Ark. Code Ann. § 23-99-201 Short title.
This subchapter may be cited as the “Patient Protection Act of 1995”.
Healthcare Providers
Ark. Code Ann. tit. 23, ch. 99
in effectArk. Code Ann. § 23-99-202 Legislative findings and intent.
The General Assembly finds that patients should be given the opportunity to see the healthcare provider of their choice. In order to assure the citizens of the State of Arkansas the right to choose the provider of their choice, it is the intent of the General Assembly to provide the opportunity of providers to participate in health benefit plans.
Ark. Code Ann. § 23-99-203 Definitions.
(a)(1) “Copayment” means a type of cost sharing whereby insured or covered persons pay a specified predetermined amount per unit of service or percentage of healthcare costs with their healthcare insurer paying the remainder of the charge.
(2) The copayment is incurred at the time the service is rendered.
(3) The copayment may be a fixed or variable amount.
(b) “Gatekeeper system” means a system of administration used by any health benefit plan in which a primary care provider furnishes basic patient care and coordinates diagnostic testing, indicated treatment, and specialty referral for persons covered by the health benefit plan.
(c) “Health benefit plan” means any entity or program that provides reimbursement, including capitation, for healthcare services, except and excluding any entity or program that provides reimbursement and benefits pursuant to Arkansas Constitution, Amendment 26, Acts 1993, No. 796, or the Public Employee Workers' Compensation Act, § 21-5-601 et seq., and rules and schedules adopted thereunder.
(d) "Healthcare provider" means those individuals or entities licensed by the State of Arkansas to provide healthcare services, limited to the following:
(1) Advanced practice nurses;
(2) Athletic trainers;
(3) Audiologists;
(4) Certified behavioral health providers;
(5) Certified orthotists;
(6) Chiropractors;
(7) Community mental health centers or clinics;
(8) Dentists;
(9) Home health care;
(10) Hospice care;
(11) Hospital-based services;
(12) Hospitals;
(13) Licensed ambulatory surgery centers;
(14) Licensed certified social workers;
(15) Licensed dieticians;
(16) Licensed intellectual and developmental disabilities service providers;
(17) Licensed professional counselors;
(18) Licensed psychological examiners;
(19) Long-term care facilities;
(20) Occupational therapists;
(21) Optometrists;
(22) Pharmacists and pharmacies;
(23) Physical therapists;
(24) Physicians and surgeons (M.D. and D.O.);
(25) Podiatrists;
(26) Prosthetists;
(27) Psychologists;
(28) Respiratory therapists;
(29) Rural health clinics; and
(30) Speech pathologists.
(31) Crisis stabilization units.
(e) “Healthcare services” means services and products provided by a healthcare provider within the scope of the healthcare provider's license.
(f) “Healthcare insurer” means any entity, including, but not limited to:
(1) Insurance companies;
(2) Hospital and medical service corporations;
(3) Health maintenance organizations;
(4) Preferred provider organizations;
(5) Physician hospital organizations;
(6) Third-party administrators; and
(7) Prescription benefit management companies,
authorized to administer, offer, or provide health benefit plans.
Ark. Code Ann. § 23-99-204 Terms of health benefit plan.
(a) A healthcare insurer shall not, directly or indirectly:
(1)(A) Impose a monetary advantage or penalty under a health benefit plan that would affect a beneficiary's choice among those healthcare providers who participate in the health benefit plan according to the terms offered.
(B) “Monetary advantage or penalty” includes:
(i) A higher copayment;
(ii) A reduction in reimbursement for services; or
(iii) Promotion of one healthcare provider over another by these methods;
(2) Impose upon a beneficiary of healthcare services under a health benefit plan any copayment, fee, or condition that is not equally imposed upon all beneficiaries in the same benefit category, class, or copayment level under that health benefit plan when the beneficiary is receiving services from a participating healthcare provider pursuant to that health benefit plan; or
(3) Prohibit or limit a healthcare provider that is qualified under § 23-99-203(d) and is willing to accept the health benefit plan's operating terms and conditions, schedule of fees, covered expenses, and utilization rules and quality standards, from the opportunity to participate in that health benefit plan.
(b) Nothing in this subchapter shall prevent a health benefit plan from instituting measures designed to maintain quality and to control costs, including, but not limited to, the utilization of a gatekeeper system, as long as such measures are imposed equally on all providers in the same class.
(c)(1) A healthcare insurer may pay a claim for healthcare services by any lawful method, including the alternative payment method by gift card, credit card, or other type of electronic payment or virtual credit card as payment if the healthcare provider is given clear instructions about how to select the alternative payment method.
(2) However, a healthcare insurer is prohibited from requiring a healthcare provider to accept a gift card, credit card, or other type of electronic payment or virtual credit card as payment of a claim for healthcare services if the method of payment charges the healthcare provider a service fee to process.
Ark. Code Ann. § 23-99-205 Construction.
(a) Nothing in this subchapter shall be construed to require any healthcare insurer to cover any specific healthcare service.
(b) Provided, however, no condition or measure shall have the effect of excluding any type or class of provider qualified under § 23-99-204(a)(3) to provide that service.
Ark. Code Ann. § 23-99-206 Violations.
It is a violation of this subchapter for any healthcare insurer or other person or entity to provide any health benefit plan providing for healthcare services to residents of this state that does not conform to this subchapter, but nothing in this subchapter shall constitute a violation on the basis of actions taken by the health benefit plan to maintain quality, enforce utilization rules, and to control costs.
Ark. Code Ann. § 23-99-207 Civil penalties.
To the extent permitted by the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq., any provider adversely affected by a violation of this subchapter may sue in circuit court only for injunctive relief against the healthcare insurer, but not for damages. The prevailing party shall be allowed a reasonable attorney's fee and costs.
Ark. Code Ann. § 23-99-208 Void provisions.
(a) To avoid impairment of existing contracts, this subchapter shall only apply to contracts issued or renewed after July 28, 1995.
(b) Any provision in a health benefit plan which is executed, delivered, or renewed, or otherwise contracts for provision of services in this state that is contrary to this subchapter, shall, to the extent of the conflict, be void.
Ark. Code Ann. § 23-99-209 Applicability.
The provisions of this subchapter shall not apply to self-funded or other health benefit plans that are exempt from state regulation by virtue of the Employee Retirement Income Security Act of 1974, as amended.
Ark. Code Ann. § 23-99-210 Healthcare provider — Adverse professional review action.
A healthcare insurer shall not exclude a physician as a participating healthcare provider in a health benefit plan based solely on an adverse professional review action, including those described in the Arkansas Peer Review Fairness Act, § 20-9-1301 et seq., unless a hospital's physician peer review committee concludes that the conduct of the physician adversely affected or could have adversely affected a patient by violating the standard of care or posing a risk to the health or welfare of a patient.
Ark. Code Ann. § 23-99-211 Pharmacy benefits manager network participation — Definitions.
(a) As used in this section:
(1) "Pharmacist" means an individual licensed as a pharmacist by the Arkansas State Board of Pharmacy;
(2) "Pharmacy" means the place licensed by the board in which drugs, chemicals, medicines, prescriptions, and poisons are compounded, dispensed, or sold at retail;
(3) "Pharmacy benefits manager" means a person, business, or entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefits manager, that:
(A) Provides claims processing services or other prescription drug or devices services, or both, for health benefit plans; and
(B) Is licensed under the Arkansas Pharmacy Benefits Manager Licensure Act, § 23-92-502;
(4)(A) "Pharmacy benefits manager network" means any network of pharmacists or pharmacies that are offered by an agreement or insurance contract to provide pharmacist services for health benefit plans.
(B) "Pharmacy benefits manager network" includes any network delegated by the healthcare payor to the pharmacy benefits manager; and
(5) "Relevant and reasonable terms of participation" means terms and conditions that:
(A) Are consistent with applicable state and federal law;
(B) Are consistent with industry standards; and
(C) Do not arbitrarily or discriminatorily exclude a qualified pharmacy or pharmacist.
(b)(1) A pharmacy benefits manager shall not deny a pharmacy or pharmacist the opportunity to participate in the pharmacy benefits manager's network if the pharmacy or pharmacist:
(A) Is licensed under the laws of this state; and
(B) Agrees to accept and comply with the relevant and reasonable terms of participation as determined under this section.
(2) A pharmacy benefits manager shall not exclude a pharmacy or pharmacist from continued participation in the pharmacy benefits manager's pharmacy benefits manager network if the pharmacy or pharmacist continues to:
(A) Be licensed under the laws of this state; and
(B) Accept and comply with the relevant and reasonable terms of participation as determined under this section.
(3) A pharmacy benefits manager shall not:
(A) Condition participation of a pharmacy or pharmacist in one (1) pharmacy benefits manager network based on participation in any other pharmacy benefits manager network or penalize a pharmacy or pharmacist for exercising his, her, or its prerogative not to participate in a specific pharmacy benefits manager network; or
(B) Limit a pharmacy benefits manager network to include solely:
(i) An affiliated pharmacy; or
(ii) An internet pharmacy or a pharmacy that does not have a physical presence in this state for consumer access.
(c)(1) If a pharmacy or pharmacist alleges that a pharmacy benefits manager has denied or excluded the pharmacy or pharmacist from participation in the pharmacy benefits manager's pharmacy benefits manager network without justification, the pharmacy or pharmacist may submit a written complaint to the Insurance Commissioner.
(2) If a dispute arises as to whether there are "relevant and reasonable terms of participation" as that term is defined in this section, the commissioner shall decide the issue by determining whether the terms or conditions:
(A) Are consistent with applicable state and federal law;
(B) Are consistent with industry standards; and
(C) Do not arbitrarily or discriminatorily exclude a qualified pharmacy or pharmacist.
(3) Within thirty (30) days of receipt of the complaint under subdivision (c)(1) of this section, the commissioner, after a hearing conducted under § 23-61-301 and consideration of evidence from all parties, shall issue a determination.
(4) The determination of the commissioner under subdivision (c)(3) of this section is binding on all parties, subject to judicial review under § 23-61-307.
(d) A pharmacy benefits manager shall not:
(1) Impose terms or conditions that do not meet the definition of "relevant and reasonable terms of participation" under this section;
(2) Utilize reimbursement methodologies or contractual clauses intended to indirectly exclude a willing pharmacy or pharmacist from participation; or
(3) Engage in a practice that discriminates against a pharmacy or pharmacist based on the pharmacy's or pharmacist's geographic location, size, or ownership structure, unless the geographic location, size, or ownership structure is directly relevant to patient care or network adequacy.
(e) This section does not:
(1) Regulate the design or administration of employee benefit plans; or
(2) Impose requirements directly on employee benefit plans.
(f) This section applies to the trade practices of pharmacy benefits managers operating in this state, including a pharmacy benefits manager's pharmacy benefits manager network participation requirements and marketing or sale of pharmacy benefits manager network products and services, as permitted under state law.
(g) This section is enforceable with respect to a pharmacy benefits manager's compliance with state rules regarding healthcare provider equity and market practices.
(h)(1) The commissioner may promulgate rules necessary to implement, administer, and enforce this section.
(2) Rules that the commissioner may adopt under this section include without limitation rules relating to:
(A) Providing a process for resolving disputes between pharmacies, pharmacists, and pharmacy benefits managers;
(B) Ensuring compliance with state and federal laws; and
(C) Monitoring compliance with this section by licensed pharmacy benefits managers.
(i)(1) After notice and opportunity for a hearing, if a pharmacy benefits manager is found to have violated this section, the commissioner may:
(A) Impose a fine of up to one hundred thousand dollars ($100,000) per violation;
(B) Prohibit the pharmacy benefits manager from marketing, selling, or utilizing one (1) or more offending products, pharmacy benefits manager networks, or services within this state until the pharmacy benefits manager complies with this section; and
(C) Revoke or suspend the license of a pharmacy benefits manager to operate in this state.
(2) A penalty under subdivision (i)(1) of this section shall be enforced by the commissioner according to rules promulgated under this section.
(j) A prohibition under this section is applicable to a person or entity that:
(1) Performs the prohibited activity;
(2) Causes another person or entity to perform the prohibited activity;
(3) Solicits, advises, encourages, or coerces another person or entity to perform the prohibited activity;
(4) Aids or attempts to aid another person or entity in performing a prohibited activity; or
(5) Indirectly performs the prohibited activity.
Ark. Code Ann. § 23-99-301 Short title.
This subchapter shall be known and may be cited as the “Primary Eye Care Provider Act”.
Ark. Code Ann. § 23-99-302 Definitions.
As used in this subchapter:
(1) “Covered persons” means any individual or family that is enrolled in a health benefit plan or policy from a healthcare insurer and on whose behalf the healthcare insurer is obligated to pay for or provide eye and/or vision care benefits;
(2) “Covered service” means those healthcare services, including eye and/or vision care benefits, which the healthcare insurer is obligated to pay for or provide to covered persons under the health benefit plan or policy;
(3)(A) “Eye and/or vision care benefits” means those services and materials which are provided by a primary eye care provider who is functioning within the scope of his or her license.
(B) The conditions imposed by any specific health benefit plan upon the provision of eye and/or vision care benefits shall not:
(i) Prohibit the primary eye care provider from providing covered services to covered persons at his or her highest level of licensure and competence at any given time, as determined by his or her respective licensing board; or
(ii) Require that the primary eye care provider hold hospital staff privileges or include any other condition as a requirement which would have the practical effect of excluding any class of provider from participation in the health benefit plan;
(4) “Gatekeeper” means a covered person's primary care provider in a gatekeeper system;
(5) “Gatekeeper system” means a system of administration used by any health benefit plan in which a primary care provider furnishes basic patient care and coordinates diagnostic testing, indicated treatment, and specialty referral for persons covered by the health benefit plan;
(6) “Health benefit plan” means any public or private health plan, program, policy, subscriber agreement, or contract implemented in the State of Arkansas which includes or may include payment, reimbursement, including capitation, or financial compensation for provision of eye and/or vision care benefits to covered persons but does not include workers' compensation coverage or reimbursement;
(7) “Healthcare insurer” means any entity, including, but not limited to, insurance companies, hospital and medical service corporations, health maintenance organizations, preferred provider organizations, and physician hospital organizations, that is authorized by the State of Arkansas to offer or provide health benefit plans, policies, subscriber contracts, or any other contracts of a similar nature which indemnify or compensate healthcare providers for the provision of healthcare services; and
(8) “Primary eye care provider” means an ophthalmologist or optometrist licensed by the State of Arkansas who has been selected by a person covered by a health benefit plan to provide eye and/or vision care benefits and who agrees to provide these services in accordance with the terms, conditions, reimbursement rates, and standards of quality as set forth within the specific health benefit plan.
Ark. Code Ann. § 23-99-303 Requirements for health benefit plans.
A health benefit plan that includes, or may include, eye and/or vision care benefits shall:
(1) Include all primary eye care providers who are selected by covered persons of the health benefit plan for the provision of all eye and/or vision care benefits provided by the health benefit plan;
(2) Permit any licensed optometrist or ophthalmologist who agrees to abide by the terms, conditions, reimbursement rates, and standards of quality of the health benefit plan to serve as a primary eye care provider to any person covered by that health benefit plan;
(3) Guarantee that all covered persons who are eligible for eye and/or vision care benefits under a health benefit plan shall have direct access to the primary eye care provider of their choice independent of, and without referral from, any other provider or entity;
(4)(A) Assure that those plans utilizing a gatekeeper system shall designate the primary eye care provider as the gatekeeper who shall provide basic patient care and coordinate diagnostic testing, indicated treatment, and specialty referral for those covered persons in the provision of eye and/or vision care benefits.
(B)(i) Nothing in this subchapter shall prevent a covered person from having direct access to that person's primary care provider, or gatekeeper, for the treatment of eye disease or injury and being reimbursed in accordance with the terms and fee schedule of the health benefit plan.
(ii) However, nothing contained in this subchapter shall require payment of the monthly patient management fee by the Arkansas Medicaid Program to a primary eye care provider gatekeeper;
(5) Not discriminate between individual providers or classes of providers in the amount of reimbursement, copayment, or other financial compensation for the same or essentially similar services provided by the health benefit plan;
(6) Not promote or recommend any individual provider or class of providers to a covered person by any method or means;
(7) Assure that all primary eye care providers selected by persons covered by a health benefit plan are included on the list of participating providers of the health benefit plan;
(8) Assure that an adequate number of primary eye care providers are included to guarantee reasonable accessibility, timeliness of care, convenience, and continuity of care to covered persons; and
(9) Make available to covered persons a listing of all primary eye care providers, their practice locations, and telephone numbers on a regular, timely basis.
Ark. Code Ann. § 23-99-304 Subchapter not to prevent treatment.
Nothing in this subchapter shall prevent any person covered by a health benefit plan from receiving emergency eye care nor shall it prevent any person from exercising his or her right to receive treatment from his or her personal doctor and being reimbursed in accordance with the terms and fee schedule of the health benefit plan.
Ark. Code Ann. § 23-99-305 Remedies.
Any person adversely affected by a violation of this subchapter may bring action in a court of competent jurisdiction for injunctive relief against the healthcare insurer and, upon prevailing, in addition to such injunctive relief, shall recover damages not less than one thousand dollars ($1,000) plus attorney's fees and costs.
Ark. Code Ann. § 23-99-401 Short title.
This subchapter shall be known and may be cited as the “Arkansas Health Care Consumer Act”.
Ark. Code Ann. § 23-99-402 Legislative findings and intent.
As the state's insurance sector becomes increasingly dominated by managed care features that include decisions regarding coverage and appropriateness of health care, there is a vital need to protect patients in this environment.
Ark. Code Ann. § 23-99-403 Definitions.
As used in this subchapter:
(1) “Acute condition” means a medical condition, illness, or disease having a short and relatively severe course;
(2) “Commissioner” means the Insurance Commissioner;
(3) “Covered person” means a person on whose behalf the healthcare insurer issuing or delivering the health benefit plan is obligated to pay benefits pursuant to the health benefit plan;
(4)(A) “Health benefit plan” means any individual, blanket, or group plan, policy, or contract for healthcare services issued or delivered by a healthcare insurer in this state, including indemnity and managed care plans and including self-insured governmental and church plans, but excluding plans providing healthcare services pursuant to 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.
(B) “Health benefit plan” does not include an accident-only, specified disease, hospital indemnity, long-term care, disability income, or other limited-benefit health insurance policy;
(5) “Healthcare insurer” or “insurer” means any insurance company, hospital and medical service corporation, or health maintenance organization issuing or delivering health benefit plans in this state and subject to the following laws:
(A) The Arkansas Insurance Code;
(B) Section 23-76-101 et seq., pertaining to health maintenance organizations;
(C) Section 23-75-101 et seq., pertaining to hospital and medical service corporations; and
(D) Any successor laws of the foregoing;
(6) “Managed care plan” means a health benefit plan that either requires a covered person to use or creates incentives, including financial incentives, for a covered person to use participating providers;
(7)(A) “Orthotic device” means an external device that is:
(i) Intended to restore physiological function or cosmesis to a patient; and
(ii) Custom-designed, fabricated, assembled, fitted, or adjusted for the patient using the device prior to or concurrent with the delivery of the device to the patient.
