Health Insurance Benefit Coverage Law Summaries
4-4000Arkansas, Health Insurance Benefit Coverage Law SummariesArkansas' mandated health care law is located in the Arkansas Code of 1987 Annotated at Title 23, Subtitle 3.
DEFINITIONS
"Children's preventive health care services" means physician-delivered or physician-supervised services for eligible dependents from birth through age 18, with periodic preventive care visits, including medical history, physical examination, developmental assessment, anticipatory guidance and appropriate immunizations and laboratory tests, in keeping with prevailing medical standards (Sec. 23-79-141, as amended by Act 685, L. 1995).
"Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date (Sec. 23-86-303, as added by Act 997 (H. 1715), L. 1997).
WHAT THE EMPLOYER MUST DO
Arkansas does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.
Mental health coverage. --Health benefit plans must provide medical coverage for the diagnosis and mental health treatment of mental illnesses and the mental health treatment of those with developmental disorders under the same terms and conditions provided for covered benefits offered under the plan for the treatment of other medical illnesses or conditions (Sec. 23-99-506, as added by H. 1525, L. 1997).
Outpatient services. --Notwithstanding any provisions of any individual or group disability insurance policy, or any provision of a policy, contract, plan, or agreement covering hospital or medical services, in cases where the policy, contract, plan, or agreement provides for payment or reimbursement for any health care service provided by hospitals or related facilities, the person entitled to payment or reimbursement or services under the policy, contract, plan, or agreement is entitled to payment or reimbursement on an equal basis for the service when the service is provided by facilities licensed by the state as outpatient psychiatric centers (Sec. 23-79-115).
Dependent care coverage. --Every disability insurance policy, contract, certificate, or health care plan sold, delivered, issued, or offered for sale, issue, or delivery in Arkansas, other than coverage limited to expenses from accidents or specified diseases, whether an individual or group policy, contract, certificate, or plan, that covers the insured and members of the insured's family, must include coverage for newborn infant children by the insured from the moment of birth. The coverage of newborn children must be the same as is provided for other members of the insured's family, and must include coverage for illness, injury, congenital defects, premature birth, and tests for hypothyroidism, phenylkaptonuria and galactosemia, and, in the case of non-Caucasian newborn infants, tests for sickle-cell anemia, as well as any testing of newborn infants hereafter mandated by law. Coverage must also be provided to pay for routine nursery care and pediatric charges for a well newborn child for up to five full days in a hospital nursery or until the mother is discharged from the hospital following the birth of the child, whichever is the lesser period of time (Sec. 23-79-129, as amended by Act 113, L. 1995).
No contract of individual or group health care coverage sold, delivered or issued for delivery, renewed, or offered for sale in Arkansas, directly or indirectly, by any insurer, health maintenance organization, self-funded group, multiple employer welfare arrangement, or hospital or medical services corporation may restrict or deny health care coverage due to the fact that a minor child does not reside with the noncustodial parent or that the parent-child relationship was established through a paternity action (Sec. 23-79-144).
Preventive care. --Every disability insurer, hospital or medical corporation, health maintenance organization, fraternal benefit society and self-insured plan transacting disability insurance or providing disability coverage in Arkansas that delivers, issues for delivery in Arkansas, or renews, extends or modifies disability policies, contracts, certificates, and plans providing hospital and medical coverage on an expense-incurred, service, or prepaid basis, which contracts provide coverage for a family member of the insured person, must provide to the contract holder coverage for periodic preventive care visits for covered persons from the moment of birth through the age of 18 (Sec. 23-79-141, as amended by Act 685, L. 1995).
Each disability insurance policy, contract, certificate, or plan providing benefits for children's preventive health care services on a periodic basis must include 20 visits at approximately the following age intervals: birth, two weeks, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, three years, four years, five years, six years, eight years, 10 years, 12 years, 14 years, 16 years, and 18 years (Sec. 23-79-141, as amended by Act 685, L. 1995).
Mandated children's preventive health care benefits must be reimbursed at levels established by the Insurance Commissioner, which may not exceed those established for the same services under the Medicaid program in Arkansas. Benefits for recommended immunization services are exempt from any copayment, coinsurance, deductible or dollar limit provisions in the health insurance policy (Sec. 23-79-141, as amended by Act 685, L. 1995).
