this subsection to establish for those individuals;

(5) (A) (i) The board shall offer a choice of health-care coverages consistent with major medical coverage under the alternative plans authorized by this subsection to every individual qualifying for coverage under this subsection.

(ii) The coverages to be offered under the plans, the schedule of benefits, deductibles, copayments, coinsurance, exclusions, and other limitations shall be approved by the board.

(B) One (1) optional form of coverage shall be comparable to comprehensive health insurance coverage offered in the individual market in the State of Arkansas or a standard option of coverage available under the individual health insurance laws of the State of Arkansas. The standard plan that is authorized by § 23-79-510 may be used for this purpose.

(C) The board also may offer a preferred provider option and such other options as the board determines may be appropriate for individuals who qualify for plan coverage pursuant to this subsection;

(6) Notwithstanding the requirements of § 23-79-510(f), any plan coverage that is issued to individuals who qualify for plan coverage pursuant to the portability provisions of this subsection shall not be subject to any preexisting conditions exclusion, waiting period, or other similar limitation on coverage;

(7) Individuals who qualify and enroll in the plan pursuant to this subsection shall be required to pay such premium rates as the board shall establish and approve in accordance with the requirements of § 23-79-507(a);

(8) The total premium, without regard to any subsidy of premium, for individuals who qualify and enroll in the plan pursuant to this subsection shall not be greater than a similarly situated individual qualifying for pool coverage under subsection (a) of this section; and

(9) A federally eligible individual who qualifies and enrolls in the plan pursuant to this subsection must continue to satisfy all of the other eligibility requirements of this subchapter to the extent not inconsistent with the Health Insurance Portability and Accountability Act of 1996 in order to maintain continued eligibility for coverage under the plan.

(c) Any person who was issued a policy pursuant to the provisions of Acts 1995, No. 1339, shall be deemed continuously covered consistent with the terms of this subchapter and reissued a new policy in accordance with the provisions of this subchapter.