(B) “Orthotic device” does not include a cane, a crutch, a corset, a dental appliance, an elastic hose, an elastic support, a fabric support, a generic arch support, a low-temperature plastic splint, a soft cervical collar, a truss, or other similar device that:
(i) Is carried in stock and sold without therapeutic modification by a corset shop, department store, drug store, surgical supply facility, or similar retail entity; and
(ii) Has no significant impact on the neuromuscular, musculoskeletal, or neuromusculoskeletal functions of the body;
(8) “Orthotic service” means the evaluation and treatment of a condition that requires the use of an orthotic device;
(9) “Participating provider” means a provider who or that has agreed to provide healthcare services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly, from the healthcare insurer;
(10) “Person” or “entity” means and includes, individually and collectively, any individual, corporation, partnership, firm, trust, association, voluntary organization, or any other form of business enterprise or legal entity;
(11) “Policyholder” means the employer, union, individual, or other person or entity that purchases, issues, or sponsors a health benefit plan;
(12)(A) “Prosthetic device” means an external device that is:
(i) Intended to replace an absent external body part for the purpose of restoring physiological function or cosmesis to a patient; and
(ii) Custom-designed, fabricated, assembled, fitted, or adjusted for the patient using the device prior to or concurrent with being delivered to the patient.
(B) “Prosthetic device” does not include an artificial eye, an artificial ear, a dental appliance, a cosmetic device such as artificial eyelashes or wigs, a device used exclusively for athletic purposes, an artificial facial device, or other device that does not have a significant impact on the neuromuscular, musculoskeletal, or neuromusculoskeletal functions of the body;
(13) “Prosthetic service” means the evaluation and treatment of a condition that requires the use of a prosthetic device;
(14) “Specialty” means a provider's particular area of specialty within his or her licensed scope of practice; and
(15) “Type” of provider means the licensed scope of practice.
Ark. Code Ann. § 23-99-404 Benefits for mothers and newborns.
(a)(1) Except as provided in subsection (b) of this section, a healthcare insurer may not restrict benefits for any hospital stay in connection with childbirth for the mother or newborn child to less than forty-eight (48) hours following a normal vaginal delivery or to less than ninety-six (96) hours following cesarean section.
(2) A healthcare insurer may not require that a provider obtain authorization for prescribing any length of stay required under subdivision (a)(1) of this section.
(b) Subdivision (a)(1) of this section shall not apply if the decision to discharge the mother or her newborn child prior to the expiration of the minimum stay is made by the attending physician in consultation with the mother.
Ark. Code Ann. § 23-99-405 Mastectomies.
(a) Every health benefit plan providing mastectomy benefits and issued or renewed after July 16, 2003, shall conform with the requirements of the Women's Health and Cancer Rights Act of 1998, 42 U.S.C. §§ 300gg-6 and 300gg- 52, as it existed on January 1, 2025.
(b) To the extent the requirements of this section do not conflict with federal law, rules, or regulations, each healthcare insurer providing mastectomy benefits in a health benefit plan shall provide, in a manner determined in consultation with the attending physician and the enrollee or insured:
(1) For medical and surgical benefits for any hospital stay in connection with a mastectomy for not less than forty-eight (48) hours unless the decision to discharge the patient before the expiration of the minimum length of stay is made by an attending physician in consultation with the enrollee or insured;
(2) The following medical and surgical benefits with respect to mastectomy coverage if an enrollee or insured receives benefits in connection with a mastectomy and elects breast reconstruction:
(A) Surgery and reconstruction of the breast on which the mastectomy has been performed;
(B) Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
(C) Prostheses and coverage for physical complications at all stages of a mastectomy, including lymphedemas;
(3) Written notice of the availability of coverage under this section to the enrollee or insured upon enrollment and annually thereafter; and
(4)(A) Medical and surgical benefits for:
(i) Artificial or biological mesh used to support tissue; and
(ii) A nerve graft to preserve or restore nerve function.
(B) A healthcare insurer, health benefit plan, or group health plan shall reimburse a healthcare provider for the supplies required for the healthcare services provided under subdivision (b)(4)(A) of this section at a rate equal to or greater than one hundred percent (100%) of the healthcare provider's acquisition cost.
(c) A healthcare insurer providing mastectomy benefits under this section shall not:
(1) Deny an enrollee or insured eligibility or continued eligibility to enroll or renew coverage under the terms of the health benefit plan solely for the purpose of avoiding the requirements of this section; or
(2) Penalize, reduce, or limit the reimbursement of an attending provider or induce the provider to provide care in a manner inconsistent with this section.
(d) A healthcare insurer or health benefit plan shall cover the healthcare services under this section if the service is performed at a licensed facility, including without limitation:
(1) A hospital;
(2) A hospital outpatient department; and
(3) An ambulatory surgery center.
(e) This section does not apply to a plan providing health benefits to state and public school employees under § 21-5-401 et seq.
(f) This section expires on June 30, 2031, unless extended by the General Assembly.
Ark. Code Ann. § 23-99-406 Obstetrical and gynecological services.
(a) In order to ensure that healthcare benefits are safely and appropriately delivered to women, insurers which require the selection or assignment of a primary care physician shall allow each covered person who is a woman to select a participating obstetrician/gynecologist in addition to her primary care physician.
(b) If the woman chooses to make this selection, the insurer shall allow the woman to go directly to her selected obstetrician/gynecologist, without referral from her primary care physician, for obstetrical and gynecological services.
Ark. Code Ann. § 23-99-407 “Gag clause” prohibition.
No participating provider may be prohibited, restricted, or penalized in any way from disclosing to any covered person any healthcare information that the participating provider deems appropriate regarding the nature of treatment, risks, or alternatives thereto, the availability of alternate therapies, consultations, or tests, the decision of utilization reviewers or similar persons to authorize or deny services, the process that is used to authorize or deny healthcare services or benefits, or information on financial incentives and structures used by the insurer.
Ark. Code Ann. § 23-99-408 Continuity of care.
(a) When healthcare insurers use participating providers, the healthcare insurers shall develop procedures to provide for the continuity of care of their covered persons. At a minimum, the procedures shall:
(1) Ensure that when a new patient is enrolled in a health benefit plan and is being treated by a nonparticipating provider for a current episode of an acute condition, the patient may continue to receive treatment as an in-network benefit from that provider until the current episode of treatment ends or until the end of ninety (90) days, whichever occurs first;
(2) Ensure that when a provider's participation is terminated, his or her patients under the health benefit plan may continue to receive care from that provider as an in-network benefit until a current episode of treatment for an acute condition is completed or until the end of ninety (90) days, whichever occurs first; and
(3) Explain how the covered person may request to continue services under subdivisions (a)(1) and (2) of this section.
(b) During the period covered by subdivisions (a)(1) and (2) of this section, the provider shall be deemed to be a participating provider for purposes of reimbursement, utilization management, and quality of care.
(c) Nothing in this section shall require a healthcare insurer to provide benefits that are not otherwise covered under the terms and provisions of the health benefit plan.
Ark. Code Ann. § 23-99-409 Prescription drug formulary.
When a healthcare insurer uses a formulary for prescription drugs, the insurer shall include a written procedure whereby covered persons can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the formulary when:
(1) The formulary's equivalent has been ineffective in the treatment of the covered person's disease or condition; or
(2) The formulary's drug causes or is reasonably expected to cause adverse or harmful reactions in the covered person.
Ark. Code Ann. § 23-99-410 Grievance procedures.
(a) A healthcare insurer issuing or delivering a managed care plan shall establish for those managed care plans a grievance procedure which provides covered persons with a prompt and meaningful review on the issue of denial, in whole or in part, of a healthcare treatment or service.
(b)(1) The covered person shall be provided prompt notice in writing of the outcome of the grievance procedure.
(2) In the event the outcome is adverse to the covered person, the notice shall include specific findings related to the grievance.
Ark. Code Ann. § 23-99-411 Processing applications of providers.
(a)(1)(A) Healthcare insurers shall establish mechanisms to ensure timely processing of requests for participation or renewal by providers and in making decisions that affect participation status.
(B) These mechanisms shall include, at a minimum, provisions for the provider to receive a written statement of reasons for the healthcare insurer's denial of a request for initial participation or renewal.
(2)(A) A healthcare insurer shall make a decision within:
(i) Sixty (60) calendar days from the date of submission of a completed application as defined by rule of the Insurance Commissioner for participation or a request for renewal by a physician licensed under the Arkansas Medical Practices Act, § 17-95-201 et seq., § 17-95-301 et seq., and § 17-95-401 et seq.; and
(ii) ninety (90) calendar days from the date of submission of a completed application as defined by rule of the commissioner for participation or a request for renewal by any other provider.
(B) However, when a physician's credentials are verified through the Arkansas State Medical Board's Centralized Credentials Verification Service under § 17-95-107, the sixty (60) days specified under subdivision (a)(2)(A)(i) of this section is tolled from the date an order is received by the Centralized Credentials Verification Service from the healthcare insurer until the date the healthcare insurer receives notification by the Centralized Credentials Verification Service that the file is complete and available for retrieval.
(C)(i) A healthcare insurer shall provide written acknowledgement to a provider within ten (10) days of the insurer's receipt of an application.
(ii)(a) Upon receipt of an application, a healthcare insurer shall review the application to determine if the application is complete.
(b) If the application is incomplete, a healthcare insurer shall notify the applicant provider in writing within fifteen (15) calendar days that the application is incomplete.
(c) The notice shall include a list of the items required for the application to be complete.
(d) If the healthcare insurer does not send the notice within the required timeframe, the application shall be deemed complete.
(iii) If the information provided by a complete application, the healthcare insurer's investigation, or the Centralized Credentials Verification Service requires the healthcare insurer to collect more detailed information from the provider to fairly and responsibly process the application, the time specified under subdivision (a)(2)(A)(i) of this section is tolled, and the application is suspended from the date a written request for the information is sent to the provider until the request is fully and completely answered and sent to the healthcare insurer by the provider.
(iv) If application information specified under subdivision (a)(2)(C)(ii) of this section is missing and not received within ninety (90) days of notification by the healthcare insurer or if the request is not fully answered within ninety (90) days of the date it was sent, the healthcare insurer, in its discretion, may treat the application as abandoned and deny it.
(v) The request and response under this section shall be sent by regular mail or other means of delivery as may be allowed by rules adopted by the commissioner.
(3)(A) If a physician is already credentialed by the healthcare insurer but changes employment or location, joins a new group or clinic, or opens an additional location, the healthcare insurer shall only require the submission of such additional information, if any, as is necessary to continue the physician's credentials based upon the changed employment, location, new group or clinic, or additional location.
(B) The healthcare insurer shall not require a new application or recredentialing application due solely to the changes listed in subdivision (a)(3)(A) of this section.
(C) Any change listed in subdivision (a)(3)(A) of this section shall be reflected within the healthcare insurer's system within thirty (30) calendar days of written notification by the physician of the change.
(4) Healthcare insurers shall promptly notify providers:
(A) Of any delay in processing applications; and
(B) Of the reasons for a delay in processing applications.
(5)(A) A healthcare insurer shall notify a physician in writing at least ninety (90) days before the deadline to submit a recredentialing application.
(B)(i) The healthcare insurer shall give the physician written notice at least forty-five (45) calendar days prior to terminating the physician for failure to submit a recredentialing application.
(ii) If the physician submits the recredentialing application during the forty-five-day period, the termination shall not take effect.
(C) During the forty-five-day period, the healthcare insurer shall not represent to the policyholder, plan members, or the general public that the physician has been or will be terminated from the network unless the termination is for some reason other than failure to obtain recredentialing.
(D) If a termination occurs for any reason, the healthcare insurer shall formally notify the physician in writing of the effective date of the termination and the basis for the termination.
(6)(A)(i) Except as provided in subdivision (a)(6)(B) of this section, for payment purposes, a healthcare insurer shall treat an applicant physician as a participating physician from the date of submission of a substantially completed application once an applicant physician has been approved through an insurer's credentialing process.
(ii) As used in subdivision (a)(6)(A)(i) of this section, "date of submission of a substantially completed application" means the date a healthcare insurer receives an applicant physician's credentialling information, as defined under § 17-95-107, from the Centralized Credentials Verification Service of the Arkansas State Medical Board.
(B) Subdivision (a)(6)(A) of this section does not apply to the Arkansas Medicaid Program.
(7) Written notice under this section may be provided by electronic means for a provider who supplies an electronic mailing address to the healthcare insurer.
(8) The commissioner may adopt rules to ensure that covered healthcare claims submitted by patients or their providers are not negatively affected by delays in processing participation applications.
(9) In addition to any legal remedies or actions that may be brought against a healthcare insurer by the commissioner, a fine of one thousand dollars ($1,000) per day shall be imposed for each day exceeding the sixty (60) days under subdivision (a)(2)(A)(i) of this section.
(10) The commissioner shall adopt rules to implement this subsection.
(b) This section does not prevent a provider or a healthcare insurer from terminating a participating provider contract in accordance with its terms.
Ark. Code Ann. § 23-99-412 Provider input.
All healthcare insurers issuing or delivering managed care plans shall be required to establish a mechanism whereby participating providers provide input into the healthcare insurer's medical policy, utilization review criteria and procedures, quality and credentialing criteria, and medical management procedures.
Ark. Code Ann. § 23-99-413 Disclosure requirements.
Upon request, healthcare insurers must provide the following information in a clear and understandable form to all prospective policyholders, policyholders, and covered persons. Insurers shall notify policyholders and covered persons of their right to request the information, which must include:
(1) Coverage provisions, benefits, and exclusions by category of service and provider;
(2) A description of the prior authorization, precertification, and referral requirements;
(3) The existence of prescription drug formularies and prior approval requirements for prescription drugs;
(4) The name, number, type, specialty, and geographic location of participating providers; and
(5)(A) Criteria by which providers are evaluated for network participation.
(B) Proprietary information shall not be disclosed.
(C) Criteria may include, but are not limited to, geographic limitations, geographic distribution of patients, specialty limitation, anticipated numbers and types of providers needed, and economic considerations. This information shall also be made available to providers upon request.
Ark. Code Ann. § 23-99-414 Rules.
The Insurance Commissioner may promulgate necessary rules for carrying out this subchapter.
Ark. Code Ann. § 23-99-415 Enforcement and penalties.
The Insurance Commissioner shall have all the powers to enforce this subchapter as are granted to the commissioner elsewhere in the Arkansas Insurance Code.
Ark. Code Ann. § 23-99-416 Application of subchapter.
This subchapter applies to all health benefit plans issued, renewed, extended, or modified on or after August 1, 1997. “Renewed, extended, or modified” shall include all health benefit plans in which the insurer has reserved the right to change the premium.
Ark. Code Ann. § 23-99-417 Coverage required for orthotic devices, orthotic services, prosthetic devices, and prosthetic services.
(a)(1) Subject to subdivision (a)(2) of this section and subsections (b) and (c) of this section, a health benefit plan that is issued for delivery, delivered, renewed, or otherwise contracted for in this state shall provide coverage for eligible charges within limits of coverage that are no less than eighty percent (80%) of Medicare allowable as defined by the Centers for Medicare & Medicaid Services, Healthcare Common Procedure Coding System as of January 1, 2009, or as of a later date if adopted by rule of the Insurance Commissioner for:
(A) An orthotic device;
(B) An orthotic service;
(C) A prosthetic device;
(D) A prosthetic service;
(E) A prosthetic device for athletics or recreation; and
(F) A prosthetic device for showering or bathing.
(2) This section does not require coverage for an orthotic device, an orthotic service, a prosthetic device, a prosthetic service, a prosthetic device for athletics or recreation, or a prosthetic device for showering or bathing for a replacement that occurs more frequently than one (1) time every three (3) years unless medically necessary .
(b)(1) Eligible charges for coverage under subsection (a) of this section shall be based on medical necessity , which may include without limitation:
(A) The information and recommendation from the treating physician in consultation with the insured and a prosthetic provider regarding the most appropriate model that adequately meets the medical and recreational needs of the covered person; and
(B) The results of a functional outcomes test.
(2) As used in this section:
(A) "Functional outcomes test” includes without limitation the insured's:
(i) Medical history, including prior use of orthotic devices, prosthetic devices, or prosthetic devices for athletics or recreation if applicable;
(ii) Current condition, including the status of the musculoskeletal system and the nature of other medical problems; and
(iii) Desire to:
(a) Ambulate or recreate with respect to lower-limb orthotic devices, prosthetic devices, or prosthetic devices for athletics or recreation; or
(b) Maximize upper-limb function with respect to upper-limb orthotic devices, prosthetic devices, or prosthetic devices for athletics or recreation; and
(B)(i) "Prosthetic device for athletics or recreation" means a device that provides an individual with the ability or potential for prosthesis ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels.
(ii) "Prosthetic device for athletics or recreation" includes prostheses meeting the description of utilizing a blade-type foot designed for running and other high activity or high-impact endeavors.
(3) A denial or limitation of coverage based on lack of medical necessity is subject to external review under State Insurance Department Rule 76, the Arkansas External Review Regulation.
(c) A health benefit plan:
(1) May require prior authorization for an orthotic device, an orthotic service, a prosthetic device, a prosthetic service, a prosthetic device for athletics or recreation, or a prosthetic device for showering or bathing in the same manner that prior authorization is required for any other covered benefit;
(2) May impose copayments, deductibles, or coinsurance amounts for an orthotic device, an orthotic service, a prosthetic device, a prosthetic service, a prosthetic device for athletics or recreation, or a prosthetic device for showering or bathing if the amounts are no greater than the copayments, deductibles, or coinsurance amounts that apply to other benefits under the health benefit plan;
(3) When the replacement or repair is necessitated by anatomical change or normal use, shall cover the necessary repair and necessary replacement of an orthotic device, a prosthetic device, a prosthetic device for athletics or recreation, or a prosthetic device for showering or bathing subject to copayments, coinsurance, and deductibles that are no more restrictive than the copayments, coinsurance, and deductibles that apply to other benefits under the health benefit plan, unless the repair or replacement is necessitated by misuse or loss; and
(4) Shall include a requirement that an orthotic device, an orthotic service, a prosthetic device, a prosthetic service, a prosthetic device for athletics or recreation, or a prosthetic device for showering or bathing be prescribed by a licensed doctor of medicine, doctor of osteopathy, or doctor of podiatric medicine and provided by a doctor of medicine, a doctor of osteopathy, a doctor of podiatric medicine, an orthotist, or a prosthetist licensed by the State of Arkansas.
(d) Coverage of an orthotic device, an orthotic service, a prosthetic device, a prosthetic service, a prosthetic device for athletics or recreation, or a prosthetic device for showering or bathing may be made subject to but no more restrictive than the provisions of the health benefit plan that apply to other benefits under the health benefit plan.
