As used in this part:

1. (1) “ADHS” means the Department of Human Services;

2. (2) "Associated participant" means an organization or individual that is a member or contractor of a risk-based provider organization and provides necessary administrative functions, including without limitation:

   1. (A) Claims processing;
   2. (B) Data collection; and
   3. (C) Outcome reporting;
3. (3) "Capitated" means an actuarially sound healthcare payment that is based on a payment per person that covers the total risk for providing healthcare services as provided in the Medicaid Provider-Led Organized Care Act, Arkansas Code § 20-77-2701 et seq., for a person;

4. (4)

   1. (A) "Care coordination" means the coordination of healthcare services delivered by healthcare provider teams to:

      1. (i) Empower patients in their health care; and
      2. (ii) Improve the efficiency and effectiveness of the healthcare sector.

   2. (B) "Care coordination" includes without limitation:

      1. (i) Health education and coaching;
      2. (ii) Promoting linkages with medical home services and the healthcare system in general;

      3. (iii) Coordination with other healthcare providers for:

         1. (a) (a) Diagnostics;
         2. (b) (b) Ambulatory care; and
      4. (c) (c) Hospital services;
      5. (iv) Assistance with social determinants of health, such as access to healthy food and exercise;

      6. (v) Promotion of activities focused on the health of a patient and the community, including without limitation:

         1. (a) (a) Outreach;
         2. (b) (b) Quality improvement; and
      7. (c) (c) Patient panel management; and
      8. (vi) Community-based management of medication therapy;

5. (5) "Carrier" means an organization that is:

   1. (A) Licensed or otherwise authorized to provide health insurance or health benefit plans under Arkansas Code § 23-85-101 or Arkansas Code § 23-76-101:
   2. (B) Licensed or otherwise authorized to transact health insurance as an insurance company under Arkansas Code § 23-62-103;
   3. (C) Authorized to provide healthcare plans under Arkansas Code § 23-76-108 as a health maintenance organization; or
   4. (D) Authorized to issue hospital service or medical service plans as a hospital medical service corporation under Arkansas Code § 23-75-108;
6. (6) “Commissioner” means the Insurance Commissioner;

7. (7)

   1. (A) "Covered Medicaid beneficiary population" means a group of individuals with:

      1. (i) Significant behavioral health needs, including substance abuse treatment and services, and who are eligible for participation in the Medicaid provider-led organized care system as determined by an independent assessment under criteria established by the Department of Human Services; or
      2. (ii) Intellectual or developmental disabilities who are eligible for participation in the Medicaid provider-led organized care system as determined by an independent assessment under criteria established by the Department of Human Services.
   2. (B) “Covered Medicaid beneficiary population” does not include individuals enrolled in any long-term services and supports program under 42 U.S.C. § 1396n or 42 U.S.C. § 1315 by reason of a physical functional limitation;
8. (8) “Department” means the State Insurance Department;
9. (9) "Direct service provider" means an organization or individual that delivers healthcare services to enrollable Medicaid beneficiary populations;

10. (10) “Enrollable Medicaid beneficiary population” means a group of individuals who are either:

    1. (A) Members of a covered Medicaid beneficiary population; or
    2. (B) Members of a voluntary Medicaid beneficiary population;
11. (11) "Flexible services" means alternative services that are not included in the state plan or waiver of the Arkansas Medicaid Program and that are appropriate and cost-effective services that improve the health or social determinants of a member of an enrollable Medicaid beneficiary population that affect the health of the member of an enrollable Medicaid beneficiary population;
12. (12) "Global payment" means a population-based payment methodology that is actuarially sound and based on an all-inclusive per-person-per-month calculation for all benefits, administration, care management, and care coordination for enrollable Medicaid beneficiary populations;
13. (13) "Medicaid" means the programs authorized under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., and Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq., as they existed on January 1, 2017, for the provision of healthcare services to members of enrollable Medicaid beneficiary populations;
14. (14) “NAIC” means the National Association of Insurance Commissioners;
15. (15) "Participating provider" means an organization or individual that is a member of or has an ownership interest in a risk-based provider organization and delivers healthcare services to enrollable Medicaid beneficiary populations;
16. (16) "Quality incentive pool" means a funding source established and maintained by the Department of Human Services to be used to reward risk-based provider organizations that meet or exceed specific performance and outcome measures;

17. (17)

    1. (A) "Risk assumption" or "risk sharing" means, for the purpose of this part, a transaction whereby the chance of loss, including the expenses for the delivery of service, with respect to the health care of a person, is transferred to or shared with another entity, in return for a consideration.
    2. (B) Examples include, but are not limited to, full or partial capitation agreements, withholds, risk corridors, and indemnity agreements;
18. (18) "Risk-based capital" means the “RBC level” defined under Arkansas Code § 23-63-1501(8);

19. (19) "Risk-based provider organization" means an entity that:

    1. (A)

       1. (i) Is licensed by the Insurance Commissioner under this part.
       2. (ii) Notwithstanding any other provision of law, a risk-based provider organization is an insurance company upon licensure by the commissioner.
       3. (iii) The commissioner shall not license a risk-based provider organization except as provided under the Medicaid Provider-Led Organized Care Act;
    2. (B) Is obligated to assume the financial risk for the delivery of specifically defined healthcare services to an enrollable Medicaid beneficiary population; and
    3. (C) Is paid by the Department of Human Services on a capitated basis with a global payment made, whether or not a particular member of an enrollable Medicaid beneficiary population receives services during the period covered by the payment; and

20. (20) “Voluntary Medicaid beneficiary populations” means individuals who:

    1. (A) Are in need of behavioral health services or developmental disabilities services;
    2. (B) Are not otherwise excluded in the Medicaid Provider-Led Organized Care Act;
    3. (C) Are eligible for Medicaid; and
    4. (D) May elect to enroll in a risk-based provider organization.