Arkansas Administrative Code › Agency 003 - DEPARTMENT OF COMMERCE › Division 22 - Insurance Department › Rule 003.22.21-004 - Network Adquacy Requirements for Health Benefit Plans

Current through Register Vol. 49, No. 6, June, 2024
Section 1.
Authority
This Rule is issued pursuant to the authority granted the
				Arkansas Insurance Commissioner ("Commissioner") under Ark. Code Ann. §
									23-61-108(a)(l)
				and by Ark. Code Ann. §
									23-61-108(b)
				( 1) to promulgate rules necessary for the effective regulation of the business
				of insurance and as required for this State to be in compliance with federal
				laws, namely Section 2702(c) of the Public Health Service Act and
				45 CFR §
										156.230 which require that Qualified Health
				Plans provide sufficiently accessible medical providers. In addition, this Rule
				is issued pursuant to the authority granted the Commissioner to issue
				regulations related to the provision of adequate health care services by health
				maintenance organizations under Ark. Code Ann. §
									23-76-108(a).
Section 2.
Purpose
The purpose of this Rule is to establish minimum standards for
				the creation and maintenance of networks by Health Carriers and to assure the
				adequacy, accessibility and quality of Health Care Services offered under
				Health Benefit Plans.
Section
			 3.
Definitions
For purposes of this Rule:
A. Accredited Health Carrier" means a Health
			 Carrier which has an adequate network as certified by an approved accrediting
			 organization under the provisions of Section Five (5) (K) of this
			 Rule.
B. "Commissioner" means the
			 Arkansas Insurance Commissioner.
C.
			 "Covered Benefits" or "benefits" means those Health Care Services to which a
			 Covered Person is entitled under the terms of a Health Benefit Plan.
D. "Covered Person" means a policyholder,
			 subscriber, enrollee or other individual participating in a Health Benefit
			 Plan.
E. "Dental Benefits" means
			 benefits for dental services embedded in, or offered by a rider attached to,
			 (i) a QHP offered through the ACA approved marketplace or (ii) an ACA compliant
			 non-Grandfathered plan.
F.
			 "Emergency Medical Condition" means the sudden and, at the time, unexpected
			 onset of a health condition that requires immediate medical attention, where
			 failure to provide medical attention would result in serious impairment to
			 bodily functions or serious dysfunction of a bodily organ or part, or would
			 place the person's health in serious jeopardy.
G. "Emergency Services" means health care
			 items and services furnished or required to evaluate and treat an emergency
			 medical condition.
H. "Essential
			 Community Provider" means a provider that serves predominantly low income,
			 medically underserved individuals as defined in
			 45 CFR §
										156.235.
I. "Facility" means an institution providing
			 Health Care Services or a health care setting, including but not limited to
			 hospitals and other licensed inpatient centers, ambulatory surgical or
			 treatment centers, skilled nursing centers, residential treatment centers,
			 diagnostic, laboratory and imaging centers, and rehabilitation and other
			 therapeutic health settings.
J.
			 "Health Benefit Plan" means any individual, blanket, or group plan, policy or
			 contract for Health Care Services issued or renewed by a Health Carrier on or
			 after January 1, 2015 which requires a Covered Person to use Health Care
			 Providers managed, owned, under contract with or employed by the Health
			 Carrier. "Health Benefit Plan" does not include a plan providing Health Care
			 Services pursuant to the Arkansas Constitution, Article 5, § 32, the
			 Workers' Compensation Law, §
									11-9-101 et seq.,
			 and the Public Employee Workers' Compensation Act, §
									21-5-601 et
			 seq., nor include an accident-only, specified disease, hospital indemnity,
			 long-term care, disability income, or limited-benefit health insurance policy.
			 The provisions of this Rule also do not apply to Medicare Supplement or
			 Medicare Advantage policies. This Rule applies to Dental Benefits as defined in
			 Section (3)(E) and Vision Benefits as Defined in Section (3)(W), as well as
			 plans offered by Stand-alone Dental Carriers as defined in Section (3)(U) of
			 this rule,
K. "Health Care
			 Professional" means a physician or other health care practitioner licensed,
			 accredited or certified to perform physical, behavioral, mental health or
			 substance use disorder and health services consistent with state law.