(e) The Insurance Commissioner may adopt necessary rules to enforce this section.
(f) A recreational prosthesis shall be deemed as medically necessary by the treating or referring physician who is prescribing the prosthesis.
(g) A patient who is a candidate for a recreational prosthesis shall qualify in the Medicare functional level status as a K-3 or K-4 functional level as a user who:
(1) Can achieve any high-level activity pursuits; and
(2) Exhibits an ability to perform above and beyond normal ambulation.
Ark. Code Ann. § 23-99-418 Coverage for autism spectrum disorders required — Definitions.
(a) As used in this section:
(1) “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications by a board- certified behavior analyst using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior;
(2) “Autism services provider” means a person, entity, or group that provides diagnostic evaluations and treatment of autism spectrum disorders, including licensed physicians, licensed psychiatrists, licensed speech-language pathologists, licensed occupational therapists, licensed physical therapists, licensed psychologists, and board- certified behavior analysts;
(3) “Autism spectrum disorder” means a condition diagnosed according to the diagnostic criteria under the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders;
(4) “Board-certified behavior analyst” means an individual certified by the Behavior Analyst Certification Board, a national nongovernmental agency that certifies individuals who have completed academic, examination, training, and supervision requirements in applied behavior analysis;
(5)(A) “Diagnosis” means medically necessary assessment, evaluations, or tests to diagnose whether or not an individual has an autism spectrum disorder.
(B) Diagnostic evaluations do not need to be completed concurrently to diagnose autism spectrum disorder;
(6) “Evidence-based treatment” means treatment subject to research that applies rigorous, systematic, and objective procedures to obtain valid knowledge of effectiveness relevant to autism spectrum disorders as published in the National Standards Report of the National Autism Center;
(7)(A) “Health benefit plan” means any group or blanket plan, policy, or contract for healthcare services issued or delivered in this state by healthcare insurers, including indemnity and managed care plans and the plans providing health benefits to state and public school employees under § 21-5-401 et seq., but excluding individual major medical plans and plans providing healthcare services under 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.
(B) “Health benefit plan” does not include an accident- only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income, or other limited benefit health insurance policy;
(8) “Healthcare insurer” means any insurance company, hospital and medical service corporation, or health maintenance organization issuing or delivering health benefit plans in this state and subject to any of the following laws:
(A) The insurance laws of this state;
(B) Section 23-75-101 et seq., pertaining to hospital and medical service corporations; and
(C) Section 23-76-101 et seq., pertaining to health maintenance organizations;
(9) “Medically necessary” means reasonably expected to do the following:
(A) Prevent the onset of an illness, condition, injury, or disability;
(B) Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or
(C) Assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age;
(10) “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications;
(11) “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices;
(12) “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices;
(13) “Therapeutic care” means services provided by licensed speech-language pathologists, occupational therapists, or physical therapists; and
(14) “Treatment” includes:
(A) The following care prescribed, provided, or ordered for a specific individual diagnosed with an autism spectrum disorder , including without limitation:
(i) Applied behavior analysis when provided by or supervised by a board-certified behavior analyst;
(ii) Pharmacy care;
(iii) Psychiatric care;
(iv) Psychological care;
(v) Therapeutic care; and
(vi) Equipment determined necessary to provide evidence-based treatment; and
(B) Any care for an individual with autism spectrum disorder that is determined by a licensed physician to be:
(i) Medically necessary; and
(ii) Evidence-based.
(b) To the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by a health benefit plan, coverage under this section shall be included in a health benefit plan that is delivered, executed, issued, amended, adjusted, or renewed in this state on or after October 1, 2011.
(c) Applied behavior analysis services shall:
(1) Have an annual limitation of fifty thousand dollars ($50,000); and
(2) Be limited to children under eighteen (18) years of age.
(d)(1) The coverage required by this section is not subject to:
(A) Any limits on the number of visits an individual may make to an autism services provider; or
(B) Dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to a physical illness generally under a health benefit plan.
(2) The coverage may be subject to other general exclusions and limitations of the health insurance plan, including without limitation coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and utilization review of healthcare services, including review of medical necessity, case management, and other managed care provisions.
(e) This section does not limit benefits that are otherwise available to an individual under a health benefit plan.
(f) Coverage for treatment under this section shall not be denied on the basis that the treatment is habilitative in nature.
(g)(1) If an individual is receiving treatment for an autism spectrum disorder, an insurer shall not request a review of the medical necessity of the treatment for autism spectrum disorder to a greater extent than it does for other illnesses covered in the policy.
(2) The cost of obtaining the review shall be borne by the insurer.
(h)(1) This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program under the Individuals with Disabilities Education Act, Pub. L. No. 101-476, or an individualized service plan.
(2) In accordance with the Individuals with Disabilities Education Act, Pub. L. No. 101-476, nothing in this section relieves an insurer from an otherwise valid obligation to provide or to pay for services provided to an individual with a disability.
(i) On and after January 1, 2014:
(1) To the extent that this section requires benefits that exceed the essential health benefits specified under section 1302(b) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended, the specific benefits that exceed the specified essential health benefits shall not be required of a health benefit plan when the health benefit plan is offered by a healthcare insurer in this state through the state medical exchange; and
(2) This section continues to apply to plans offered outside the state medical exchange.
Ark. Code Ann. § 23-99-419 Gastric pacemakers.
(a) As used in this section:
(1) “Gastric pacemaker” means a medical device that:
(A) Uses an external programmer and implanted electrical leads to the stomach; and
(B) Transmits low-frequency, high-energy electrical stimulation to the stomach to entrain and pace the gastric slow waves to treat gastroparesis; and
(2)(A) “Gastroparesis” means a neuromuscular stomach disorder in which food empties from the stomach more slowly than normal.
(B) In most people, undigested food moves from the stomach into the duodenum and small intestine within two (2) to four (4) hours after eating.
(C) In contrast, a patient who has gastroparesis will retain a significant amount of food in his or her stomach hours after eating.
(D) A patient with gastroparesis experiences a variety of upper gastrointestinal symptoms that prevents him or her from eating normally and that may lead to dehydration, weight loss, and eventually life-threatening electrolyte imbalances and malnutrition.
(E) Moreover, delayed stomach emptying interferes with oral drug absorption and, in patients with diabetes mellitus, prevents effective control of blood glucose levels.
(F) The Enterra Therapy for gastroparesis received humanitarian device exemption approval from the Food and Drug Administration in March 2000.
(G) The humanitarian device exemption authorizes Medtronic to market Enterra Therapy for the treatment of chronic intractable, drug-refractory, nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology.
(H) The effectiveness of Enterra Therapy for this use has not been demonstrated.
(I) Enterra Therapy may be used only in medical centers in which an institutional review board has approved use of the device.
(J)(i) When the battery in a neurostimulator runs down, the physician will obtain prior authorization from the health insurance company and approval for a replacement surgery and then schedule a procedure.
(ii) During the surgery, the physician will remove the neurostimulator and implant a new one.
(iii) The implanted leads will also be checked to make sure they are working properly.
(iv) If the leads are working properly, the new neurostimulator will be connected to the leads that are already in place.
(v) If the leads are not working as they should be, they will also be replaced.
(b) Except as provided under subsection (c) or subsection (d) of this section, a health benefit plan that is issued for delivery, delivered, renewed, or otherwise contracted for in this state shall provide coverage for gastric pacemakers.
(c) Eligible charges and limits of or exclusions from coverage under subsection (b) of this section shall be based on medical necessity or the health benefit plan's coverage criteria for other medical services.
(d) A health benefit plan may:
(1) Require prior authorization for a gastric pacemaker in the same manner that prior authorization is required for any other covered benefit; and
(2) Impose copayments, deductibles, or coinsurance amounts for a gastric pacemaker if the amounts are no greater than the copayments, deductibles, or coinsurance amounts that apply to other benefits under the health benefit plan.
Ark. Code Ann. § 23-99-421 Pediatric dental benefits — Definitions.
(a) As used in this section:
(1) “Exchange” means a health benefit exchange that offers health benefits under a health benefit plan offered by a healthcare insurer in this state through a state-based health insurance exchange or a health insurance exchange operated by the federal government under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152;
(2) “Qualified dental plan” means a limited scope dental plan that has a certification that the qualified dental plan meets the criteria for certification under 42 U.S.C. § 18031(d)(2)(B)(ii), in effect on January 1, 2015; and
(3) “Qualified health plan” means a health benefit plan that provides healthcare coverage of essential health benefits under 42 U.S.C. § 18021(a), in effect on January 1, 2015.
(b) Beginning January 1, 2016, a qualified health plan offering healthcare coverage under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, satisfies the minimum essential pediatric oral health benefits under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, for health benefit plans offered through an exchange or outside an exchange that do not include the minimum essential pediatric oral health benefits if the healthcare insurer has reasonable assurance that the minimum essential pediatric oral health benefits are otherwise provided to the purchaser of the health benefit plan.
(c) The healthcare insurer shall be considered to have reasonable assurance that the minimum essential pediatric oral health benefits are otherwise provided to the purchaser of the health benefit plan if:
(1) At least one (1) qualified dental plan offers the minimum essential pediatric oral health benefits that are available to the purchaser of the health benefit plan; and
(2) A qualified health plan prominently discloses at the time of purchase on a form approved by the Insurance Commissioner that the qualified health plan does not provide the minimum essential pediatric oral health benefits.
Ark. Code Ann. § 23-99-422 Benefits for mental illness or substance use disorders delivered through psychiatric collaborative care model — Definitions — Rules.
(a) As used in this section:
(1)(A) “Healthcare insurer” means an insurance company, hospital and medical service corporation, or health maintenance organization issuing or delivering health benefit plans in this state and subject to the following laws:
(i) The Arkansas Insurance Code;
(ii) Section 23-76-101 et seq., pertaining to health maintenance organizations; and
(iii) Section 23-75-101 et seq., pertaining to hospital and medical service corporations;
(B) "Healthcare insurer" does not mean the Arkansas Medicaid Program and Medicaid services provided under the Arkansas Medicaid Program if those services are managed or reimbursed by another healthcare insurer or a risk-based provider organization; and
(2) "Psychiatric collaborative care model" means the delivery of care that is:
(A) An evidence-based, integrated behavioral health service delivery method described at 81 Fed. Reg. 80230-80239, as it existed on March 31, 2023, and the MLN Booklet for Behavioral Health Integration Services published by the Centers for Medicare & Medicaid Services, as it existed on March 31, 2023; and
(B) A method typically used by a primary care team consisting of a primary care provider and a care manager who works in collaboration with a psychiatric consultant, including without limitation a psychiatrist.
(b) A healthcare insurer that provides benefits for the treatment of mental illness or substance use disorders shall provide reimbursement for those benefits if the benefits are delivered through a psychiatric collaborative care model.
(c) The care provided by a primary care team shall:
(1) Be directed by the primary care team;
(2) Include structured care management with regular assessments of clinical status using validated tools; and
(3) Include modification of treatment, as appropriate.
(d) A psychiatric consultant who participates in a primary care team shall:
(1) Provide regular consultations to the primary care team;
(2) Review the clinical status and care of the covered person; and
(3) Make recommendations.
(e)(1) A healthcare insurer may deny reimbursement for healthcare services delivered through a psychiatric collaborative care model on the grounds of medical necessity only if the medical necessity determinations are in compliance with state law and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, Pub. L. No. 110-343, § 511 et seq.
(2) For care provided through a psychiatric collaborative care model, a healthcare insurer shall not:
(A) Place a benefit limitation or cap on the amount of time, number of units, or dollar payments for care manager activities in any month in a manner that is contrary to state law or the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, Pub. L. No. 110-343, § 511 et seq.;
(B) Limit the ability of federally qualified health centers or rural health clinics to receive reimbursement;
(C) Impose any licensure requirements enacted by state or federal law for a care manager;
(D) Limit the age of a patient for whom the care is a covered service; or
(E) Limit coverage to a patient with a specific diagnosis.
(f)(1) The Arkansas Medicaid Program may:
(A) Apply for a grant for a psychiatric collaborative care model; and
(B) Work in consultation with nongovernmental entities that are recognized to have expertise in psychiatric collaborative care models.
(2) Beginning on September 1, 2023, and on a quarterly basis thereafter, the Arkansas Medicaid Program shall report to the Senate Committee on Insurance and Commerce and the House Committee on Insurance and Commerce concerning the progress and activities under subdivision (f)(1) of this section.
(g) The Insurance Commissioner may promulgate rules necessary to implement this section.
Ark. Code Ann. § 23-99-501 Short title.
This subchapter shall be known and may be cited as the “Arkansas Mental Health Parity Act of 2009”.
Ark. Code Ann. § 23-99-502 Legislative findings and intent.
It is the intent of this state that if a health benefit plan provides insurance coverage for a mental illness or substance abuse disorder, the treatment of the mental illness or substance abuse disorder shall be as available as and at parity with that for other medical illnesses.
Ark. Code Ann. § 23-99-503 Definitions.
As used in this subchapter:
(1) “Carve-out arrangement” means an arrangement in which a healthcare insurer contracts with a separate person or entity to arrange for the delivery of specific types of healthcare benefits under a health benefit plan;
(2) “Commissioner” means the Insurance Commissioner;
(3) “Financial requirements” means copayments, deductibles, out-of-network charges, out-of-pocket contributions or fees, annual limits, lifetime aggregate limits imposed on individual patients, and other patient cost-sharing amounts;
(4) “Health benefit plan” means any group or blanket plan, policy, or contract for healthcare services issued or delivered in this state by healthcare insurers, including indemnity and managed care plans and the plans providing health benefits to state and public school employees pursuant to § 21-5-401 et seq., but excluding plans providing health care services pursuant to 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.;
(5) “Healthcare insurer” means any insurance company, hospital and medical service corporation, or health maintenance organization issuing or delivering health benefit plans in this state and subject to any of the following laws:
(A) The Arkansas Insurance Code;
(B) Section 23-75-101 et seq., pertaining to hospital and medical service corporations;
(C) Section 23-76-101 et seq., pertaining to health maintenance organizations; and
(D) Any successor law of the foregoing;
(6)(A) “Mental illnesses” and “substance use disorders” mean those illnesses and disorders that are covered by a health benefit plan listed in the International Classification of Diseases manual and the Diagnostic and Statistical Manual of Mental Disorders.
(B) Unless specifically otherwise stated, “mental illness” includes substance use disorders;
(7) “Person” or “entity” means and includes, individually and collectively, any individual, corporation, partnership, firm, trust, association, voluntary organization, or any other form of business enterprise or legal entity; and
(8) “Small employer” means any person or entity actively engaged in business who, on at least fifty percent (50%) of its working days during the preceding year, employed no more than fifty (50) eligible employees.
Ark. Code Ann. § 23-99-504 Exclusions.
This subchapter does not apply to:
(1) Dental insurance plans;
(2) Vision insurance plans;
(3) Specified-disease insurance plans;
(4) Accidental injury insurance plans;
(5) Long-term care plans;
(6) Disability income plans;
(7) Individual health benefit plans if the healthcare insurers offer individuals who satisfy the healthcare insurer's underwriting standards the option of purchasing a plan that, other than being optional, meets all the other requirements of this subchapter;
(8) Health benefit plans for small employers if the healthcare insurers offer purchasers the option of purchasing a plan that, other than being optional, meets all the other requirements of this subchapter; and
(9) Medicare supplement plans, as subject to section 1882(g)(1) of the Social Security Act.
Ark. Code Ann. § 23-99-505 Increased cost exemption.
(a)(1) This subchapter does not apply to a health benefit plan during the health benefit plan's following health benefit plan year if the application of this subchapter to the health benefit plan in a health benefit plan year resulted in an increase in the actual costs of coverage with respect to medical and surgical benefits and mental illness benefits under the health benefit plan as determined and certified under subsection (b) of this section by an amount that exceeds:
(A) Two percent (2%) for the first health benefit plan year in which this section is applied; or
(B) One percent (1%) for each subsequent health benefit plan year.
(2) The exemption provided by subdivision (a)(1) of this section applies to a health benefit plan for one (1) year.
(3) A healthcare insurer may elect to continue to apply mental health parity under this subchapter to its health benefit plans regardless of any increase in its total costs of coverage.
(b)(1) A determination under this section of increases to the actual costs of coverage of a health benefit plan shall be made and certified by a qualified and licensed actuary who is a member in good standing of the American Academy of Actuaries.
(2) The determination shall be in a written report prepared by the actuary.
(3) The report and all underlying documentation relied upon by the actuary shall be maintained by the healthcare insurer for a period of six (6) years following the notification required by subsection (d) of this section.
(c) To obtain an exemption under this section, a healthcare insurer shall make the increased cost determination required by this section after the health benefit plan has complied with this section for the first six (6) months of the health benefit plan year.
(d)(1) A healthcare insurer that elects to claim an exemption for a qualifying health benefit plan under this section based upon a certification under subsection (b) of this section shall promptly notify the Insurance Commissioner, the policyholder or contract holder, and the certificate holders, subscribers, and enrollees covered by the health benefit plan of its election.
(2) The notification to the commissioner under subdivision (d)(1) of this section shall include:
(A) A description of the number of covered lives under the health benefit plan at the time of the notification and, if applicable, at the time of any prior election of the increased cost exemption under this section; and
(B) For the current and previous health benefit plan year:
(i) A description of the actual total costs of coverage for medical and surgical benefits and mental illness benefits under the health benefit plan; and
(ii) The actual total costs of coverage with respect to mental illness benefits under the health benefit plan.
(3)(A) A notification under this subsection is confidential.
(B) The commissioner shall make available upon request, but not more than annually, an anonymous itemization of notifications under this section that includes a summary of the data received under subdivision (d)(2) of this section.
(e) To determine compliance with this section, the commissioner may audit the books and records of a healthcare insurer relating to an exemption, including without limitation any actuarial reports prepared pursuant to subsection (b) of this section during the six-year period following the notification required by subsection (d) of this section.
(f) The commissioner may promulgate rules to implement this section.
Ark. Code Ann. § 23-99-506 Parity requirements.
(a) Except as provided in § 23-99-504, a health benefit plan that provides benefits for the diagnosis and treatment of mental illnesses shall provide the benefits under the same terms and conditions as provided for covered benefits offered under the health benefit plan for the treatment of other medical illnesses and conditions, including without limitation:
(1) The duration or frequency of coverage;
(2) The dollar amount of coverage; or
(3) Financial requirements.
(b) This subchapter does not:
(1) Require equal coverage between treatments for a mental illness with coverage for preventive care;
(2) Prohibit a healthcare insurer from:
(A) Negotiating separate reimbursement rates and service delivery systems, including without limitation a carve-out arrangement;
(B) Managing the provision of mental health benefits for mental illnesses by common methods used for other medical conditions, including without limitation preadmission screening, prior authorization of services, or other mechanisms designed to limit coverage of services or mental illnesses to mental illnesses that are deemed medically necessary;
(C) Limiting covered services to covered services authorized by the health benefit plan, if the limitations are made in accordance with this subchapter;
(D) Using separate but equal cost-sharing features for mental illnesses; or
(E) Using a single lifetime or annual dollar limit as applicable to other medical illness; and
(3) Include a Medicare or Medicaid plan or contract or any privatized risk or demonstration program for Medicare or Medicaid coverage.