Provisions for children's preventive health care do not apply to disability income, specified disease, Medicare supplement, hospital indemnity, or accident-only policies (Sec. 23-79-141, as amended by Act 685, L. 1995).
Disabilities. --In any group accident and health insurance policy that contains a provision whereby coverage of a dependent in a family group terminates at a specified age, there must also be a provision that coverage of an unmarried dependent who is incapable of sustaining employment by reason of mental retardation or physical disability, who became so incapacitated prior to the attainment of age 19 and who is chiefly dependent upon the employee for support and maintenance, must not terminate, but must continue so long as the coverage of the employee or member remains in force and so long as the dependent remains in such condition (Sec. 23-86-108, as amended by Act 1063 (S. 716), L. 2001).
Adoption. --Every disability insurance policy, self-insured health plan, hospital and medical service contract, contract, certificate, or health care plan sold, delivered, issued, or offered for sale, issue, or delivery in Arkansas, whether an individual or group policy, contract, or plan, that covers the insured and members of the insured's family, must include coverage for any minor under the charge, care, and control of the insured whom the insured has filed a petition to adopt. The coverage of the minor must be the same as provided for other members of the insured's family (Sec. 23-79-137).
Coverage must begin on the date of the filing of a petition for adoption if the insured applies for coverage within 60 days after the filing of the petition for adoption. However, coverage must begin from the moment of birth if the petition for adoption and application for coverage is filed within 60 days after the birth of the minor. Coverage terminates upon the dismissal or denial of a petition for adoption (Sec. 23-79-137).
Substance abuse coverage. --Every insurer, hospital and medical service corporation, and health maintenance organization transacting health, accident, or disability insurance in Arkansas must offer and make available under all group policies, contracts, and plans providing hospital and medical coverage on an expense-incurred, service, or prepaid basis benefits for the necessary care and treatment of alcohol and other drug dependency that are not less favorable than for physical illness generally, subject to the same durational limits, dollar limits, deductibles, and coinsurance factors, except as provided below (Sec. 23-79-139).
The offer for these benefits is subject to the right of the policy or contract holder to reject the coverage or select any alternative level of benefits (Sec. 23-79-139).
Facilities. --Any benefits provided under alcohol or drug dependency coverage must be determined as necessary care and treatment in an alcohol or drug dependency treatment facility or care and treatment in a hospital (Sec. 23-79-139).
The facility or unit may be (Sec. 23-79-139):
(1) a unit within a general hospital or an attached or freestanding unit of a general hospital;
(2) a unit within a psychiatric hospital or an attached or freestanding unit of a psychiatric hospital;
(3) a freestanding facility specializing in treatment of persons who are substance abusers or are alcohol or drug dependent, and may be identified as "chemical dependency, substance abuse, alcoholism, or drug abuse facilities," "social setting detoxification facilities," and "medical detoxification facilities," or by other names if the purpose is to provide treatment of alcohol or drug dependent or substance abusing persons, but may not include halfway houses or recovery farms.
Minimum benefits. --Every policy or contract of insurance that provides benefits for alcohol or drug dependency treatment and that provides total annual benefits for all illnesses in excess of $6,000 is subject to the following conditions (Sec. 23-79-139):
(1) The policy or contract must provide, for each 24-month period, a minimum benefit of $6,000 for the necessary care and treatment of alcohol or drug dependency.
(2) No more than one-half of the policy's or contract's maximum benefits for alcohol or drug dependency for a 24-month period may be paid for the necessary care and treatment of alcohol or drug dependency in any 30 consecutive day period.
(3) The policy or contract must provide a minimum benefit of $12,000 for the necessary care and treatment of alcohol or drug dependency for the life of the recipient of benefits.
Substance abuse coverage is not mandated for the following: blanket short-term travel accident only; limited or specified disease; conversion policies or contracts; policies or contracts referred to as Medicare supplement policies designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act (Sec. 23-79-139).
Coordination of benefits. --An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.