L. "Health Care Provider" or "provider" means
			 a participating health care or dental professional or a facility.
M. "Health Care Services" means services for
			 the diagnosis, prevention, treatment, cure or relief of a health condition,
			 illness, injury or disease.
N.
			 "Health Carrier" means an entity subject to the insurance laws and regulations
			 of this State, or subject to the jurisdiction of the Commissioner, which
			 contracts or offers to contract, or enters into an agreement to provide,
			 deliver, arrange for, pay for or reimburse any of the costs of Health Care
			 Services, including a health insurer, a health maintenance organization, a
			 hospital and medical service corporation, or any other entity providing Health
			 Benefit Plans. A Health Carrier does not include an automobile insurer paying
			 medical or hospital benefits under Ark. Code Amr. §
									23-89-202(1)
			 nor shall it include a self-insured employer Health Benefits Plan. A Health
			 Carrier does not include any person, company, or organization, licensed or
			 registered to issue or who issues any insurance policy or insurance contract in
			 this State providing medical or hospital benefits for accidental injury or
			 accidental disability. A Health Carrier shall include an entity that provides
			 Dental and/or Vision Benefits as defined in Section (3)(E) and Section (3)(W)
			 of this rule, respectively, or is a Stand-alone Dental Carrier as defined by
			 Section Three (3)(U) of this Rule.
O. "Network" means the collection of all
			 participating providers providing services to a Health Benefit Plan. The
			 network associated with a health benefit plan should be identifiable using a
			 suitable network ID, and one Health Benefit Plan can have only one such network
			 ID.
P "Provider" means a provider
			 who, under a contract with a Health Carrier or with its contractor or
			 subcontractor, has agreed to provide Health Care Services to covered persons
			 with an expectation of receiving payment, other than coinsurance, copayments or
			 deductibles, directly or indirectly from the Health Carrier.
Q. "Patient Centered Medical Home" ("PCMH")
			 means a local point of access to care that proactively looks after patients'
			 health on a "24-7" basis. A PCMH supports patients to connect with other
			 Providers to form a health services team, customized for their patients' care
			 needs with a focus on prevention and management of chronic disease through
			 monitoring patient progress and coordination of care.
R. "Person" means an individual, a
			 corporation, a partnership, an association, a joint venture, a joint stock
			 company, a trust, an unincorporated organization, any similar entity or any
			 combination of the foregoing.
S.
			 "Primary Care Professional" means a participating Health Care Professional
			 practicing within their licensed scope of practice and designated by the Health
			 Carrier to supervise, coordinate or provide initial care or continuing care to
			 a covered person, and who may be required by the Health Carrier to initiate a
			 referral for specialty care and maintain supervision of Health Care Services
			 rendered to the Covered Person.
T.
			 "Qualified Health Plan" means an insurance policy that meets the requirements
			 of
			 42 U.S.C. §
										18021(a)(1).
U. "Specialty Care Professional" means a
			 participating Health Care Professional that is specially qualified to practice
			 by having attended an advanced program of study, passed an examination given by
			 an organization of the members of the specialty, or gained experience through
			 extensive practice in the specialty.
V. "Stand-alone Dental Carrier" means an
			 entity subject to the insurance laws and regulations of this State, or subject
			 to the jurisdiction of the Commissioner, which (i) offers plans through the ACA
			 approved Marketplace and/or (ii) offers plans outside the ACA approved
			 Marketplace for the purpose of providing the essential health benefits category
			 of pediatric level oral benefits.
W. "Service Area" means the collection of
			 counties serviced by a Health Benefit Plan. Counties may be grouped into larger
			 aggregations called Health Rating Areas and a Health Benefit Plan is required
			 to cover at least one Health Rating Area. The aggregation of counties is
			 published in the annual bulletin setting forth requirements for ACA
			 submissions.
X. "Telemedicine"
			 means the use of electronic information and communication technology to deliver
			 healthcare services, including without limitation the assessment, diagnosis,
			 consultation, treatment, education, care management, and self management of a
			 patient, as well as store-and-forward technology and remote patient
			 monitoring.
Y. "Vision Benefits"
			 means benefits for vision services embedded in, or offered by a rider attached
			 to, a QHP offered through (i) the ACA approved marketplace or (ii) an ACA
			 compliant non-Grandfathered plan.