Ark. Code Ann. § 23-99-507 Medical necessity.
(a) The criteria for medical necessity determinations for mental illness made under a health benefit plan shall be made available by the healthcare insurer in accordance with rules established by the Insurance Commissioner to any current or potential covered individual or contracting provider upon request.
(b) On request, the reason for a denial of reimbursement or payment for services to diagnose or treat mental illness under a health benefit plan shall be made available by the healthcare insurer to a covered individual in accordance with the rules of the commissioner.
Ark. Code Ann. § 23-99-508 Permitted provisions.
(a) A healthcare insurer may at the healthcare insurer's option provide coverage for a health service, such as intensive case management, community residential treatment programs, or social rehabilitation programs, that is used in the treatment of mental illnesses but is generally not used for other injuries, illnesses, and conditions if the other requirements of this subchapter are met.
(b) Healthcare insurers providing educational remediation may, but are not required to, comply with the terms of this subchapter in regard to the treatment or remediation.
(c) A healthcare insurer may provide coverage for a health service, including without limitation physical rehabilitation or durable medical equipment, which generally is not used in the diagnosis or treatment of serious mental illnesses but is used for other injuries, illnesses, and conditions if the other requirements of this subchapter are met.
(d) A healthcare insurer may utilize common utilization management protocols, including without limitation preadmission screening, prior authorization of service, or other mechanisms designed to limit coverage of service for mental illness to individuals whose diagnosis or treatment coverage is considered medically necessary although the protocols are not used in conjunction with other medical illnesses or conditions covered by the health benefit plan.
Ark. Code Ann. § 23-99-509 Applicability.
(a) On or after October 3, 2009, this subchapter shall apply to health benefit plans on the health benefit plans' anniversaries or start dates but in no event later than one (1) year after October 3, 2009.
(b) If a health benefit plan provides coverage or benefits to an Arkansas resident, the health benefit plan shall be deemed to be delivered in this state within the meaning of this subchapter, regardless of whether the healthcare insurer or other entity that provides the coverage is located within or outside Arkansas.
Ark. Code Ann. § 23-99-510 Rules.
The Insurance Commissioner shall enforce this subchapter and shall promulgate necessary rules for carrying out this subchapter.
Ark. Code Ann. § 23-99-511 Enforcement.
The Insurance Commissioner shall have all the powers to enforce this subchapter as are granted to the commissioner elsewhere in the Arkansas Insurance Code.
Ark. Code Ann. § 23-99-512 Out-of-network providers.
In the case of a health benefit plan that provides both medical benefits and mental illness benefits, if the health benefit plan provides coverage for medical benefits provided by out-of-network providers, the health benefit plan shall provide coverage for mental illness benefits provided by out-of-network providers pursuant to this subchapter.
Ark. Code Ann. § 23-99-601 Short title.
This subchapter shall be cited as the “Dental Point of Service Act”.
Ark. Code Ann. § 23-99-602 Legislative findings.
The General Assembly finds that the quality of dental care is improved through patient choice among dentists and that utilization of dentists varies less than utilization of other providers. Patients should have the freedom to go to dentists outside their managed care network when the carrier is not required to pay the dentist more than it pays in-network dentists. Therefore, health carriers should be required to offer a point-of-service option for dental care.
Ark. Code Ann. § 23-99-603 Definitions.
As used in this subchapter:
(1) “Commissioner” means the Insurance Commissioner;
(2) “Covered person” means a person covered by a health plan including an enrollee, subscriber, policyholder, beneficiary of a group plan, or individual covered by any other health plan;
(3) “Dentist” means a person licensed under the Arkansas Dental Practice Act, § 17-82-101 et seq.;
(4) “Healthcare service” means that service offered or provided by the healthcare providers within the scope of their practice and relating to the prevention, cure, or treatment of illness or disease;
(5) “Health carrier” means any insurance company, health maintenance organization, or hospital and medical service corporation as defined in § 23-75-101, subject to the following laws:
(A) The Arkansas Insurance Code;
(B) Provisions pertaining to health maintenance organizations, § 23-76-101 et seq.; and
(C) Any successor laws of the foregoing; and
(6) “Health plan” means any policy, contract, or agreement offered by a health carrier to provide, reimburse, or pay for healthcare services except the following:
(A) Workers' compensation coverage;
(B) Self-funded or self-insured health plans, unless the plan is established or maintained for employees of a governmental entity; and
(C) A policy, contract, or agreement that limits coverage for dental services in connection with the treatment of a covered accidental injury or the treatment of a nondental physiological condition.
Ark. Code Ann. § 23-99-604 Coverage for out-of-network dentists.
(a) Every health plan which provides dental benefits issued, renewed, extended, or modified by a health carrier shall also include a point-of-service option which provides benefits to covered persons through dentists who are not members of the health carrier's provider network.
(b)(1) The benefits offered under this option shall be the same as those offered through the network.
(2) The rate of reimbursement for out-of-network dentists may differ from the rate of reimbursement for noncapitated dentists in the network but by no more than ten percent (10%).
(3) The copayment, coinsurance, and other cost-sharing features may differ between the use of in-network and out-of-network dentists but by no more than twenty-five percent (25%).
(c) The out-of-network dentist may bill the patient for the balance of any charges which are not otherwise reimbursed by the health carrier. However, if after a request by the covered person in advance of treatment the provider fails to disclose a reasonable range of the total of charges for nonemergency services to be provided, the covered person shall not be liable for such additional charges.
(d) The health carrier shall fully disclose to the covered person, in clear, understandable language, the terms and conditions of this option. This requirement may be satisfied by the health carrier's providing to the employer or other purchaser of the health plan presentation materials for dissemination to covered persons.
Ark. Code Ann. § 23-99-605 Rules.
Within one hundred twenty (120) days of July 30, 1999, the Insurance Commissioner shall promulgate necessary rules for carrying out this subchapter, giving maximum possible effect to the General Assembly's intent to promote quality medical care through increased choice.
Ark. Code Ann. § 23-99-606 Insurance Commissioner's enforcement authority.
The Insurance Commissioner shall enforce this subchapter, using the powers granted to the commissioner elsewhere in the Arkansas Insurance Code.
Ark. Code Ann. § 23-99-607 Duty of Attorney General to defend.
In any legal proceeding in which the validity of this subchapter is challenged, the Attorney General shall defend the subchapter regardless of the state agency or official named as an official party.
Ark. Code Ann. § 23-99-608 Applicability of subchapter.
This subchapter applies to health plans issued, renewed, extended, or modified by a health carrier on or after July 30, 1999. “Renewed, extended, or modified” shall include a change in premium or other financial term.
Ark. Code Ann. § 23-99-701 Legislative findings.
The General Assembly finds and declares the following:
(1) The State of Arkansas has an interest in protecting its citizens and in pursuing reasonable means to improve the quality of life and health of those citizens;
(2) In the healthcare field, the State of Arkansas has traditionally regulated utilization review as well as the quality of care provided by healthcare providers, insurance companies, and organizations which assume the risk of providing healthcare services for citizens of this state, such as health maintenance organizations; and
(3) Dynamic changes in how health care is delivered to citizens of this state require the state to oversee the quality of healthcare processes and outcomes resulting from health carriers and networks.
Ark. Code Ann. § 23-99-702 Definitions.
As used in this subchapter:
(1) “Commissioner” means the Insurance Commissioner;
(2) [Repealed.]
(3) “Healthcare services” means any services included in the furnishing to any individual of medical or dental care, hospitalization, or services incident to the furnishing of care or hospitalization, as well as the furnishing to any person of any and all other services or goods for the purpose of preventing, alleviating, curing, or healing human illness or injury;
(4) “Health carrier” means any person who undertakes to provide or arrange for one (1) or more managed care plans;
(5) “Managed care plan” means any arrangement whereby a health carrier undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any healthcare services, and at least part of the arrangement consists of arranging for or the provision of healthcare services as distinguished from mere indemnifications against the cost of the healthcare services on a prepaid basis through insurance or otherwise; and
(6) “Network” when used to describe a provider of health services, including, but not limited to, a hospital, physician, home health agency, pharmacy, etc., means that the provider has a participation agreement in effect with a health carrier, directly or through another entity, to provide health services to covered persons.
Ark. Code Ann. § 23-99-703 Grievance system.
(a) All health carriers and networks shall make arrangements for handling and resolving grievances.
(b) Each health carrier and network shall:
(1) Maintain records of grievances filed with the health carrier and network concerning the quality of healthcare services; and
(2) Submit in the form and manner prescribed by the Secretary of the Department of Health a periodic report which shall include:
(A) A written description of the processes and procedures for resolving grievances; and
(B) The total number of grievances handled through the grievance system, including a compilation of the dates of the grievances, the reason for the grievances, and resolutions of each grievance.
(c) In consultation with the Insurance Commissioner, the secretary may promulgate rules in accordance with the Arkansas Administrative Procedure Act, § 25-15-201 et seq., to carry out the provisions of this subchapter to enable the state to be properly informed of quality issues within the state and to adequately respond to any quality concerns expressed through grievances.
Ark. Code Ann. § 23-99-704 Quality assessment and improvement systems.
(a) Each health carrier and network shall:
(1) Make arrangements for measuring and improving the quality of healthcare services;
(2) Maintain quality assessment and improvement programs and records measuring the outcomes of healthcare services; and
(3) Submit to the Secretary of the Department of Health in the time, manner, and form prescribed the following information:
(A) A written description of any quality assessment and quality improvement systems; and
(B) Findings of relevant quality data as determined by the secretary.
(b) In consultation with the Insurance Commissioner, the secretary may promulgate rules in accordance with the Arkansas Administrative Procedure Act, § 25-15-201 et seq., to carry out the provisions of this subchapter to enable the state to be properly informed of quality issues within the state and to adequately respond to any quality concerns found through the outcome data.
(c) The provisions of § 16-46-105 and § 20-9-501 et seq. shall apply to all records maintained pursuant to this subchapter.
Ark. Code Ann. § 23-99-705 Applicability and scope.
(a) This subchapter shall not apply to disability income, specified disease, Medicare supplement, hospital indemnity, accident-only policies, long-term care, short-term limited duration insurance, and all other supplemental insurance products issued by health carriers.
(b) In terms of the Secretary of the Department of Health's regulatory authority pursuant to §§ 23-99-703 and 23-99-704, such authority shall apply to the quality of care provided by health carriers and networks operating in this state and shall not apply to the benefits offered by any health carrier and network or to the administration of such benefits.
Ark. Code Ann. § 23-99-706 Enforcement and penalties.
The Secretary of the Department of Health shall have the power to implement and enforce this subchapter.
Ark. Code Ann. § 23-99-801 Application and intent.
(a) The state's any willing provider laws shall not be construed:
(1) To require all physicians or a percentage of physicians in the state or a locale to participate in the provision of services for a health maintenance organization; or
(2) To take away the authority of health maintenance organizations that provide coverage of physician services to set the terms and conditions for participation by physicians, though health maintenance organizations shall apply the terms and conditions in a nondiscriminatory manner.
(b)(1) The state's any willing provider laws shall apply to:
(A) All health insurers, regardless of whether they are providing insurance, including prepaid coverage, or administering or contracting to provide provider networks; and
(B) All multiple-employer welfare arrangements and multiple-employer trusts.
(2) This subsection shall apply only to the extent permitted by the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq.
(c)(1) The state's any willing provider laws shall be construed to include within their provider definitions all those providers of the same class or classes who are:
(A) Practicing or operating within a border city in an adjoining state; and
(B) Licensed or authorized to practice or operate by the adjoining state, regardless of whether the provider is licensed or otherwise authorized to operate in Arkansas.
(2) As used in this section, “border city” means a city in a state adjoining Arkansas which adjoins the Arkansas state line and is not separated from an Arkansas city only by a navigable river.
(d)(1) As clarification, nothing in the state's any willing provider laws shall be construed to cover or regulate healthcare provider networks offered by noninsurers.
(2) If an employer sponsoring a self-insured health benefit plan contracts directly with providers or contracts for a healthcare provider network through a noninsurer, then the any willing provider law does not apply.
(3) If a health insurer subcontracts with a noninsurer whose healthcare network does not meet the requirements of the any willing provider law, then the noninsurer may create a separate healthcare provider network that meets the requirements of the any willing provider law.
(4) If the noninsurer chooses not to create the separate healthcare provider network, then the responsibility for compliance with the any willing provider law is the obligation of the health insurer to the extent permitted by the federal Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq.
(e) Notwithstanding the provisions of subsection (d) of this section, the Patient Protection Act of 1995, § 23-99-201 et seq., and this subchapter apply to a health benefit plan provided by the State of Arkansas to state employees and public school personnel under § 21-5-401 et seq., whether self-funded or insured.
Ark. Code Ann. § 23-99-802 Definitions.
As used in this subchapter:
(1) “Any willing provider law” means a law that prohibits discrimination against a provider willing to meet the terms and conditions for participation established by a health insurer or that otherwise precludes an insurer from prohibiting or limiting participation by a provider who is willing to accept a health insurer's terms and conditions for participation in the provision of services through a health benefit plan;
(2) “ERISA” means the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq.;
(3) “Health benefit plan” means any health insurance policy or certificate, health maintenance organization contract, hospital and medical service corporation contract or certificate, a self-insured plan or a plan provided by a multiple employer welfare arrangement, to the extent permitted by ERISA, the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq., or any health benefit plan that affects the rights of an Arkansas insured and bears a reasonable relation to Arkansas, whether delivered or issued for delivery in Arkansas;
(4) "Healthcare provider" or “provider” means those individuals or entities licensed by the State of Arkansas to provide healthcare services, limited to the following:
(A) Advanced practice nurses;
(B) Athletic trainers;
(C) Audiologists;
(D) Certified behavioral health providers;
(E) Certified orthotists;
(F) Chiropractors;
(G) Community mental health centers or clinics;
(H) Dentists;
(I) Home health care;
(J) Hospice care;
(K) Hospital-based services;
(L) Hospitals;
(M) Licensed ambulatory surgery centers;
(N) Licensed certified social workers;
(O) Licensed dieticians;
(P) Licensed durable medical equipment providers;
(Q) Licensed intellectual and developmental disabilities service providers;
(R) Licensed professional counselors;
(S) Licensed psychological examiners;
(T) Long-term care facilities;
(U) Occupational therapists;
(V) Optometrists;
(W) Pharmacists and pharmacies;
(X) Physical therapists;
(Y) Physicians and surgeons (M.D. and D.O.);
(Z) Podiatrists;
(AA) Prosthetists;
(BB) Psychologists;
(CC) Respiratory therapists;
(DD) Rural health clinics;
(EE) Speech pathologists; and
(FF) Other healthcare practitioners as determined by the State Insurance Department in rules promulgated under the Arkansas Administrative Procedure Act, § 25-15-201 et seq.;
(GG) Crisis stabilization units.
(5) “Health insurer” or “healthcare insurer” means any entity that is authorized by the State of Arkansas to offer or provide health benefit plans, policies, subscriber contracts, or any other contracts of a similar nature which indemnify or compensate healthcare providers for the provision of healthcare services;
(6) “Noninsurer” means an entity that is not required to obtain authorization from the department to do business as a health insurer but that does have a provider network; and
(7) “Self-insured” includes self-funded and vice versa.
(AA) Prosthetists;
(BB) Psychologists;
(CC) Respiratory therapists;
(DD) Rural health clinics;
(EE) Speech pathologists; and
(FF) Other healthcare practitioners as determined by the State Insurance Department in rules promulgated under the Arkansas Administrative Procedure Act, § 25-15-201 et seq.;
Ark. Code Ann. § 23-99-803 Agency enforcement.
The Insurance Commissioner shall:
(1) Enforce the state's any willing provider laws using powers granted to the commissioner in the Arkansas Insurance Code; and
(2) Be entitled to seek an injunction against a health insurer in a court of competent jurisdiction.
Ark. Code Ann. § 23-99-804 Health insurer — Healthcare provider contracts.
(a) A healthcare provider, including without limitation a physician, nurse, pharmacist, dentist, physical therapist, physician assistant, or any other healthcare provider licensed and in good standing with the state licensing board responsible for the licensing of the healthcare provider, shall not be excluded from contracting with a health insurer, third-party administrator, pharmacy benefits manager, or other entity that is subject to § 23-99-802, if the healthcare provider is permitted to participate in Medicare, Medicaid, or any other federal health benefit plan.
(b) This section does not preempt § 23-99-204 regarding the requirement that a healthcare provider accept a health benefit plan's operating terms and conditions, schedule of fees, covered expenses, and utilization regulations and quality standards to participate in that health benefit plan.
Ark. Code Ann. § 23-99-901 Legislative findings.
The General Assembly finds that:
(1) Under an alternative payment system, a healthcare payor, when determining a healthcare provider's patient care costs, may use factors that are not under the control of the healthcare provider;
(2) A healthcare provider may not receive an appropriate share of savings or reduction in recoupment under an alternative payment system if the healthcare provider's patients have a higher cost of care; and
(3) A healthcare provider should not be penalized for higher patient care costs if any of the costs, or other factors determining reimbursement, are not under the control of the healthcare provider.
Ark. Code Ann. § 23-99-902 Definitions.
As used in this subchapter:
(1) “Alternative payment system” means a payment methodology used by a healthcare payor that includes a risk-sharing or gain-sharing component for a healthcare provider that participates in a plan, program, or network offered by the healthcare payor;
(2) “Gain-sharing payment” means an increase in a payment or additional payments made by a healthcare payor to a healthcare provider as a result of the achievement of identified benchmarks, including without limitation that patient care costs fall below cost thresholds of any form;
(3)(A) “Healthcare payor” means an entity that reimburses a physician for the delivery of healthcare services that are covered by a plan administered, issued, or delivered by the entity.
(B) “Healthcare payor” does not include a provider-based network or system that utilizes risk-sharing including an accountable care organization or a clinically integrated network;
(4) “Healthcare provider” means any type of provider that renders healthcare services to patients for compensation, including:
(A) A doctor of medicine, a doctor of osteopathy, or another licensed healthcare professional acting within the professional's licensed scope of practice; or
(B) A healthcare facility, including a hospital, ambulatory surgery center, or other type of facility licensed in this state to provide healthcare services; and
(5)(A) “Risk-sharing payment” means a reduction in a payment to or refund of a payment already made to a healthcare provider as a result of failure to achieve identified benchmarks, including without limitation that patient care costs exceed cost thresholds of any form.
(B) “Risk-sharing payment” includes the alternative payment method by gift card, credit card, or other type of electronic payment or virtual credit card as payment if the healthcare provider is given clear instructions about how to select an alternative payment method that does not result in the healthcare provider's being charged a service fee to process.
