Current through Register Vol. 49, No. 9, September, 2024
Section 1.
Authority
This Rule is issued pursuant to Section One of Act 1498 of 2013
of the Arkansas Eighty-Ninth General Assembly, also known as the "Health Care
Independence Act of 2013" (hereafter, the "Health Care Independence Program,"
or "HCIP"), now codified in Ark. Code Ann. §§
20-77-2401
et seq. Pursuant to Ark. Code Ann. §
20-77-2405(g)(l)
and Ark. Code Ann. §
20-77-2406(e),
the Arkansas Insurance Department ("AID") and Arkansas Department of Human
Services ("ADHS") are authorized to issue Rules to implement provisions under
HCIP. In addition, this Rule is issued pursuant to Ark. Code Ann. §
23-61-108(b)(l)
which states that the Arkansas Insurance Commissioner ("Commissioner") has
authority to promulgate rules and regulations necessary for the effective
regulation of the business of insurance.
Section 2.
Purpose
The purpose of this Rule is to provide standards for
patient-centered medical home ("PCMH") programs for Health Carriers in the
Health Insurance Marketplace which issue Qualified Health Plans ("QHPs") on or
after January 1,2015.
Section
3.
Applicability & Scope
This Rule applies to all Health Carriers issuing QHPs in the
Health Insurance Marketplace on or after January 1,2015. Under Ark. Code Ann.
§
20-77-2406(d),
Health Carriers participating in the Health Insurance Marketplace are required
to participate in the Arkansas Payment Improvement Initiative ("APII")
including:
(1) Assignment of primary
care clinician;
(2) Support for
patient-centered medical home; and
(3) Access of clinical performance data for
providers. The HOP requires Health Carriers to participate in the APII as
multi-payer participants. This Rule requires Health Carriers to participate in
PCMH standards as one active or available option in QHP networks on or after
January 1,2015. Additionally, these standards set a floor for participation and
do not preclude Health Carriers from developing and implementing standards that
exceed the requirements set forth in this Rule.
Section 4.
Definitions
The following definitions shall apply in this Rule, unless
otherwise defined by HCIP:
(1) "ADHS"
means the Arkansas Department of Human Services;
(2) "AID" means the Arkansas Insurance
Department;
(3) "APII" means the
Arkansas Payment Improvement Initiative, as referenced in Ark. Code Ann. §
20-77-2406(d),
which is a multi-payer program that connects medical payment to medical
providers to achieve high quality care at an appropriate cost;
(4) "Arkansas PCMH Model" means the
provisions in Section 200 of the Arkansas Medicaid PCMH Provider
Manual;
(5) "DMS" means the
Division of Medical Services under ADHS;
(6) "HCIP" means the Program established
under Act 1498 of 2013 by the Arkansas State Legislature known as the "Health
Care Independence Act of 2013";
(7)
"Health Carrier" means a private entity certified by AID and offering plans
through the Health Insurance Marketplace;
(8) "Healthcare coverage" shall mean
healthcare benefits as defined under Ark. Code Ann. §
20-77-2404(4);
(9) "Health Insurance Marketplace" means the
marketplace as defined by Ark. Code Ann. §
20-77-2404(5);
(10) "Qualified Health Plan" means an AID
certified individual health insurance plan offered by a Health Carrier through
the Health Insurance Marketplace;
(11) "QHP Enrollee" means a person insured
under a Qualified Health Plan;
(12)
"Patient Centered Medical Home" ("PCMH") means a "Patient Centered Medical
Home" as defined under Section 200 of the Arkansas Medicaid PCMH Provider
Manual.
(13) "Primary Care
Physician" means a "Primary Care Physician" as defined under Section 171 of the
Arkansas Medicaid PCMH Provider Manual.
Section 5.
Requirements
For QHPs issued on or after January 1,2015, Health Carriers shall
adopt the following requirements and provide the opportunity for primary care
physicians eligible to participate in the Arkansas PCMH model to participate in
a PCMH program according to these standards:
(a) A Health Carrier shall follow the
requirements of the Arkansas PCMH Model or may develop its own PCMH standards
based upon an accepted national PCMH model, as approved by the Commissioner, to
the extent that such provisions are consistent with and not in conflict with
this Rule or the Arkansas PCMH Model.
(b) Health Carriers will prospectively
attribute QHP enrollees to primary care practices either based on enrollee
choice or according to the plurality of professional visits for primary care
evaluation and management paid by the Health Carrier over the prior year.
Health Carriers may develop their own method for attributing enrollees for whom
coverage was discontinuous during the prior year. Health Carriers must
attribute QHP enrollees on at least a quarterly basis and provide AID with
access to timely and sufficient data upon request to complete an audit of
Health Carriers' attribution process and to ensure appropriate QHP enrollee
attribution;
(c) Notwithstanding
the PCMH Model chosen by the Health Carrier in Section Five (5) (a) of this
Rule, Health Carriers will offer practice support to primary care physician
practices that have been identified by Medicaid as participating in the
Arkansas PCMH model through the APII. Health Carriers may identify additional
PCMH participants with at least three hundred (300) enrollees for inclusion in
the Arkansas PCMH Model. Practice support will be provided in the form of care
coordination payments equivalent to or greater than an average of five dollars
($5.00) per enrollee per month. Health Carriers may use a risk adjustment
method of their choosing for determining the actual payment, so long as the
average payment per enrollee is no less than five dollars ($5.00) per
month;
(d) Health Carriers may
terminate payment of practice support for a primary care physician's failure to
meet milestones or deadlines for practice transformation activities and
benchmarks or targets for clinical quality. In order to minimize provider
administrative burden and encourage meaningful data reporting, quality metrics
collected and reported by Health Carriers must incorporate Arkansas PCMH model
requirements;
(e) Health Carriers
shall provide performance reports for PCMH practice transformation and quality
on a quarterly basis. A standardized report form shall be made available to
Health Carriers from the Arkansas Health Care Payment Improvement Initiative
Web Site (www.pavmentinitiative.orgl and reporting should include total cost of
patient care and care categories (not shown in referenced report);
(f) Health Carriers shall share statistics
with AID or its designee(s) (output of analyzed claims data used to create
above reports) for streamlined provider use at an aggregate multi-payer
level;
(g) On or after January 1,
2016, Health Carriers should expect to participate in development of mechanisms
to share savings with PCMH practices for achieving a per issuer enrollee cost
of care that is below its benchmark cost.
(h) Health Carriers shall educate QHP
enrollees about the Health Carrier's PCMH program and indicate which practices
are participating in the program.
Section 6.
Enforcement
AID shall review a Health Carrier's compliance with the
provisions of this Rule in its role of recommending approval or non-approval
for certification of qualified health plans sold in the Health Insurance
Marketplace.
Section 7.
Effective Date
The effective date of this Rule shall be January 1,
2015.
