20-77-2703. Definitions.

20-77-2703. Definitions. As used in this subchapter: (1) “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 claims processing, data collection, and outcome reporting; (2) “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 this subchapter for a person; (3)(A) “Care coordination” means the coordination of healthcare services delivered by healthcare provider teams to empower patients in their health care and to improve the efficiency and effectiveness of the healthcare sector. (B) “Care coordination” includes without limitation: (i) Health education and coaching; (ii) Promotion of links with medical home services and the healthcare system in general; (iii) Coordination with other healthcare providers for diagnostics, ambulatory care, and hospital services; (iv) Assistance with social determinants of health, such as access to healthy food and exercise; (v) Promotion of activities focused on the health of a patient and the community, including without limitation outreach, quality improvement, and patient panel management; and (vi) Community-based management of medication therapy; (4) “Carrier” means an organization that is: (A) Licensed or otherwise authorized to transact health insurance as an insurance company under § 23-62-103; (B) Authorized to provide healthcare plans under § 23-76-108 as a health maintenance organization; or (C) Authorized to issue hospital service or medical service plans as a hospital medical service corporation under § 23-75-108; (5)(A) “Covered Medicaid beneficiary population” means a group of individuals with: (i) Significant behavioral health needs, including for 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 (ii) Intellectual or developmental disabilities 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. (B) “Covered Medicaid beneficiary population” does not include individuals enrolled in a long-term care services and supports program under 42 U.S.C. § 1396n or 42 U.S.C. § 1315, due to a physical functional limitation; (6) “Direct service provider” means an organization or individual that delivers healthcare services to enrollable Medicaid beneficiary populations; (7) “Enrollable Medicaid beneficiary population” means a group of individuals who are either: (A) Members of a covered Medicaid beneficiary population; or (B) Members of a voluntary Medicaid beneficiary population; (8) “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 the enrollable Medicaid beneficiary population; (9) “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; (10) “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; (11) “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; (12) “Quality incentive pool” means a funding source established and maintained by the department to be used to reward risk-based provider organizations that meet or exceed specific performance and outcome measures; (13) “Risk-based provider organization” means an entity that: (A)(i) Is licensed by the Insurance Commissioner under the rules established for risk-based provider organizations by the commissioner. (ii) Notwithstanding any other provision of law, a risk-based provider organization is an insurance company upon licensure by the commissioner but is not deemed an insurer for purposes of the Arkansas Life and Health Insurance Guaranty Association Act, § 23-96-101 et seq. (iii) The commissioner shall not license a risk-based provider organization except as provided in this subchapter; (B) Is obligated to assume the financial risk for the delivery of specifically defined healthcare services to an enrollable Medicaid beneficiary population; and (C) Is paid by the department 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 (14) “Voluntary Medicaid beneficiary population” means a group of individuals who: (A) Are in need of behavioral health services or developmental disabilities services; (B) Are eligible for the Arkansas Medicaid Program; and (C) May elect to enroll in a risk-based provider organization if the group is not otherwise excluded by this subchapter.