Ark. Code Ann. § 23-99-903 Physician penalties — Limitation.
(a) A healthcare payor doing business in this state, when determining any gain-sharing or risk-sharing for a healthcare provider, shall not attribute to a healthcare provider any costs that are a result of variations in the healthcare payor's freely negotiated contract pricing with other persons or entities outside the healthcare provider's practice if including the costs reduces a healthcare provider's gain-sharing amount or increases a healthcare provider's risk-sharing amount.
(b)(1) When determining any gain-sharing or risk-sharing for a healthcare provider based on the achievement of or failure to attain certain benchmarks, a healthcare payor doing business in this state shall use clearly expressed and identifiable benchmarks.
(2) At least ninety (90) days in advance of implementation, the healthcare payor shall explain to the healthcare provider the applicability of the identifiable benchmarks.
(3) Any identifiable benchmarks shall be within the control of the healthcare provider to achieve or fail to attain.
Ark. Code Ann. § 23-99-904 Waiver prohibited.
(a) The provisions of this subchapter shall not be waived by contract.
(b) Contractual arrangements or actions taken in conflict with this subchapter or that purport to waive any requirements of this subchapter are void.
Ark. Code Ann. § 23-99-905 Enforcement.
(a) The State Insurance Department shall develop and promulgate rules for the implementation and enforcement of this subchapter.
(b) In addition to or as an alternative to any enforcement action by the department, a healthcare provider or an organization that represents healthcare providers may enforce this subchapter by filing suit against a healthcare payor in:
(1) Pulaski County Circuit Court; or
(2) The circuit court of a county in Arkansas in which one (1) of the healthcare provider claimants resides or does business.
Ark. Code Ann. § 23-99-1001 Title.
This subchapter shall be known and may be cited as the “Vision Care Plan Act of 2015”.
Ark. Code Ann. § 23-99-1002 Definitions.
As used in this subchapter:
(1) "Covered materials" means materials for which reimbursement from the insurer, vision benefit manager, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;
(2) "Covered services" means services for which reimbursement from the insurer, vision benefit manager, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;
(3) "Enrollee" means an individual participating in a health benefit plan, vision benefit plan, or vision benefit discount plan that is purchased by an individual or provided to an individual by an insurer, company, organization, group, employer, government assistance program, or another entity that purchases or supplies coverage for a health benefit plan, vision care benefit plan, or vision benefit discount plan;
(4) "Extrapolation" means a mathematical formula, process, or technique used by a vision benefit manager or the vision benefit manager's agent, in an audit of an optometrist to estimate audit results or findings for a larger batch or group of claims not reviewed by the vision benefit manager;
(5) "Insurer" means an insurance company, a health maintenance organization, a hospital and medical service corporation, or a self-insured health plan for employees of a governmental entity;
(6) "Materials" means ophthalmic devices, including without limitation:
(A) Lenses;
(B) Devices containing lenses;
(C) Contact lenses;
(D) Artificial intraocular lenses;
(E) Ophthalmic frames;
(F) Lens-mounting apparatus;
(G) Prisms;
(H) Spectacle or contact lens treatments and coatings;
(I) Prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa;
(J) Low-vision devices; and
(K) Vision therapy devices;
(7) "Noncovered materials" means materials that are not covered by an insurer, a vision benefit manager, a vision care plan, or a vision care discount plan;
(8) "Noncovered services" means services that are not covered by an insurer, a vision benefit manager, a vision care plan, or a vision care discount plan;
(9) "Participating provider agreement" means an agreement between a vision care provider and an insurer that obligates a vision care provider to provide for compensation services and materials to an individual who is insured by the insurer;
(10) "Services" means benefits or services provided by a vision care provider;
(11) "Vision benefit manager" means an individual, company, organization, group, or other entity, including without limitation an insurer, third party administrator, and a subcontractor, that creates, promotes, sells, provides, advertises, or administers an integrated or stand- alone vision benefit plan, vision benefit discount plan, or other insurance policy or contract that provides vision benefits or discounts to an enrollee pertaining to the provision of covered services or covered materials;
(12) "Vision benefit plan or contract" means a plan, contract, or policy of insurance issued by an insurer that provides for vision care benefits, materials, or services;
(13) "Vision care discount plan" means a separate plan to provide benefits or services under a rider to a health benefit plan or as a stand-alone agreement that is authorized by a vision care provider to provide discounts to individuals under the Primary Eye Care Provider Act, § 23-99-301 et seq.;
(14) "Vision care plan" means an entity that provides health benefits and that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone vision benefit plan or contract; and
(15) "Vision care provider" means an individual licensed as an optometrist under § 17-90-301 et seq., or a licensed osteopathic or medical physician licensed under § 17-91-101 et seq. or § 17-95-401 et seq., if the physician has also completed a residency in ophthalmology.
Ark. Code Ann. § 23-99-1003 Prohibited practices — Agreements.
(a) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not establish a fee that a vision care provider shall charge for services or materials that are not covered by a vision benefit plan or contract.
(b) A vision care provider shall not charge a fee for services or materials that is more than the vision care provider's normal rate for the services or materials if the services or materials are noncovered services or noncovered materials.
(c)(1) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not require a vision care provider to apply a discount to an individual who is insured by the insurer with a participating vision care provider for noncovered services or noncovered materials.
(2) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not avoid the restriction under subdivision (c)(1) of this section by providing minimal reimbursement for a service or materials to apply a discount.
(d) A reimbursement paid by an insurer, vision benefit manager, vision care plan, or vision care discount plan to a vision care provider for covered services and covered materials shall not be:
(1) Nominal or de minimis; or
(2) Less than the current calendar year Medicare reimbursement rate for the covered service or covered materials provided to the enrollee.
(e) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not require that a vision care provider participate with or be credentialed by any specific vision care plan or vision care discount plan as a condition to join an insurer's provider panel.
(f) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not restrict or limit, directly or indirectly, the vision care provider's choice of optical labs or choice of sources and suppliers of services or materials provided by the vision care provider to an individual who is insured by the insurer.
(g) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall identify participating vision care providers in a neutral manner and shall not distinguish between participating vision care providers based on the following characteristics:
(1) Discount or incentive offered by the vision care provider on services and materials that are not covered by the insurer or vision benefit manager, vision care plan, or vision care discount plan;
(2) The dollar amount, volume amount, or percent usage amount of any material or good purchased by the vision care provider; or
(3) The brand, source, manufacturer, or supplier of a covered service or covered product utilized by the vision care provider.
(h) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not advertise that services and materials are covered with additional copay or coinsurance if the health benefit plan, vision benefit plan, or vision benefit discount plan does not reimburse the participating vision care provider for the services or materials in order to claim that services and materials are covered services and materials.
(i) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not steer enrollees to, or limit the enrollees’ choice of, vision care provider for services or materials that are not covered services or not covered materials.
(j) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not incentivize, recommend, encourage, persuade, or attempt to persuade an enrollee to obtain covered services, noncovered services, covered materials, or noncovered materials:
(1) At any particular participating vision care provider over another participating vision care provider;
(2) At a retail establishment owned by, partially owned by, contracted with, or otherwise affiliated with the insurer, vision benefit manager, vision care plan, or vision care discount plan instead of a different vision care provider; or
(3) At any internet or virtual provider or retailer owned by, partially owned by, contracted with, or otherwise affiliated with the vision plan instead of a different participating vision care provider.
(k) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not reimburse a vision care provider a different amount for covered services or covered materials because of the vision care provider’s choice of:
(1) Optical laboratory;
(2) Source of supplier of:
(A) Contact lenses;
(B) Ophthalmic lenses;
(C) Ophthalmic glasses frames; or
(D) Covered services, covered materials, noncovered services, or noncovered materials;
(3) Equipment used for patient care;
(4) Retail optical affiliation;
(5) Vision support organization;
(6) Group purchasing organization;
(7) Doctor alliance;
(8) Professional trade association membership;
(9) Electronic health record software, electronic medical record software, or practice management software; or
(10) Third-party claim filing service, billing service, or electronic data interchange clearinghouse company.
(l) The terms, discounts, and reimbursement rates in a participating contract between an insurer, vision benefit manager, vision care plan, or vision care discount plan with a vision care provider shall not be modified during the term of a participating contract absent written authorization from the vision care provider.
(m) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not require a vision care provider to accept a reimbursement payment in the form of a virtual credit card or any other payment method wherein a processing fee, administrative fee, percentage amount, or dollar amount is assessed to the vision care provider to receive a reimbursement payment.
(n)(1) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not use extrapolation to complete an audit of a participating vision care provider.
(2) An additional payment due to a participating vision care provider or a refund due to the insurer or vision benefit manager shall not be based on an extrapolation, but shall be based on the actual overpayment or underpayment, as determined after an investigation by the insurer, vision benefit manager, vision care plan, or vision care discount plan, and participating vision care provider has been afforded, and has exhausted, all opportunities to appeal the insurer, vision benefit manager, vision care plan, or vision care discount plan’s findings, as stated in the provider manual or policy document, or applicable law.
(o)(1) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not prohibit a vision care provider from accepting a cash payment option from the enrollee if the cash payment option is less costly to the enrollee than the total out-of-pocket cost of the service or material.
(2) A vision care provider shall not be subject to an audit for offering a cash price option for services and materials.
(p) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not withhold or recoup a contracted amount for a covered service or covered material provided to an enrollee if the enrollee is verified to be eligible by the vision care provider through customary verification methods of the insurer, vision benefit manager, vision care plan, or vision care discount plan to receive the covered service or covered material on the date of service.
(q) An optician licensed under the Ophthalmic Dispensing Act, § 17-89-101 et seq., is subject to:
(1) Subsections (c) and (f) of this section; and
(2) Subsection (b) of this section in regard to materials.
Ark. Code Ann. § 23-99-1004 Private civil action.
(a) A vision care provider adversely affected by any violation of this subchapter by an insurer, vision care plan, or a vision care discount plan may bring a civil action in a court of competent jurisdiction against the insurer, vision care plan, or a vision care discount plan for injunctive relief.
(b) If a person prevails in the civil action under subsection (a) of this section, the person shall recover:
(1) Monetary damages not less than one thousand dollars ($1,000);
(2) Three (3) times the amount of actual damages, if any; and
(3) Reasonable attorney's fees, costs, and any other proper relief.
Ark. Code Ann. § 23-99-1005 Rules — Enforcement — Effective date.
(a) The State Insurance Department shall develop and promulgate rules for the implementation and administration of this subchapter.
(b) The Insurance Commissioner shall enforce this subchapter and may seek injunctive relief for violations of this subchapter.
(c) This subchapter is applicable to a vision benefit plan or contract issued, renewed, or recredentialed in this state on and after July 22, 2015.
Ark. Code Ann. § 23-99-1101 Title.
This subchapter shall be known and may be cited as the “Prior Authorization Transparency Act”.
Ark. Code Ann. § 23-99-1102 Legislative findings and intent.
(a) The General Assembly finds that:
(1) A physician-patient relationship is paramount and should not be subject to third-party intrusion; and
(2) Prior authorizations can place attempted cost savings ahead of optimal patient care.
(b) The General Assembly intends for this subchapter to:
(1) Ensure that prior authorizations do not hinder patient care or intrude on the practice of medicine; and
(2) Guarantee that prior authorizations include the use of written clinical criteria and reviews by appropriate physicians to secure a fair authorization review process for patients.
Ark. Code Ann. § 23-99-1104 Disclosure required.
(a)(1)(A) A utilization review entity shall disclose all of its prior authorization requirements, clinical criteria, and restrictions in a publicly accessible manner on its website.
(B) The disclosure under subdivision (a)(1)(A) of this section shall be explained in detail and in clear and ordinary terms, and include:
(i)(a) A list of any healthcare services that require prior authorization.
(b) The list under subdivision (a)(1)(B)(i)(a) of this section shall:
(1) Be available in a format that can be easily understood by a subscriber and in a machine-readable format that allows for automated retrieval and processing; and
(2) Include the following information:
(A) The name of the healthcare service and any billing codes associated with the healthcare service; and
(B)(i) The effective date and end date of the prior authorization requirement policy for the healthcare service.
(ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2);
(ii)(a) Any written clinical criteria for services that require prior authorizations.
(b) The information described in subdivision (a)(1)(B)(ii)(a) of this section shall be explained in detail and in clear and ordinary terms; and
(iii) Any written clinical criteria for services that do not require prior authorization but are subject to review for medical necessity.
(2)(A) Utilization review entities that have agreed, by contract with vendors or third-party administrators, to use licensed, proprietary, or copyrighted protected clinical criteria from the vendors or administrators may satisfy the disclosure requirement under subdivision (a)(1) of this section by making all relevant proprietary clinical criteria available to a healthcare provider that submits a prior authorization request to the utilization review entity through a secured link on the utilization review entity's website that is accessible to the healthcare provider from the public part of its website as long as any link or access restrictions to the information do not cause any delay to the healthcare provider.
(B) For out-of-network providers, a utilization review entity may meet the requirements of this subdivision (a)(2) by:
(i) Providing the healthcare provider with temporary electronic access in a timely manner to a secure site to review copyright- protected clinical criteria; or
(ii) Disclosing copyright-protected clinical criteria in a timely manner to a healthcare provider through other electronic or telephonic means.
(b) Before a utilization review entity implements a new or amended prior authorization requirement, clinical criteria, or restriction as described in subdivision (a)(1) of this section, the utilization review entity shall update its website to reflect the new or amended requirement or restriction.
(c)(1) Before implementing a new or amended prior authorization requirement, clinical criteria, or restriction, a utilization review entity shall provide contracted healthcare providers written notice of the new or amended requirement or restriction at least sixty (60) days before implementation of the new or amended requirement or restriction.
(2) As used in subdivision (c)(1) of this section, "written notice" means actual notice to the healthcare provider via mail, email, or fax.
(d)(1) A utilization review entity shall make statistics available regarding prior authorization approvals and denials on its website in a readily accessible format.
(2) The statistics made available by a utilization review entity under this subsection shall categorize approvals and denials by:
(A) Physician specialty;
(B) Medication or diagnostic test or procedure;
(C) Medical indication offered as justification for the prior authorization request; and
(D) Reason for denial.
(e)(1) If a utilization review entity provides information to a healthcare provider indicating that a prior authorization is not required for a specific healthcare service, then the utilization review entity shall disclose any other restriction, limitation, or requirement that may preclude coverage of the specific healthcare service, including without limitation:
(A) A step therapy requirement;
(B) A restriction on the place of the specific healthcare service;
(C) A restriction on the healthcare provider type or benefit category;
(D) Clinical criteria that completely excludes the specific healthcare service from coverage; and
(E) Any post-service review, information request, or audit responsibility that is applicable to the specific healthcare service based on the billing code or category.
(2)(A) Subdivision (e)(1) of this section does not apply if a utilization review entity provides a document on the utilization review entity's website or in a format available to download from the utilization review entity's website that includes the following information in an aggregated format:
(i) A list of step therapy requirements;
(ii) A list of any restrictions on the site of service for a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;
(iii) A list of any restrictions to the benefit category of a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;
(iv) A list of any specific healthcare services that are completely excluded from coverage based on clinical criteria; and
(v) A list of any specific healthcare services for which the billing code or category requires a post-service review, information request, or audit.
(B) The document under subdivision (e)(2)(A) of this section shall include the name of the healthcare service and any billing codes associated with the healthcare service.
(C) A utilization review entity shall provide a contracted healthcare provider written notice of any changes to the document under subdivision (e)(2)(A) of this section at least sixty (60) days before implementation of the change via mail, email, or fax.
Ark. Code Ann. § 23-99-1105 Prior authorization — Nonurgent healthcare service.
(a) If a utilization review entity requires prior authorization of a nonurgent healthcare service, the utilization review entity shall make an authorization or adverse determination and notify the subscriber and the subscriber's nonurgent healthcare provider of the decision within two (2) business days of obtaining all necessary information to make the authorization or adverse determination.
(b) For purposes of this section, “necessary information” includes the results of any face-to-face clinical evaluation or second opinion that may be required.
(c)(1) If a utilization review entity denies a prior authorization of a nonurgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the nonurgent healthcare service.
(2) If a denial of a prior authorization of a nonurgent healthcare service is appealed to the utilization review entity, then within four (4) business days of receiving all necessary information required, the utilization review entity shall:
(A) Make an authorization or adverse determination; and
(B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the nonurgent healthcare service of the decision.
(3) This subsection applies to an enrollee who is being evaluated or treated for:
(A) A hematology diagnosis;
(B) An oncology diagnosis; or
(C) An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.
Ark. Code Ann. § 23-99-1106 Prior authorization — Urgent healthcare service.
(a) A utilization review entity shall render an expedited authorization or adverse determination concerning an urgent healthcare service and notify the subscriber and the subscriber's healthcare provider of that expedited prior authorization or adverse determination no later than one (1) business day after receiving all information needed to complete the review of the requested urgent healthcare service.
(b)(1) If a utilization review entity denies a prior authorization of an urgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the urgent healthcare service.
(2) If a denial of a prior authorization of an urgent healthcare service is appealed to the utilization review entity, then within two (2) business days of receiving all necessary information required, the utilization review entity shall:
(A) Make an authorization or adverse determination; and
(B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision.
(3) This subsection applies to an enrollee who is being evaluated or treated for:
(A) A hematology diagnosis;
(B) An oncology diagnosis; or
(C) An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.
Ark. Code Ann. § 23-99-1107 Prior authorization — Emergency healthcare service.
(a) A utilization review entity shall not require prior authorization for prehospital transportation or for provision of an emergency healthcare service.
(b)(1) A utilization review entity shall allow a subscriber and the subscriber's healthcare provider a minimum of twenty-four (24) hours following an emergency admission or provision of an emergency healthcare service for the subscriber or healthcare provider to notify the utilization review entity of the admission or provision of an emergency healthcare service.
(2) If the admission or emergency healthcare service occurs on a holiday or weekend, a utilization review entity shall not require notification until the next business day after the admission or provision of the emergency healthcare service.
(c)(1) A utilization review entity shall cover emergency healthcare services necessary to evaluate and assess the health condition of a subscriber or to stabilize a subscriber.
(2) If a healthcare provider certifies in writing to a utilization review entity within seventy-two (72) hours of a subscriber's admission that the subscriber's condition required an emergency healthcare service, that certification will create a presumption that the emergency healthcare service was medically necessary, and such presumption may be rebutted only if the utilization review entity can establish, with clear and convincing evidence, that the emergency healthcare service was not medically necessary.
(d)(1) The determination by a utilization review entity of medical necessity of an emergency healthcare service shall not be based on whether the emergency healthcare service was provided by a healthcare provider that is a member of the health benefit plan's provider network.
(2) Restrictions on coverage for an emergency healthcare service provided by a healthcare provider that is not a member of the health benefit plan's provider network shall not be greater than restrictions on coverage for an emergency healthcare service provided by a healthcare provider that is a member of the health benefit plan's provider network.
