For purposes of this part:

1. (1) “Accredited health carrier" means a health carrier that has an adequate network as certified by an approved accrediting organization under the provisions of 23 CAR § 137-104(k);
2. (2) "Commissioner" means the Insurance Commissioner;
3. (3) "Covered benefits" or "benefits" means those healthcare services to which a covered person is entitled under the terms of a health benefit plan;
4. (4) "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;

5. (5) "Dental benefits" means benefits for dental services embedded in, or offered by, a rider attached to:

   1. (A) A QHP offered through the Affordable Care Act-approved marketplace; or
   2. (B) An Affordable Care Act-compliant nongrandfathered plan;

6. (6) "Emergency medical condition" means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would:

   1. (A) Result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part; or
   2. (B) Place the person's health in serious jeopardy;
7. (7) "Emergency services" means healthcare items and services furnished or required to evaluate and treat an emergency medical condition;
8. (8) "Essential community provider" means a provider that serves predominantly low-income, medically underserved individuals as defined in 45 C.F.R. § 156.235;

9. (9) "Facility" means an institution providing healthcare services or a healthcare setting, including, but not limited to:

   1. (A) Hospitals and other licensed inpatient centers;
   2. (B) Ambulatory surgical or treatment centers;
   3. (C) Skilled nursing centers;
   4. (D) Residential treatment centers;
   5. (E) Diagnostic, laboratory, and imaging centers; and
   6. (F) Rehabilitations and other therapeutic health settings;

10. (10)

    1. (A) "Health benefit plan" means any individual, blanket, or group plan, policy, or contract for healthcare services issued or renewed by a health carrier on or after January 1, 2015, that requires a covered person to use healthcare providers managed, owned, under contract with, or employed by the health carrier.
    2. (B) "Health benefit plan" does not include a plan providing healthcare services pursuant to the Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, Arkansas Code § 11-9-101 et seq., and the Public Employee Workers' Compensation Act, Arkansas Code § 21-5-601 et seq., nor include an accident-only, specified disease, hospital indemnity, long-term care, disability income, or limited-benefit health insurance policy.
    3. (C) The provisions of this part also do not apply to Medicare Supplement or Medicare Advantage policies.
    4. (D) This part applies to dental benefits as defined in subdivision (5) of this section and vision benefits as defined in subdivision (25) of this section, as well as plans offered by standalone dental carriers as defined in subdivision (23) of this section;

11. (11)

    1. (A) "Health carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the Insurance Commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including:

       1. (i) A health insurer;
       2. (ii) A health maintenance organization;
       3. (iii) A hospital and medical service corporation; or
       4. (iv) Any other entity providing health benefit plans.
    2. (B) A “health carrier” does not include an automobile insurer paying medical or hospital benefits under Arkansas Code § 23-89-202(1) nor shall it include a self-insured employer health benefits plan.
    3. (C) A “health carrier” does not include any person, company, or organization, licensed or registered to issue or who issues any insurance policy or insurance contract in this state providing medical or hospital benefits for accidental injury or accidental disability.
    4. (D) A “health carrier” shall include an entity that provides dental and/or vision benefits as defined in subdivision (5) of this section and subdivision (25) of this section, respectively, or is a standalone dental carrier as defined by subdivision (23) of this section;
12. (12) "Healthcare professional" means a physician or other healthcare practitioner licensed, accredited, or certified to perform physical, behavioral, mental health, or substance use disorder and health services consistent with state law;
13. (13) "Healthcare provider" or "provider" means a participating healthcare or dental professional or a facility;

14. (14) "Healthcare services" means services for the diagnosis, prevention, treatment, cure, or relief of:

    1. (A) A health condition;
    2. (B) An illness;
    3. (C) An injury; or
    4. (D) A disease;

15. (15)

    1. (A) "Network" means the collection of all participating providers providing services to a health benefit plan.
    2. (B) The network associated with a health benefit plan should be identifiable using a suitable network ID, and one (1) health benefit plan can have only one (1) such network ID;

16. (16)

    1. (A) “Patient-centered medical home (PCMH)” means a local point of access to care that proactively looks after patients' health on a twenty-four-hours-per-day, seven-days-per-week basis.
    2. (B) A PCMH supports patients to connect with other providers to form a health services team, customized for their patients' care needs with a focus on prevention and management of chronic disease through monitoring patient progress and coordination of care;

17. (17) "Person" means:

    1. (A) An individual;
    2. (B) A corporation;
    3. (C) A partnership;
    4. (D) An association;
    5. (E) A joint venture;
    6. (F) A joint stock company;
    7. (G) A trust;
    8. (H) An unincorporated organization;
    9. (I) Any similar entity; or
    10. (J) Any combination of the foregoing;
18. (18) "Primary care professional" means a participating healthcare professional practicing within their licensed scope of practice and designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of healthcare services rendered to the covered person;
19. (19) "Provider" means a provider who, under a contract with a health carrier or with its contractor or subcontractor, 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 health carrier;
20. (20) "Qualified health plan" means an insurance policy that meets the requirements of 42 U.S.C. § 18021(a)(1);

21. (21)

    1. (A) "Service area" means the collection of counties serviced by a health benefit plan.
    2. (B) Counties may be grouped into larger aggregations called health rating areas, and a health benefit plan is required to cover at least one (1) health rating area.
    3. (C) The aggregation of counties is published in the annual bulletin setting forth requirements for Affordable Care Act submissions;

22. (22) "Specialty care professional" means a participating healthcare professional that is specially qualified to practice by having:

    1. (A) Attended an advanced program of study;
    2. (B) Passed an examination given by an organization of the members of the specialty; or
    3. (C) Gained experience through extensive practice in the specialty;
23. (23) "Standalone dental carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the Insurance Commissioner, that offers plans through the Affordable Care Act-approved marketplace and/or offers plans outside the Affordable Care Act-approved marketplace for the purpose of providing the essential health benefits category of pediatric-level oral benefits;
24. (24) "Telemedicine" means the use of electronic information and communication technology to deliver healthcare services, including without limitation the assessment, diagnosis, consultation, treatment, education, care management, and self­management of a patient, as well as store-and-forward technology and remote patient monitoring; and

25. (25) "Vision benefits" means benefits for vision services embedded in, or offered by a rider attached to, a QHP offered through:

    1. (A) The Affordable Care Act-approved marketplace; or
    2. (B) An Affordable Care Act-compliant nongrandfathered plan.

Codification Notes: “QHP” means qualified health plan.