(a) Insurance coverage for a member enrolled in an individual qualified health insurance plan shall be obtained, at a minimum, through silver-level metallic plans as provided in 42 U.S.C. § 18022(d) and 42 U.S.C. § 18071, as they existed on January 1, 2025, that restrict out-of-pocket costs to amounts that do not exceed applicable out-of-pocket cost limitations.
(b) As provided under § 23-61-1004(e)(2), health insurers shall track the applicable premium payments and cost sharing collected from members to ensure that the total amount of an individual's payments for premiums and cost sharing does not exceed the aggregate cap imposed by 42 C.F.R. § 447.56.
(c) All health benefit plans purchased by the Department of Human Services shall:(1) Conform to the requirements of this section and applicable insurance rules;(2) Be certified by the State Insurance Department;(3) (A) Maintain a medical-loss ratio of at least eighty-five percent (85%) for an individual qualified health insurance plan as permitted under 45 C.F.R. § 158.211, as it existed on January 1, 2025, or rebate the difference between the health insurer's actual medical-loss ratio and eighty-five percent (85%) to the Department of Human Services for members.(B) However, the Department of Human Services may approve up to one percent (1%) of revenues as community investments and as benefit expenses in calculating the medical-loss ratio of a plan in accordance with 45 C.F.R. § 158.150;(4) Develop:(A) An annual quality assessment and performance improvement strategic plan to be approved by the Department of Human Services that aligns with federal quality improvement initiatives and quality and reporting requirements of the Department of Human Services; and(B) Targeted initiatives based on requirements established by the Department of Human Services in consultation with the Department of Health; and(5) Make reports to the Department of Human Services regarding quality and performance metrics in a manner and frequency established by a memorandum of understanding.
(1) Conform to the requirements of this section and applicable insurance rules;
(2) Be certified by the State Insurance Department;
(3) (A) Maintain a medical-loss ratio of at least eighty-five percent (85%) for an individual qualified health insurance plan as permitted under 45 C.F.R. § 158.211, as it existed on January 1, 2025, or rebate the difference between the health insurer's actual medical-loss ratio and eighty-five percent (85%) to the Department of Human Services for members.(B) However, the Department of Human Services may approve up to one percent (1%) of revenues as community investments and as benefit expenses in calculating the medical-loss ratio of a plan in accordance with 45 C.F.R. § 158.150;
(A) Maintain a medical-loss ratio of at least eighty-five percent (85%) for an individual qualified health insurance plan as permitted under 45 C.F.R. § 158.211, as it existed on January 1, 2025, or rebate the difference between the health insurer's actual medical-loss ratio and eighty-five percent (85%) to the Department of Human Services for members.
(B) However, the Department of Human Services may approve up to one percent (1%) of revenues as community investments and as benefit expenses in calculating the medical-loss ratio of a plan in accordance with 45 C.F.R. § 158.150;
(4) Develop:(A) An annual quality assessment and performance improvement strategic plan to be approved by the Department of Human Services that aligns with federal quality improvement initiatives and quality and reporting requirements of the Department of Human Services; and(B) Targeted initiatives based on requirements established by the Department of Human Services in consultation with the Department of Health; and
(A) An annual quality assessment and performance improvement strategic plan to be approved by the Department of Human Services that aligns with federal quality improvement initiatives and quality and reporting requirements of the Department of Human Services; and
(B) Targeted initiatives based on requirements established by the Department of Human Services in consultation with the Department of Health; and
(5) Make reports to the Department of Human Services regarding quality and performance metrics in a manner and frequency established by a memorandum of understanding.
(d) A health insurer offering individual qualified health insurance plans for members shall participate in the Arkansas Patient-Centered Medical Home Program, including:(1) Attributing enrollees in individual qualified health insurance plans, including members, to a primary care physician;(2) Providing financial support to patient-centered medical homes to meet practice transformation milestones; and(3) Supplying clinical performance data to patient-centered medical homes, including data to enable patient-centered medical homes to assess the relative cost and quality of healthcare providers to whom patient-centered medical homes refer patients.
(1) Attributing enrollees in individual qualified health insurance plans, including members, to a primary care physician;
(2) Providing financial support to patient-centered medical homes to meet practice transformation milestones; and
(3) Supplying clinical performance data to patient-centered medical homes, including data to enable patient-centered medical homes to assess the relative cost and quality of healthcare providers to whom patient-centered medical homes refer patients.
(e) (1) Each individual qualified health insurance plan shall provide for a health improvement initiative, subject to the review and approval of the Department of Human Services, to provide incentives to its enrolled members to participate in one (1) or more health improvement initiatives as defined in § 23-61-1003(9).(2) (A) The Department of Human Services shall work with health insurers offering individual qualified health insurance plans to ensure the economic independence initiative offered by the health insurer includes a robust outreach and communications effort which targets specific health, education, training, employment, and other opportunities appropriate for its enrolled members.(B) The outreach and communications effort shall recognize that enrolled members receive information from multiple channels, including without limitation:(i) Community service organizations;(ii) Local community outreach partners;(iii) Email;(iv) Radio;(v) Religious organizations;(vi) Social media;(vii) Television;(viii) Text message; and(ix) Traditional methods such as newspaper or mail.
(1) Each individual qualified health insurance plan shall provide for a health improvement initiative, subject to the review and approval of the Department of Human Services, to provide incentives to its enrolled members to participate in one (1) or more health improvement initiatives as defined in § 23-61-1003(9).
(2) (A) The Department of Human Services shall work with health insurers offering individual qualified health insurance plans to ensure the economic independence initiative offered by the health insurer includes a robust outreach and communications effort which targets specific health, education, training, employment, and other opportunities appropriate for its enrolled members.(B) The outreach and communications effort shall recognize that enrolled members receive information from multiple channels, including without limitation:(i) Community service organizations;(ii) Local community outreach partners;(iii) Email;(iv) Radio;(v) Religious organizations;(vi) Social media;(vii) Television;(viii) Text message; and(ix) Traditional methods such as newspaper or mail.
(A) The Department of Human Services shall work with health insurers offering individual qualified health insurance plans to ensure the economic independence initiative offered by the health insurer includes a robust outreach and communications effort which targets specific health, education, training, employment, and other opportunities appropriate for its enrolled members.
(B) The outreach and communications effort shall recognize that enrolled members receive information from multiple channels, including without limitation:(i) Community service organizations;(ii) Local community outreach partners;(iii) Email;(iv) Radio;(v) Religious organizations;(vi) Social media;(vii) Television;(viii) Text message; and(ix) Traditional methods such as newspaper or mail.
(i) Community service organizations;
(ii) Local community outreach partners;
(iii) Email;
(iv) Radio;
(v) Religious organizations;
(vi) Social media;
(vii) Television;
(viii) Text message; and
(ix) Traditional methods such as newspaper or mail.
(f) On or before January 1, 2022, the State Insurance Department and the Department of Human Services may implement through certification requirements or rule, or both, the applicable provisions of this section.