(e)(1) If a subscriber receives an emergency healthcare service that requires an immediate post-evaluation or post-stabilization healthcare service, a utilization review entity shall make an authorization within sixty (60) minutes of receiving a request.
(2) If the authorization is not made within sixty (60) minutes, the emergency healthcare service shall be approved.
Ark. Code Ann. § 23-99-1108 Subscribers with terminal illness — Denial of prior authorization for covered prescription pain medication prohibited.
If a subscriber's covered prescription pain medication requires a prior authorization, then the prior authorization shall not be denied if the subscriber has a terminal illness.
Ark. Code Ann. § 23-99-1109 Rescission of prior authorizations — Denial of payment for prior authorized services — Limitations.
(a) A decision on a request for prior authorization by a utilization review entity shall include a determination as to whether or not the individual is covered by a health benefit plan and eligible to receive the requested service under the health benefit plan.
(b)(1) A utilization review entity shall not rescind, limit, condition, or restrict an authorization based upon medical necessity unless the utilization review entity notifies the healthcare provider at least three (3) business days before the scheduled date of the admission, service, procedure, or extension of stay.
(2) Notwithstanding subdivision (b)(1) of this section, a utilization review entity may rescind, limit, condition, or restrict an authorization if:
(A) The subscriber was not covered by the health benefit plan and was not eligible to receive the requested service under the health benefit plan on the date of the admission, service, procedure, or extension of stay; and
(B) The utilization review entity has provided to the healthcare provider a means to confirm whether or not the subscriber is covered by the health benefit plan and eligible to receive the requested service up to the date of admission, service, procedure, or extension of stay.
(c) A healthcare insurer shall pay a claim for a healthcare service for which prior authorization was received regardless of the terminology used by the utilization review entity or health benefit plan when reviewing the claim, unless:
(1) The authorized healthcare service was never performed;
(2) The submission of the claim for the healthcare service with respect to the subscriber was not timely under the terms of the applicable provider contract or policy;
(3) The subscriber had not exhausted contract or policy benefit limitations based on information available to the utilization review entity or healthcare insurer at the time of the authorization but subsequently exhausted contract or policy benefit limitations after the authorization was issued, in which case the utilization review entity or healthcare insurer shall include language in the notice of authorization to the subscriber and healthcare provider that the visits or services authorized might exceed the limits of the contract or policy and would accordingly not be covered under the contract or policy; or;
(4) There is specific information available for review by the appropriate state or federal agency that the subscriber or healthcare provider has engaged in material misrepresentation, fraud, or abuse regarding the claim for the authorized service .
(d)(1)(A) A utilization review entity doing business in this state shall strive to implement no later than July 1, 2018, a mechanism by which healthcare providers may request prior authorizations through an automated electronic system as an alternative to telephone-based prior authorization systems.
(B) The State Insurance Department may promulgate a rule mandating the implementation of a mechanism described in this subsection and defining the services to which this subsection applies.
(2) A healthcare provider shall retain the ability to use either the automated electronic system or a telephone-based system.
(3) The automated electronic system shall be capable of handling benefit inquiries under § 23-99-1113.
(e) A service authorized and guaranteed for payment under this section for which the prior authorization is not rescinded or reversed under subsection (b) of this section is not subject to audit recoupment under § 23-63-1801 et seq., except as provided for in subsection (b) of this section.
(f)(1) A healthcare insurer shall pay a claim for a healthcare service under the medical benefit of a health benefit plan in the absence of a prior authorization if:
(A) At the time the healthcare service was provided, the patient had been covered by a health benefit plan for sixty (60) days or less; and
(B) The healthcare service is part of a course of treatment initiated before the patient is covered by the health benefit plan.
(2) Subdivision (f)(1) of this section does not apply to a healthcare service provided under the pharmacy benefit of a health benefit plan.
Ark. Code Ann. § 23-99-1110 Waiver prohibited.
(a) The provisions of this subchapter shall not be waived by contract.
(b) Any contractual arrangements or actions taken in conflict with this subchapter or that purport to waive any requirements of this subchapter are void.
Ark. Code Ann. § 23-99-1112 Application of subchapter.
This subchapter applies to a healthcare insurer, whether or not the healthcare insurer is:
(1) Acting directly or indirectly through a private utilization review entity; or
(2) Located in this state.
Ark. Code Ann. § 23-99-1113 Benefit inquiries authorized.
(a)(1) An in-network or out-of-network healthcare provider may submit a benefit inquiry to a healthcare insurer or utilization review entity for a healthcare service not yet provided to determine whether or not the healthcare service meets medical necessity and all other requirements for payment under a health benefit plan if the healthcare service were to be provided to a specific subscriber.
(2)(A) The State Insurance Department shall issue a rule on or before January 1, 2018, that defines which benefits are subject to the requirements of this section.
(B) Until a rule is promulgated under subdivision (a)(2)(A) of this section, all benefit inquiries shall be processed according to this section.
(b) If a healthcare insurer or utilization review entity lacks sufficient information to respond to a benefit inquiry, the healthcare insurer or utilization review entity shall notify the healthcare provider within two (2) business days of the additional information that is required to respond to the benefit inquiry.
(c)(1) A healthcare insurer, either directly or through a utilization review entity, shall respond to a benefit inquiry authorized in subsection (a) of this section within ten (10) business days of receipt of information required to make a decision on the benefit inquiry.
(2) Responses to a benefit inquiry shall be provided in the same form and manner as responses to requests for prior authorization.
(d) Every healthcare insurer shall provide a convenient and accessible procedure for healthcare providers to submit benefit inquiries under this section.
(e) Sections 23-99-1109 — 23-99-1111 and 23-99-1114 — 23-99-1116 apply to the benefit inquiry process of any healthcare insurer or utilization review entity.
(f) A healthcare service approved under the benefit inquiry process authorized in this section is not subject to audit recoupment under § 23-63-1801 et seq., except as provided for in § 23-99-1109(b).
Ark. Code Ann. § 23-99-1114 Limitation on step therapy — Definitions.
(a) An insurance policy shall not limit or exclude coverage under the health benefit plan for a drug approved by the United States Food and Drug Administration that is on the prescription drug formulary of the insurance policy by mandating that a covered person undergo step therapy if the insurance policy provides coverage for the treatment of:
(1) Psychosis and serious mental illness through antipsychotic prescription drugs; and
(2) Metastatic cancer unless the preferred drug is consistent with best practices that:
(A) Are used for the treatment of metastatic cancer or associated conditions under:
(i) United States Food and Drug Administration-approved indication; or
(ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or
(B) Use evidence-based, peer-reviewed, recognized medical literature.
(b) As used in this section:
(1) "Metastatic cancer” means cancer that has spread from a primary or original site of the cancer to surrounding or nearby tissues, lymph nodes, or other parts of the body;
(2)(A) "Psychosis" means a condition that affects the mind and affects the way the brain processes information.
(B) "Psychosis" includes delusions and hallucinations; and
(3) "Serious mental illness" means a mental, behavioral, or emotional disorder resulting in serious functional impairment, that substantially interferes with or limits one (1) or more major life activities.
(c) For psychosis and serious mental illness, if there is a generic drug equivalent approved by the United States Food and Drug Administration under the same chemical or generic name of a name brand drug that is available, it is not considered step therapy to allow access to and coverage for both the generic drug and the name brand drug.
(c) If a request for prior authorization is denied due to a step therapy requirement under this section, then the utilization review entity shall authorize the preferred treatment required under the step therapy if a prior authorization for the preferred treatment is required without requiring the healthcare provider to submit a new or revised request.
Ark. Code Ann. § 23-99-1116 Failure to comply with subchapter — Enforcement — Fines.
(a)(1) For any provision of this subchapter that relates to a specific request from a healthcare provider for a prior authorization, if a healthcare insurer or utilization review entity fails to comply with this subchapter, the requested healthcare services shall be deemed authorized or approved.
Within two (2) days after a healthcare provider provides notice that the healthcare insurer or utilization review entity has failed to comply with this subchapter, the healthcare insurer or utilization review entity shall:
(A) Issue the authorization for the requested healthcare service;
(B) Resend to a healthcare provider any request for information previously sent to, and unanswered by, the healthcare provider; or
(C)(i) Refer the matter to the State Insurance Department for review.
(ii) If the matter is referred to the department under subdivision (a)(2)(C)(i) of this section, then after notice to the healthcare insurer or utilization review entity, the Insurance Commissioner may conduct an investigation and hold a hearing under § 23-66-209, to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter.
(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter, then the commissioner may order the healthcare insurer or utilization review entity to:
(a) Issue the authorization for the requested healthcare service;
(b) Pay the costs of a hearing; and
(c)(1) Pay a monetary penalty as described in § 23-66-210(a)(1) of not more than one thousand dollars ($1,000) for each violation, not to exceed an aggregate penalty of ten thousand dollars ($10,000), unless the person knew or reasonably should have known he or she was in violation of this subchapter.
(2) If a person knew or reasonably should have known he or she was in violation of this subchapter, the penalty under subdivision (c)(1) of this section shall not be more than five thousand dollars ($5,000) for each violation, not to exceed an aggregate penalty amount of fifty thousand dollars ($50,000) in any six-month period.
(iv) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:
(a) The healthcare insurer or utilization review entity; and
(b) The requesting healthcare provider.
(b) A healthcare service that is authorized or approved under subsection (a) of this section is not subject to audit recoupment under § 23-63-1801 et seq.
(c)(1) For any provision of this subchapter not subject to subsection (a) of this section, if a healthcare insurer or utilization review entity fails to comply with this subchapter, a healthcare provider may provide notice to the healthcare insurer or utilization review entity of the failure to comply.
(2) Within (1) business day after a healthcare provider provides notice that the healthcare insurer or utilization review entity has failed to comply with this subchapter, the healthcare insurer or utilization review entity shall:
(A) Take action to address the failure retrospectively and prospectively to ensure compliance; or
(B)(i) Refer the matter to the department for review.
(ii) If the matter is referred to the department under subdivision (c)(2)(B)(i) of this section or by a complaint filed by a healthcare provider or a subscriber, the commissioner may conduct an investigation and hold a hearing under § 23-66-209 to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice.
(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice, then the commissioner shall order the healthcare insurer or utilization review entity to:
(a) Take action to address the failure retrospectively and prospectively to ensure compliance; and
(b) Pay a civil fine not to exceed five thousand dollars ($5,000) per day of noncompliance up to one hundred thousand dollars ($100,000).
(C) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:
(i) The healthcare insurer or utilization review entity; and
(ii) The requesting healthcare provider.
(d) This section does not prohibit a healthcare provider or subscriber from filing a complaint with the department based on a violation of this subchapter. (e) A fine imposed and collected under this section shall be deposited as special revenues into the State Treasury and credited to the Prior Authorization Transparency Act Fund.
(f) A healthcare insurer or utilization review entity does not violate this subchapter if:
(1) Upon request, a healthcare insurer or a pharmacy benefits manager shall send additional information from the healthcare provider in compliance with this subchapter; and
(2) The healthcare provider fails to send the requested information to the healthcare insurer or utilization review entity.
(g) If the commissioner imposes a fine under this subchapter, the commissioner shall not impose an additional fine for the same underlying act or omission under any other provision of state law.
Ark. Code Ann. § 23-99-1117 Standardized form required for prescription drug benefits.
(a) On and after January 1, 2017, to establish uniformity in the submission of prior authorization forms for prescription drugs, a utilization review entity shall utilize only a single standardized prior authorization form for obtaining approval in written or electronic form for prescription drug benefits.
(b) A utilization review entity may make the form required under subsection (a) of this section accessible through multiple computer operating systems.
(c) The form required under subsection (a) of this section shall:
(1) Not exceed two (2) pages; and
(2) Be designed to be submitted electronically from a prescribing provider to a utilization review entity.
(d) This section does not prohibit prior authorization by verbal means without a form.
(e) If a utilization review entity fails to use or accept the form developed under this section or fails to respond as soon as reasonably possible, but no later than seventy-two (72) hours, after receipt of a completed prior authorization request using the form developed under this section, the prior authorization request is deemed authorized or approved.
(f)(1) On and after January 1, 2017, each utilization review entity shall submit its prior authorization form to the State Insurance Department to be kept on file.
(2) A copy of a subsequent replacement or modification of a utilization review entity's prior authorization form shall be filed with the department within fifteen (15) days before the form is used or before implementation of the replacement or modification.
Ark. Code Ann. § 23-99-1118 Rules.
The State Insurance Department may promulgate rules for the implementation of this subchapter.
Ark. Code Ann. § 23-99-1119 Medication-assisted treatment for opioid addiction.
(a) A healthcare insurer, including Medicaid, shall not:
(1) Require prior authorization in order for a patient to obtain coverage of buprenorphine, naloxone, naltrexone, methadone, and their various formulations and combinations approved by the United States Food and Drug Administration for the treatment or detoxification of opioid and alcohol addiction; or
(2) Impose any other requirement other than a valid prescription and compliance with the medication-assisted treatment guidelines issued by the United States Substance Abuse and Mental Health Services Administration under the United States Department of Health and Human Services in order for a patient to obtain coverage for buprenorphine, naloxone, naltrexone, methadone, and their various formulations and combinations approved by the United States Food and Drug Administration for the treatment or detoxification of opioid and alcohol addiction.
(b) Subdivision (a)(1) of this section shall only apply to the Arkansas Medicaid Program as it pertains to prescription drugs for treatment or detoxification of opioid and alcohol addiction designated as preferred on the evidence-based preferred drug list, provided there is at least one (1) of each of the drugs listed in subdivision (a)(1) of this section with the preferred designation on the preferred drug list or available without prior authorization.
(c) If a new formulation or medication approved by the United States Food and Drug Administration for use as a prescription for medication- assisted treatment becomes available after April 12, 2019, and is either more expensive or has not been shown to be more effective than the formulations and medications in subsection (a) of this section, then the healthcare insurer may require prior authorization of the new formulation or medication.
(d) A healthcare insurer utilizing a tiered drug formulary shall place on the lowest-cost benefit tier at least one (1) product for each of the following medications that is approved by the United States Food and Drug Administration:
(1) Buprenorphine;
(2) Naloxone;
(3) Naltrexone;
(4) Methadone; and
(5) A product containing both buprenorphine and naloxone.
(e) For purposes of any limit a healthcare insurer imposes on the number of prescriptions for a patient, a prescription for medication-assisted treatment shall not be counted.
(f) This section does not affect the responsibility of a healthcare provider to comply with the standard of care for medication-assisted treatment, including without limitation the use of therapy in combination with medication.
Ark. Code Ann. § 23-99-1121 Duration of prior authorization exemption.
(a) Unless a prior authorization exemption is continued for a longer period of time by a healthcare insurer under § 23-99-1120(c), a healthcare provider's exemption from prior authorization requirements under § 23-99-1120 remains in effect until the later of:
(1) The thirtieth day after the date the healthcare insurer notifies the healthcare provider of the healthcare insurer's determination to rescind the exemption as described under § 23-99-1122, if the healthcare provider does not appeal the healthcare insurer's determination within thirty (30) days of notification of the determination;
(2) If the healthcare provider appeals the determination within thirty (30) days of notification of the determination, the fifth day after the date an independent review organization affirms the healthcare insurer's determination to rescind the exemption; or
(3) Twelve (12) months after the effective date of the exemption.
(b) If a healthcare provider appeals the determination to rescind the exemption more than thirty (30) days after notification of the determination and the independent review organization overturns the rescission, the healthcare provider’s exemption is restored the fifth day after the date of the independent review organization’s decision, and the exemption remains in effect for twelve (12) months after restoration unless rescinded under § 23-99-1122.
(c) If a healthcare insurer does not finalize a rescission determination as specified in subsection (a) of this section, then the healthcare provider is considered to have met the criteria under § 23-99-1120 to continue to qualify for the exemption.
(d) A healthcare provider shall not rely on another healthcare provider’s exemption except when the healthcare provider with an exemption is the healthcare provider that orders healthcare services that are rendered by a healthcare provider without an exemption.
Ark. Code Ann. § 23-99-1123 Independent review of exemption determination.
(a)(1) A healthcare provider has a right to a review of an adverse determination regarding a prior authorization exemption within twelve (12) months of receiving proper notice of recission from a healthcare insurer to be conducted by an independent review organization.
(2) A healthcare insurer shall not require a healthcare provider to engage in an internal appeal process before requesting a review by an independent review organization under this section.
(3) A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity.
(b) A healthcare insurer shall pay:
(1) For any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section; and
(2) A reasonable fee determined by the Arkansas State Medical Board for any copies of medical records or other documents requested from a healthcare provider during an exemption rescission review requested under this section.
(c) An independent review organization shall complete an expedited review of an adverse determination regarding a prior authorization exemption no later than the thirtieth day after the date a healthcare provider files the request for a review under this section.
(d)(1) A healthcare provider may request that the independent review organization consider another random sample of no fewer than five (5) and no more than twenty (20) claims submitted to the healthcare insurer by the healthcare provider during the relevant evaluation period for the relevant healthcare service as part of the review under this section.
(2) If a healthcare provider makes a request under subdivision (d)(1) of this section, the independent review organization shall base its determination on the medical necessity of claims reviewed:
(A) By the healthcare insurer under § 23-99-1122; and
(B) By the independent review organization under subdivision (d)(1) of this section.
(e) The Insurance Commissioner may refuse, suspend, revoke, or not renew a license or certificate of authority of a healthcare insurer that has fifty percent (50%) of healthcare provider appeals overturned in a twelve- month period by an independent review organization under this section.
Ark. Code Ann. § 23-99-1124 Effect of appeal of independent review organization determination.
(a) A healthcare insurer is bound by an appeal or independent review organization determination that does not affirm the determination made by the healthcare insurer to rescind a prior authorization exemption.
(b) A healthcare insurer shall not retroactively deny a healthcare service on the basis of a rescission of an exemption, even if the healthcare insurer's determination to rescind the prior authorization exemption is affirmed by an independent review organization.
(c) If a determination of a prior authorization exemption made by the healthcare insurer is overturned on review by an independent review organization, the healthcare insurer:
(1) Shall not attempt to rescind the exemption before the end of the next evaluation period; and
(2) May only rescind the exemption if the healthcare insurer complies with §§ 23-99-1122 and 23-99-1123.
Ark. Code Ann. § 23-99-1125 Eligibility for prior authorization exemption following finalized exemption rescission or denial.
(a) After a final determination or review affirming the rescission or denial of an exemption for a specific healthcare service under § 23-99-1120, a healthcare insurer shall conduct another evaluation to determine whether or not the exemption should be granted or reinstated based on the six-month evaluation period that follows the evaluation period that formed the basis of the rescission or denial of an exemption.
(b) A time period that is included in a previous evaluation or determination period shall not be included in a subsequent evaluation period.
