Arkansas Administrative Code › Agency 054 - Arkansas Insurance Department › Rule 054.00.14-002 - Rule 106: Network Adequacy 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)(1)
			 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 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. "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.
F.
		  "Emergency Services" means health care items and services furnished or required
		  to evaluate and treat an emergency medical condition.
G. "Essential Community Provider" means a
		  provider that serves predominantly low income, medically underserved
		  individuals as defined in
		  45 CFR §
									156.235.
H. "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.
I.
		  "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 does not apply to vision or dental only
		  plans unless such plans are offered by Stand-alone Dental Carriers as defined
		  in Section Three (3) (U) of this Rule.
J. "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.
K. "Health Care Provider" or "provider" means
		  a participating health care or dental professional or a facility.
L. "Health Care Services" means services for
		  the diagnosis, prevention, treatment, cure or relief of a health condition,
		  illness, injury or disease.
M.
		  "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 Ann. §
								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 not include a vision or dental
		  insurer unless it is a Stand-alone Dental Carrier as defined by Section Three
		  (3) (U) of this Rule.
N. "Network"
		  means the group of participating providers providing services to a Health
		  Benefit Plan.
O. "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.
P. "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.
Q. "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.
R.
		  "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.
S.
		  "Qualified Health Plan" means an insurance policy that meets the requirements
		  of
		  42 U.S.C. §
									18021(a)(1).
T. "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.
U. "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.