2019 Arkansas Code
Title 23 - Public Utilities and Regulated Industries
Subtitle 3 - Insurance
Chapter 99 - Healthcare Providers
Subchapter 12 - Healthcare Contracting Simplification Act
§ 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 nonfederal governmental plans as defined in 29 U.S.C. § 1002(32), as it existed on January 1, 2019.
(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;
(x) A dental-only plan; or
(xi) A vision-only plan;
(5) “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;
(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; and
(v) A sponsor of a nonfederal self-funded governmental plan;
(7) “Healthcare provider” means a person or entity that is licensed, certified, or otherwise authorized by the laws of this state to provide healthcare services;
(8) “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;
(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.