Ark. Code Ann. § 23-99-1126 Effect of prior authorization exemption.
(a)(1) A healthcare insurer shall not deny or reduce payment to a healthcare provider for a healthcare service for which the healthcare provider has qualified for an exemption from prior authorization requirements under § 23-99-1120, including a healthcare service performed or supervised by another healthcare provider, if the healthcare provider who ordered the healthcare service received a prior authorization exemption based on medical necessity or appropriateness of care unless the healthcare provider:
(A) Knowingly and materially misrepresented the healthcare service in a request for payment submitted to the healthcare insurer with the specific intent to deceive the healthcare insurer and obtain an unlawful payment from the healthcare insurer; or
(B) Substantially failed to perform the healthcare service.
(2)(A) Subdivision (a)(1) of this section does not constitute a basis for a healthcare insurer to:
(i) Request information from a healthcare provider; or
(ii) Delay reimbursement in order to obtain information.
(B) A request for information under subdivision (a)(2)(A)(i) of this section shall comply with applicable laws and rules.
(b) A healthcare insurer shall not conduct a retrospective review of a healthcare service subject to an exemption except:
(1) To determine if the healthcare provider still qualifies for an exemption under § 23-99-1120; or
(2) If the healthcare insurer has a reasonable cause to suspect a basis for denial exists under subsection (a) of this section.
(c) For a retrospective review described by subdivision (b)(2) of this section, §§ 23-99-1120 — 23-99-1125 shall not modify or otherwise affect:
(1) The requirements under or application of § 23-99-1115, including without limitation any time frames; or
(2) Any other applicable law, except to prescribe the only circumstances under which:
(A) A retrospective review may occur as specified by subdivision (b)(2) of this section; or
(B) Payment may be denied or reduced as specified by subsection (a) of this section.
(d) A healthcare insurer shall provide to a healthcare provider a notice that includes a:
(1) Statement that the healthcare provider has an exemption from prior authorization requirements under § 23-99-1120;
(2) List of the healthcare services and health benefit plans to which the exemption applies; and
(3) Statement of the duration of the exemption.
(e) If a healthcare provider submits a prior authorization request for a healthcare service for which the healthcare provider has an exemption from prior authorization requirements under § 23-99-1120, the healthcare insurer shall promptly provide a notice to the healthcare provider that includes:
(1) The information described in subsection (d) of this section; and
(2) A notification of the healthcare insurer's payment requirements.
(f) This section and §§ 23-99-1120 — 23-99-1125 shall not be construed to:
(1) Authorize a healthcare provider to provide a healthcare service outside the scope of the healthcare provider's applicable license; or
(2) Require a healthcare insurer to pay for a healthcare service described by subdivision (f)(1) of this section that is performed in violation of the laws of this state.
(g) A healthcare insurer that offers multiple health benefit plans or that utilizes multiple healthcare provider networks shall not determine a healthcare provider’s eligibility for an exemption from prior authorization for each specific health benefit plan or each specific healthcare provider network but rather shall determine the healthcare provider’s eligibility for an exemption applicable to all health benefit plans and healthcare provider networks.
(h) If a healthcare insurer and a healthcare provider are engaged in a value-based reimbursement arrangement for particular healthcare services or subscribers, the healthcare insurer shall not impose any prior authorization requirements for any particular healthcare service that is included in that value-based reimbursement arrangement.
Ark. Code Ann. § 23-99-1127 Applicability.
(a)(1) An organization or entity directly or indirectly providing a plan or services to patients under the Medicaid Provider-Led Organized Care Act, § 20-77-2701 et seq., or any other Medicaid-managed care program operating in this state is exempt from §§ 23-99-1120 — 23-99-1126 if the program, without limiting the program's application to any other plan or program, develops and conforms to a program to reduce or eliminate prior authorizations for a healthcare provider .
(2) The Arkansas Health and Opportunity for Me Program established by the Arkansas Health and Opportunity for Me Act of 2021, § 23-61-1001 et seq., or its successor program is exempt from §§ 23-99-1120 — 23-99-1126, provided that the Arkansas Health and Opportunity for Me Program, without limiting the Arkansas Health and Opportunity for Me Program's application to any other plan or program, develops and conforms to a program to reduce or eliminate prior authorizations for a healthcare provider .
(3) A qualified health plan that is a health benefit plan under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and purchased on the Arkansas Health Insurance Marketplace created under the Arkansas Health Insurance Marketplace Act, § 23-61-801 et seq., for an individual up to four hundred percent (400%) of the federal poverty level, operating in this state is exempt from §§ 23-99-1120 — 23-99-1126 if the qualified health plan, without limiting the program's application to any other plan or program, develops and conforms to a program to reduce or eliminate prior authorizations for a healthcare provider .
(b)(1)(A) At least one (1) time every two (2) years, a program under subsection (a) of this section to reduce or eliminate prior authorization shall be:
(i) Submitted to the State Insurance Department; and
(ii) Subject to approval by the Legislative Council.
(B) A program under subsection (a) of this section shall include:
(i) Data, statistics, and other appropriate documentation demonstrating the effectiveness of the previously submitted program in reducing or eliminating prior authorizations for a healthcare provider; and
(ii) For a program that does not eliminate prior authorizations for a healthcare provider, specific initiatives or elements of the program that reduce existing prior authorizations for a healthcare provider.
(C)(i) Upon submitting the program under subdivision (b)(1) of this section, the submitting entity shall provide notice to each healthcare provider that includes:
(a) The complete program submission;
(b) The deadline for a healthcare provider to comment on the program submission; and
(c) Instructions on how a healthcare provider may comment on the program.
(ii) A healthcare provider shall have at least thirty (30) days to comment on a program submitted under subdivision (b)(1) of this section.
(2) If a program is not submitted to the department and approved by the Legislative Council as required or does not conform to the requirements of this section, the Medicaid-managed care program operating in this state, the Arkansas Health and Opportunity for Me Program established by the Arkansas Health and Opportunity for Me Act of 2021, § 23-61-1001 et seq., or its successor program, and qualified health plans under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and purchased on the Arkansas Health Insurance Marketplace created under the Arkansas Health Insurance Marketplace Act, § 23-61-801 et seq., for an individual up to four hundred percent (400%) of the federal poverty level, operating in this state shall be subject to §§ 23-99-1120 — 23-99-1126 and § 23-99-1128 .
(c) Any state or local governmental employee plan is exempt from §§ 23-99-1120 — 23-99-1126 and § 23-99-1128.
(d) A health benefit plan provided by a trust established under §§ 14-54-101 and 25-20-104 to provide benefits, including accident and health benefits, death benefits, dental benefits, and disability income benefits, is exempt from §§ 23-99-1120 — 23-99-1126.
(e) Prescription drugs, medicines, biological products, pharmaceuticals, or pharmaceutical services are subject to the gold card program unless exempted from the gold card program under § 23-99-1128(b).
(f)(1) Upon request, a healthcare insurer or a pharmacy benefits manager shall send an eligibility file notification to a healthcare provider.
(2) An eligibility file notification under subdivision (f)(1) of this section shall indicate whether a subscriber is enrolled in a:
(A) Health benefit plan that is:
(i) Self-insured under the Employee Retirement Income Security Act of 1974, Pub. L. No. 93-406;
(ii) A fully insured health benefit plan; or
(iii) A self-funded health benefit plan;
(B) Qualified health benefit plan that is a health benefit plan under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and purchased on the Arkansas Health Insurance Marketplace created under the Arkansas Health Insurance Marketplace Act, § 23-61-801 et seq., for an individual up to four hundred percent (400%) of the federal poverty level, operating in this state; or
(C) Qualified health benefit plan that is a health benefit plan under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and purchased as a health benefit plan under Arkansas Health Insurance Marketplace created under the Arkansas Health Insurance Marketplace Act, § 23-61-801 et seq., for an individual over four hundred percent (400%) of the federal poverty level.
Ark. Code Ann. § 23-99-1128 Prescription drugs, medicines, biological products, pharmaceuticals, or pharmaceutical services.
(a) If a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service is not exempt from the gold card program under subsection (b) of this section, then a healthcare provider shall be reviewed by a healthcare insurer or pharmacy benefits manager under the gold card program for the prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service.
(b)(1) For a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service to be exempt from the gold card program, a healthcare insurer or pharmacy benefits manager may submit a written request to the Arkansas State Board of Pharmacy for approval.
(2) A request under subdivision (b)(1) of this section shall state the reason the request is being made for each prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service for which exemption from the gold card program is requested.
(3) The Arkansas State Board of Pharmacy and the Arkansas State Medical Board, jointly, shall establish criteria and procedures to review whether a request for exemption from the gold card program made under subdivision (b)(1) of this section should be granted.
(4) The criteria established under subdivision (b)(3) of this section shall include criteria related to the cost and the safety of the prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service.
(5) Under the criteria established and procedures described under subdivision (b)(3) of this section, the Arkansas State Board of Pharmacy and the Arkansas State Medical Board, jointly, shall determine whether to approve a request to exempt a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service from the gold card program.
(6) The Arkansas State Board of Pharmacy shall promptly notify the entity that made the request of the joint decision made by the Arkansas State Board of Pharmacy and the Arkansas State Medical Board.
(7) The decision of the Arkansas State Board of Pharmacy and the Arkansas State Medical Board, jointly, regarding each prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service shall apply to all healthcare insurers or pharmacy benefits managers.
(8) The Arkansas State Board of Pharmacy shall post on the Arkansas State Board of Pharmacy's website a list of prescription drugs, medicines, biological products, pharmaceuticals, or pharmaceutical services that are exempt from the gold card program.
(9) An approval for exemption from the gold card program is valid for two (2) years from the date of the notice provided under subdivision (b)(6) of this section.
Ark. Code Ann. § 23-99-1129 Appeals process for disallowance of prior authorization.
(a) If the Arkansas State Board of Pharmacy and the Arkansas State Medical Board, jointly, disallow a prior authorization of a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service requested under § 23-99-1128, a healthcare insurer, pharmacy benefits manager, or other interested party may file an appeal to the State Insurance Department within ninety (90) days of the disallowance of the prior authorization.
(b) The healthcare insurer, pharmacy benefits manager, or other interested party shall provide a notice of seven (7) days to the Arkansas State Board of Pharmacy and the Arkansas State Medical Board of the healthcare insurer's, pharmacy benefits manager's, or other interested party's intent to file an appeal.
(c) No later than the thirtieth day after the date a healthcare insurer, pharmacy benefits manager, or other interested party files an appeal under subsection (a) of this section, the Insurance Commissioner shall appoint an independent review organization to review the appeal.
(d) A healthcare insurer, pharmacy benefits manager, or other interested party that files an appeal under subsection (a) of this section shall pay for the independent review organization appointed under subsection
(c) of this section to review the appeal.
(e)(1) If a healthcare insurer, pharmacy benefits manager, or other interested party succeeds in its appeal and overturns the decision of the Arkansas State Board of Pharmacy and the Arkansas State Medical Board, the healthcare insurer, pharmacy benefits manager, or other interested party shall be reimbursed for fifty percent (50%) of the cost remitted to the independent review organization under subsection (d) of this section.
(2) The Arkansas State Board of Pharmacy and the Arkansas State Medical Board shall each provide twenty-five percent (25%) of the total reimbursement to the healthcare insurer, pharmacy benefits manager, or other interested party under subdivision (e)(1) of this section.
(f) A healthcare insurer, pharmacy benefits manager, or other interested party is bound by the independent review organization's determination of the appeal under this section.
Ark. Code Ann. § 23-99-1201 Title.
This subchapter shall be known and may be cited as the “Healthcare Contracting Simplification Act”.
Ark. Code Ann. § 23-99-1202 Definitions.
As used in this subchapter:
(1) “All-products clause” means a provision in a healthcare contract that requires a healthcare provider, as a condition of participation or continuation in a provider network or a health benefit plan, to:
(A) Serve in another provider network utilized by the contracting entity or a healthcare insurer affiliated with the contracting entity; or
(B) Provide healthcare services under another health benefit plan or product offered by a contracting entity or a healthcare insurer affiliated with the contracting entity;
(2) “Contracting entity” means a healthcare insurer or a subcontractor, affiliate, or other entity that contracts directly or indirectly with a healthcare provider for the delivery of healthcare services to enrollees;
(3) “Enrollee” means an individual who is entitled to receive healthcare services under the terms of a health benefit plan;
(4)(A) “Health benefit plan” means a plan, policy, contract, certificate, agreement, or other evidence of coverage for healthcare services offered or issued by a healthcare insurer in this state.
(B) “Health benefit plan” includes:
(i) A nonfederal governmental plan as defined in 29 U.S.C. § 1002(32), as it existed on January 1, 2023; and
(ii) A contract for providing benefits for dental care pursuant to:
(a) A healthcare insurance policy or certificate;
(b) A dental-only plan;
(c) A health maintenance organization provider contract; or
(d) A managed healthcare plan.
(C) “Health benefit plan” does not include:
(i) A disability income plan;
(ii) A credit insurance plan;
(iii) Insurance coverage issued as a supplement to liability insurance;
(iv) A medical payment under automobile or homeowners insurance plans;
(v) A health benefit plan provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., or the Public Employee Workers' Compensation Act, § 21-5-601 et seq.;
(vi) A plan that provides only indemnity for hospital confinement;
(vii) An accident-only plan;
(viii) A specified disease plan;
(ix) A long-term care only plan; or
(x) A vision-only plan;
(5)(A) "Health benefit plan" means a plan, policy, contract, certificate, agreement, or other evidence of coverage for healthcare services offered or issued by a healthcare insurer in this state.
(B) "Health benefit plan" includes:
(i) A nonfederal governmental plan as defined in 29 U.S.C. § 1002(32), as it existed on January 1, 2025;
(ii) A contract for providing benefits for dental care pursuant to:
(a) A healthcare insurance policy or certificate;
(b) A dental-only plan;
(c) A health maintenance organization provider contract; or
(d) A managed healthcare plan; and
(iii) A contract for providing benefits for vision care under a healthcare insurance policy or certificate, a vision-only plan, a health maintenance organization provider contract, or a managed healthcare plan.
(C) "Health benefit plan” does not include:
(i) A disability income plan;
(ii) A credit insurance plan;
(iii) Insurance coverage issued as a supplement to liability insurance;
(iv) A medical payment under automobile or homeowners insurance plans;
(v) A health benefit plan provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., or the Public Employee Workers' Compensation Act, § 21-5-601 et seq.;
(vi) A plan that provides only indemnity for hospital confinement;
(vii) An accident-only plan;
(viii) A specified disease plan; or
(ix) A long-term care only plan ;
(6)(A) “Healthcare insurer” means an entity that is subject to state insurance regulation and provides health insurance in this state.
(B) “Healthcare insurer” includes:
(i) An insurance company;
(ii) A health maintenance organization;
(iii) A hospital and medical service corporation;
(iv) A risk-based provider organization;
(v) A sponsor of a nonfederal self-funded governmental plan; and
(vi) A dental-only plan;
(7)(A) "Healthcare insurer" means an entity that is subject to state insurance regulation and provides or administers health insurance in this state.
(B) "Healthcare insurer" includes:
(i) An insurance company;
(ii) A health maintenance organization;
(iii) A hospital and medical service corporation;
(iv) A risk-based provider organization;
(v) A sponsor of a nonfederal self-funded governmental plan;
(vi) A dental-only plan; and
(vii) A third-party administrator or other entity acting on behalf of a self-insured health benefit plan;
(8)(A) “Healthcare services” means services or goods provided for the purpose of or incidental to the purpose of preventing, diagnosing, treating, alleviating, relieving, curing, or healing human illness, disease, condition, disability, or injury.
(B) "Healthcare services" includes services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease;
(9) “Material amendment” means a change in a healthcare contract that results in:
(A) A decrease in fees, payments, or reimbursement to a participating healthcare provider;
(B) A change in the payment methodology for determining fees, payments, or reimbursement to a participating healthcare provider;
(C) A new or revised coding guideline;
(D) A new or revised payment rule; or
(E) A change of procedures that may reasonably be expected to significantly increase a healthcare provider's administrative expenses;
(10) “Most favored nation clause” means a provision in a healthcare contract that:
(A) Prohibits or grants a contracting entity an option to prohibit a participating healthcare provider from contracting with another contracting entity to provide healthcare services at a lower price than the payment specified in the healthcare contract;
(B) Requires or grants a contracting entity an option to require a participating healthcare provider to accept a lower payment in the event the participating healthcare provider agrees to provide healthcare services to another contracting entity at a lower price;
(C) Requires or grants a contracting entity an option to require termination or renegotiation of an existing healthcare contract if a participating healthcare provider agrees to provide healthcare services to another contracting entity at a lower price; or
(D) Requires a participating healthcare provider to disclose the participating healthcare provider's contractual reimbursement rates with other contracting entities;
(11) “Participating healthcare provider” means a healthcare provider that has a healthcare contract with a contracting entity to provide healthcare services to enrollees with the expectation of receiving payment from the contracting entity or a healthcare insurer affiliated with the contracting entity; and
(12) “Provider network” means a group of healthcare providers that are contracted to provide healthcare services to enrollees at contracted rates.
(13) "Affiliate" means an entity that controls, is controlled by, or is under common control with a healthcare insurer.
(14) "Downcode" means to change a claim to a lower-cost healthcare service than what was contained in the original claim that a healthcare provider submitted or billed to a contracting entity.
Ark. Code Ann. § 23-99-1203 All-products clause — Prohibition.
(a) Except as provided in subsections (b) and (d) of this section, a contracting entity shall not:
(1) Offer to a healthcare provider a healthcare contract that includes an all-products clause;
(2) Enter into a healthcare contract with a healthcare provider that includes an all-products clause;
(3) Amend or renew an existing healthcare contract previously entered into with a healthcare provider so that the healthcare contract as amended or renewed adds or continues to include an all-products clause; or
(4) Enforce a stipulation, requirement, or policy that has the effect of an all-products clause whether or not an all-products clause is included in the healthcare contract.
(b)(1) This section does not prohibit a contracting entity from:
(A) Offering a healthcare provider a contract that covers multiple health benefit plans that have the same reimbursement rates and other financial terms for the healthcare provider;
(B) Adding a new health benefit plan to an existing healthcare contract with a healthcare provider under the same reimbursement rates and other financial terms applicable under the original healthcare contract; or
(C) Requiring a healthcare provider to accept multiple health benefit plans that do not differ in reimbursement rates or other financial terms for the healthcare provider.
(2) A healthcare contract may include health benefit plans or coverage options for enrollees within a health benefit plan with different cost-sharing structures, including different deductibles or copayments, as long as the reimbursement rates and other financial terms between the contracting entity and the healthcare provider remain the same for each plan or coverage option included in the healthcare contract.
(3) This section does not authorize a healthcare provider to:
(A) Opt out of providing services to an enrollee of a particular health benefit plan after the healthcare provider has entered into a valid contract under this section to provide the services; or
(B) Refuse to disclose the provider networks or health benefit plans in which the healthcare provider participates.
(c)(1) A violation of this section is:
(A) An unfair trade practice under § 23-66-206; and
(B) Subject to the Trade Practices Act, § 23-66-201 et seq.
(2) If a healthcare contract contains a provision that violates this section, the healthcare contract is void.
(d) A contracting entity may require a healthcare provider to participate in the State and Public School Life and Health Insurance Program as a condition of contracting or continuing to contract with the healthcare provider for healthcare services under another health benefit plan, if:
(1) The other health benefit plan is an individual health plan not sold on the health insurance marketplace, as defined in § 23-64-602; and
(2) The rates offered to the healthcare provider for healthcare services to program enrollees are no lower than the rates paid to the healthcare provider under the other health benefit plan.
Ark. Code Ann. § 23-99-1204 Prohibition — Most favored nation clause.
(a) A contracting entity shall not:
(1) Offer to a healthcare provider a healthcare contract that includes a most favored nation clause;
(2) Enter into a healthcare contract with a healthcare provider that includes a most favored nation clause; or
(3) Amend or renew an existing healthcare contract previously entered into with a healthcare provider so that the contract as amended or renewed adds or continues to include a most favored nation clause.
(b)(1) A violation of this section is:
(A) An unfair trade practice under § 23-66-206; and
(B) Subject to the Trade Practices Act, § 23-66-201 et seq.
(2) If a healthcare contract contains a provision that violates this section, the healthcare contract is void.
Ark. Code Ann. § 23-99-1205 Contracting process.
(a)(1) A material amendment to a healthcare contract is allowed if a contracting entity provides to a participating healthcare provider the material amendment at least ninety (90) days before the effective date of the material amendment and in writing.
(2) The notice required under subdivision (a)(1) of this section shall specify the precise healthcare contract or healthcare contracts to which the material amendment applies and be conspicuously labeled as follows:
(3) The notice shall contain sufficient information about the amendment to allow a healthcare provider to assess the financial impact, if any, of the amendment.
(b) A notice described under subdivision (a)(1) of this section is not required for a material amendment resulting solely from a change in a fee schedule or code set if:
(1) The fee schedule or code set is published by the United States Government or another third party; and
(2) The terms of the healthcare contract expressly state that the healthcare provider's compensation or claims submission is based on the fee schedule or code set.
(c)(1) Within ten (10) business days of a healthcare provider's request, a contracting entity shall provide to the healthcare provider a full and complete copy of each healthcare contract between the contracting entity and the healthcare provider.
(2) A full and complete copy of the healthcare contract shall include any amendments to the healthcare contract.
(d)(1)(A) A healthcare contract shall open for renegotiation and revision at least one (1) time every three (3) years.
(B) Under subdivision (d)(1)(A) of this section, a party to the healthcare contract is not required to terminate the healthcare contract in order to open the healthcare contract for renegotiation of the terms.
(2) This section does not prohibit a renegotiation of a healthcare contract at any time during the term of the healthcare contract.
(e)(1) A violation of this section is:
(A) An unfair trade practice under § 23-66-206; and
(B) Subject to the Trade Practices Act, § 23-66-201 et seq.
(2) If a healthcare contract contains a provision that violates this section, the healthcare contract is void.
“Notice of Material Amendment to Healthcare Contract”.
Ark. Code Ann. § 23-99-1206 Freedom of contract.
(a) A contracting entity shall not, directly or indirectly, offer or enter into a healthcare contract that:
(1) Prohibits a participating healthcare provider from entering into a healthcare contract with another contracting entity; or
(2) Prohibits a contracting entity from entering into a healthcare contract with another healthcare provider.
(b)(1) A violation of this section is:
(A) An unfair trade practice under § 23-66-206; and
(B) Subject to the Trade Practices Act, § 23-66-201 et seq.
(2) If a healthcare contract contains a provision that violates this section, the healthcare contract is void.
Ark. Code Ann. § 23-99-1207 Enforcement.
(a) A contracting entity is subject to the Trade Practices Act, § 23-66-201 et seq.
(b) The State Insurance Department shall enforce this subchapter.
Ark. Code Ann. § 23-99-1208 Rules.
(a) The Insurance Commissioner shall promulgate rules necessary to ensure compliance with this subchapter.
(b)(1) When adopting the initial rules to ensure compliance with this subchapter, the final rule shall be filed with the Secretary of State for adoption under § 25-15-204(f):
(A) On or before March 1, 2020; or
(B) If approval under § 10-3-309 has not occurred by March 1, 2020, as soon as practicable after approval under § 10-3-309.
(2) The commissioner shall file the proposed rule with the Legislative Council under § 10-3-309(c) sufficiently in advance of March 1, 2020, so that the Legislative Council may consider the rule for approval before March 1, 2020.
Ark. Code Ann. § 23-99-1209 Effective date.
(a) This subchapter applies to the activities of risk-based provider organizations on and after January 1, 2021.
(b) Except as provided in subsection (a) of this section, this subchapter is effective on and after September 1, 2019.
Ark. Code Ann. § 23-99-1210 Healthcare contract or provider network — Prohibition.
(a) A contracting entity shall not:
(1) Lease, rent, or sell a healthcare contract or provider network of a health benefit plan to another contracting entity, healthcare insurer, or third-party administrator; or
(2) In any manner allow the use of a healthcare contract or provider network of a health benefit plan by another contracting entity, healthcare insurer, or third-party administrator.
(b)(1) A violation of this section is:
(A) An unfair trade practice under § 23-66-206; and
(B) Subject to the Trade Practices Act, § 23-66-201 et seq.
(2) If a healthcare contract contains a provision that violates this section, then the provision under the healthcare contract is void.
(c) This section does not apply if:
(1) A contracting entity is a dental-only plan and grants access to the contracting entity's provider network or healthcare contract to another healthcare insurer or entity that is:
(A) An affiliate of the healthcare insurer; or
(B) Operating according to the same brand licensee program as the healthcare insurer; or
(2) A contracting entity:
(A) Provides notice of the intent to lease, rent, or sell a healthcare contract or provider network of a health benefit plan to another healthcare insurer or third-party administrator;
(B) Allows a healthcare provider that is a party to the healthcare contract or provider network of a health benefit plan the opportunity to opt out of participating in the:
(i) Proposed lease, rental, or sale of a healthcare contract or provider network of a health benefit plan entirely upon the execution or renewal of the healthcare contract; and
(ii) Lease, rental, or sale of a healthcare contract with respect to an individual contracting entity, healthcare insurer, or third-party administrator upon notice that the individual contracting entity, healthcare insurer, or third-party administrator has violated the terms of the healthcare contract; and
(C) Provides contact information for the healthcare insurer or third-party administrator using the healthcare contract or provider network of a health benefit plan, including without limitation:
(i) Contact name;
(ii) Mailing address;
(iii) Direct telephone number for customer service matters; and
(iv) Direct email address for customer service matters.
(d) Subdivision (c)(2)(B) of this section does not apply if a contracting entity grants access to the contracting entity's provider network or healthcare contract to another healthcare insurer or contracting entity that is:
(1) An affiliate of the healthcare insurer; or
(2) Operating according to the same brand licensee program as the healthcare insurer.
Ark. Code Ann. § 23-99-1301 Definitions.
As used in this subchapter:
(1) “Contracting entity” means a healthcare insurer or any subcontractor, affiliate, or other entity that contracts directly or indirectly with a healthcare provider for the delivery of healthcare services to enrollees;
(2) “Enrollee” means a person who is entitled to receive healthcare services under the terms of a health benefit plan;
(3)(A) “Health benefit plan” means a plan, policy, contract, certificate, agreement, or other evidence of coverage for healthcare services offered or issued by a healthcare insurer in this state.
(B) “Health benefit plan” does not include:
(i) A disability income plan;
(ii) A credit insurance plan;
(iii) Insurance coverage issued as a supplement to liability insurance;
(iv) Medical payments under an automobile or homeowners insurance plan;
(v) A health benefit plan provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., or the Public Employee Workers' Compensation Act, § 21-5-601 et seq.;
(vi) A plan that provides only indemnity for hospital confinement;
(vii) An accident-only plan;
(viii) A specified disease plan;
(ix) A long-term care insurance plan; or
(x) A vision-only plan;
(4) “Healthcare contract” means a contract entered into, materially amended, or renewed between a contracting entity and a healthcare provider for the delivery of healthcare services to enrollees;
(5)(A) “Healthcare insurer” means an entity that is subject to state insurance regulation and provides health insurance in this state.
(B) “Healthcare insurer” includes:
(i) An insurance company;
(ii) A health maintenance organization;
(iii) A hospital and medical service corporation;
(iv) A risk-based provider organization; and
(v) A sponsor of a nonfederal self-funded governmental plan;
(6) “Healthcare provider” means a person or entity that is licensed, certified, or otherwise authorized by the laws of this state to provide healthcare services;
(7) “Healthcare services” means services or goods provided for the purpose of preventing, diagnosing, treating, alleviating, relieving, curing, or healing human illness, disease, condition, disability, or injury;
(8) “Out-of-network provider” means a healthcare provider that provides healthcare services to an enrollee but is not a participating provider;
(9) “Participating provider” means a healthcare provider that has a healthcare contract with a contracting entity to provide healthcare services to enrollees with the expectation of receiving payment either directly from the contracting entity or from a healthcare insurer affiliated with the contracting entity; and
(10) “Payor” means a contracting entity or healthcare insurer responsible for payment for healthcare services provided to an enrollee under the terms of a healthcare contract or a health benefit plan.
Ark. Code Ann. § 23-99-1302 Assignment of benefits — Consent and notice required.
(a) An enrollee, through an assignment of benefits, may assign to a healthcare provider the enrollee's right to receive reimbursement for any healthcare service rendered by a healthcare provider regardless of whether the healthcare provider is a participating provider or an out-of-network provider.
(b)(1) A healthcare provider that is provided an assignment of benefits by an enrollee under this section shall provide notice to the payor of the assignment of benefits with a claim for payment for healthcare services provided to an enrollee.
(2) If the healthcare provider providing notice to the payor is an out-of-network provider, the notice shall be accompanied by a complete copy of the assignment of benefits bearing the enrollee's signature and the date the assignment was executed.
(c)(1) A payor, upon receipt of the claim and notice of the assignment of benefits submitted by the healthcare provider, shall promptly remit payment of the claim directly to the healthcare provider.
(2) When payment is made directly to the healthcare provider, the payor shall give written notice of the payment to an enrollee.
(3) A violation of this subsection is:
(A) An unfair trade practice under § 23-66-206; and
(B) Subject to the Trade Practices Act, § 23-66-201 et seq.
(d)(1)(A) If an enrollee executes an assignment of benefits and the healthcare provider submits notice of that assignment of benefits with the healthcare provider's claim for payment under this section, the claim is not paid if the payor remits payment of the claim to the enrollee rather than to the healthcare provider.
(B) Notwithstanding the incorrect payment of a claim to an enrollee, a payor shall remain liable for remitting payment of the claim to the healthcare provider under the assignment of benefits.
(2) If an assignment of benefits has been executed but the payor remits payment of the claim to the enrollee, then the payor shall remit payment of the claim to the healthcare provider under the assignment of benefits within ten (10) days of receiving notice of the incorrect payment from the healthcare provider.
(e) For dental-only plans, an enrollee shall provide annual consent of an assignment of benefits to the healthcare provider and the healthcare insurer or payor.
(f) For dental-only plans, before providing healthcare services to an enrollee, a healthcare provider shall provide a notice or statement to the enrollee informing the enrollee:
(1) The healthcare provider is not a participating provider;
(2) The healthcare provider may charge the enrollee for noncovered healthcare services;
(3) The healthcare provider may charge the enrollee the balance bill for covered healthcare services;
(4) An estimate of the cost of healthcare services that the healthcare provider will provide the enrollee; and
(5) Any terms of payment that apply, including without limitation interest that the healthcare provider charges.
Ark. Code Ann. § 23-99-1303 Waiver prohibited.
(a) This subchapter shall not be waived by contract.
(b) A contractual arrangement or actions taken in conflict with this subchapter or that purport to waive any requirement of this subchapter are void.
Ark. Code Ann. § 23-99-1304 Enforcement.
(a) A contracting entity is subject to the Trade Practices Act, § 23-66-201 et seq.
(b) The State Insurance Department shall enforce this subchapter.
Ark. Code Ann. § 23-99-1305 Rules.
The Insurance Commissioner shall promulgate rules necessary to ensure compliance with this subchapter.
Ark. Code Ann. § 23-99-1405 Converting back to ambulatory surgery center.
(a) If a temporary hospital facility converts back to an ambulatory surgery center, a healthcare insurer shall not delay in providing a contract for an ambulatory surgery center based on the healthcare insurer's standard and reasonable terms and conditions.
(b) The effective date of an ambulatory surgery center contract shall be the same as the effective date of the conversion from a temporary hospital facility back to an ambulatory surgery center.
Ark. Code Ann. § 23-99-1406 Applicability.
This subchapter shall apply to any future public health emergencies if the Centers for Medicare & Medicaid Services and the Department of Health have implemented similar programs as described in § 23-99-1402(a)(2).
Ark. Code Ann. § 23-99-1407 Penalty.
A violation of this subchapter is a violation of § 23-99-804 and the Healthcare Contracting Simplification Act, § 23-99-1201 et seq.
Ark. Code Ann. § 23-99-1605 Claims.
(a) A contracting entity shall pay a claim for ambulance services for which prior authorization was received regardless of the terminology used by the transportation benefit manager or health benefit plan within thirty (30) days of receipt of the claim from an ambulance provider, unless:
(1) Authorized ambulance services were never performed; or
(2) There is specific information available for review by the appropriate state or federal agency that the subscriber or ambulance provider has engaged in material misrepresentation, fraud, or abuse regarding the claim for the authorized ambulance services.
(b)(1) A healthcare insurer or transportation benefit manager shall pay two hundred fifty percent (250%) of the Medicare Ambulance Fee Schedule, Rural Rate for a claim for ambulance services to an ambulance provider.
(2) An ambulance provider shall accept the payment under subdivision (b)(1) of this section as payment in full for services provided to the subscriber.
(3) An ambulance provider shall not balance bill or otherwise demand a payment from the subscriber other than a deductible, copayment, or coinsurance required under the subscriber's health benefit plan.
(c) Ambulance services authorized or guaranteed for payment under this section for which the prior authorization is not rescinded or reversed under subsection (a) of this section are not subject to audit recoupment.
(d) A claim submitted by an ambulance provider shall include any information as required by the Insurance Commissioner.
Ark. Code Ann. § 23-99-1606 Enforcement — Rules.
(a) A contracting entity is subject to the Trade Practices Act, § 23-66-201 et seq.
(b) The expenses of implementing this subchapter shall not be used as justification to increase premiums or decrease payments to any ambulance provider or medical facility.
(c) The Insurance Commissioner may promulgate rules necessary to implement and enforce this subchapter.
Ark. Code Ann. § 23-99-1705 Claims.
(a) A contracting entity shall pay a claim for ambulance services for which prior authorization was received regardless of the terminology used by the transportation benefit manager or health benefit plan within thirty (30) days of receipt of the claim from an ambulance provider, unless:
(1) Authorized ambulance services were never performed; or
(2) There is specific information available for review by the appropriate state or federal agency that the subscriber or ambulance provider has engaged in material misrepresentation, fraud, or abuse regarding the claim for the authorized ambulance services.
(b) Ambulance services authorized or guaranteed for payment under this section for which the prior authorization is not rescinded or reversed under subsection (a) of this section are not subject to audit recoupment.
(c) A claim submitted by an ambulance provider shall include any information as required by the Insurance Commissioner.
Ark. Code Ann. § 23-99-1905 Wholesale and pharmacy services administrative organization services — Single pharmacy services administrative organization- pharmacy contract.
(a) A pharmacy services administrative organization that owns or is owned by, in whole or in part, an entity that manufactures, sells, or distributes prescription drugs, biologicals, or medical devices, as a condition of entering into a pharmacy services administrative organization- pharmacy contract, shall not require that the pharmacy purchase any drugs or medical devices solely from the entity with which the pharmacy services administrative organization has an ownership interest or from an entity with an ownership interest in the pharmacy services administrative organization.
(b) A pharmacy services administrative organization that owns or is owned by, in whole or in part, an entity that manufactures, sells, or distributes prescription drugs, biologicals, or medical devices shall disclose to the State Insurance Department any agreement with a pharmacy in which the pharmacy purchases prescription drugs, biologicals, or medical devices from a pharmacy services administrative organization or from an entity that owns or is owned by, in whole or in part, the pharmacy services administrative organization.
Ark. Code Ann. § 23-99-1906 Notice of appeals.
(a) A pharmacy services administrative organization-pharmacy contract shall provide that if there is a dispute between a pharmacy and a pharmacy benefits manager or a third-party payer, the pharmacy services administrative organization shall ensure and facilitate timely communication from the pharmacy to the pharmacy benefits manager or the third-party payer.
(b) A pharmacy services administrative organization-pharmacy contract shall provide that the pharmacy services administrative organization shall forward a notice of appeal from a pharmacy to the pharmacy benefits manager or the third-party payer in a timely manner.
(c) If an appeal does not meet the minimum requirements described in the pharmacy services administrative organization-pharmacy contract, the pharmacy services administrative organization shall:
(1) Provide the pharmacy with the reason for the denial of the appeal; and
(2) Allow the pharmacy to resubmit the appeal for a review by a pharmacy benefits manager.
(d) In connection with an appeal or similar process under § 17-92-507, a third-party payer's or pharmacy benefits manager’s notice or provision of information to a pharmacy services administrative organization is deemed to be notice or provision of information to the pharmacy on whose behalf the pharmacy services administrative organization has contracted.
Ark. Code Ann. § 23-99-1907 Enforcement.
(a) The Insurance Commissioner shall enforce this subchapter.
(b)(1) The commissioner may examine or audit the books and records of a pharmacy services administrative organization providing claims administrative services for a pharmacy to determine if the pharmacy services administrative organization is in compliance with this subchapter.
(2) The information or data acquired during an examination under subdivision (b)(1) of this section is:
(A) Considered proprietary and confidential under §§ 23-61-107(a)(4) and 23-61-207; and
(B) Not subject to the Freedom of Information Act of 1967, § 25-19-101 et seq.
(c) After notice and opportunity for hearing, the commissioner may:
(1) Impose a civil penalty of up to five thousand dollars ($5,000) per violation against a pharmacy services administrative organization if the commissioner finds that the pharmacy services administrative organization has violated this subchapter; or
(2) Revoke or suspend the license of a pharmacy services administrative organization.
Source: Public.Resource.Org / UniCourt, Official Code of Arkansas Annotated, Release 78 (2020) (unicourt.github.io/cic-code-ar)URL: https://unicourt.github.io/cic-code-ar/transforms/ar/ocar/r78/gov.ar.code.title.23.htmlFetched: 11/8/2026