The following types of plans must specify how benefits will be coordinated: all major medical insurance policies, all catastrophic expense policies, all nonrenewable ticket disability policies, all group disability policies, including group contracts of hospital and medical service corporations, and certificates of group insurance covering Arkansas residents. Contracts of group insurance covering employees whose employer pays 100 percent of the premiums are exempt from these requirements (State of Arkansas Insurance Department Rule and Regulation 21, as authorized by Arkansas Code Annotated Secs. 23-85-132, 23-61-108, 23-86-111, and 25-15-201).
Order of benefits. --The following priority applies when coordinating health benefit payments (State of Arkansas Insurance Department Rule and Regulation 21):
(1) Employee/Dependent: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;
(2) Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one plan specifies the birthday rule and the other plan specifies priority based on the gender of the parent, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;
(3) Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent; and
(4) Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time.
Maintenance of benefits. --Benefits under all coverages may not be reduced below the lesser of 100 percent of allowable expenses or the maximum payable under all policies (State of Arkansas Insurance Department Rule and Regulation 21).
Required language. --Each certificate must contain a full explanation of the COB provision and display coordination of benefits with a page reference in the schedule.
Providers. --Nurse anesthetists. --Notwithstanding any provision of any individual or group policy of accident and health insurance, or any provision of a policy, contract, plan, or agreement for hospital or medical service or indemnity, in cases where the policy, contract, plan, or agreement provides for payment or reimbursement for any anesthesia services provided by persons licensed under the Arkansas Medical Practices Act, the person entitled to benefits or the persons providing services under the policy, contract, plan, or agreement are entitled to the same method of payment for the service when the service is provided by any person licensed as a certified registered nurse anesthetist and operating within his or her area of competence (Sec. 23-79-114).
Dentists. --Notwithstanding any provision of any health or accident insurance contract or any group disability insurance contract or blanket disability insurance contract, benefits must not be denied thereunder for any health service performed by any licensed dentist if the service performed was within the lawful scope of the person's license and the contract would have provided benefits if the service had been performed by a holder of a license issued pursuant to the provisions of the Arkansas Medical Practices Act (Sec. 23-79-114).
Psychologists. --Notwithstanding any provision of any individual or group policy of accident and health insurance, or any provision of a policy, contract, plan, or agreement for hospital or medical service or indemnity, in cases where the policy, contract, plan, or agreement provides for payment or reimbursement for any services consisting of psychological evaluation, counseling, psychotherapy, or related mental health services provided by persons licensed under the Arkansas Medical Practices Act, payment or reimbursement must be made on an equal basis for the service when it is provided by a licensed psychologist operating within his or her area of competence (Sec. 23-79-114).
Psychological examiners. --Every insurer or hospital and medical service corporation that issues a group disability insurance policy, contract or agreement in Arkansas providing for mental health coverage must offer coverage for the payment of services rendered by psychological examiners (Sec. 23-79-142).
Optometrists. --Notwithstanding any provision of any individual or group policy of accident and health insurance or any provision of a policy, contract, plan, or agreement for hospital or medical service or indemnity, wherever such policy, contract, plan, or agreement provides for payment or reimbursement for any service in the vision or human eye field provided by persons licensed in Arkansas as physicians or surgeons, the person entitled to benefits or the person performing services under such policy, contract, plan, or agreement is entitled to payment or reimbursement on an equal basis for such service when the said service is performed by any person licensed in Arkansas as an optometrist (Sec. 23-79-114).
Podiatrists. --Notwithstanding any provision of any individual or group policy of accident and health insurance or any provision of a policy, contract, plan, or agreement for hospital or medical service or indemnity, in cases where the policy, contract, plan, or agreement provides for payment or reimbursement for any services consisting of the diagnosis, medical, mechanical, or surgical treatment of ailments of the human foot provided by persons licensed in Arkansas as physicians or surgeons, the person entitled to benefits or person performing services under the policy, contract, plan, or agreement are entitled to payment or reimbursement on an equal basis for the service when the service is performed by any person licensed in Arkansas as a podiatrist (Sec. 23-79-114).
Preexisting conditions. --A group health plan and a health insurance issuer offering group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if (Sec. 23-86-304, as added by Act 997 (H. 1715), L. 1997):
(1) the exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment date;
(2) the exclusion extends for a period of not more than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and
(3) the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the participant or beneficiary as of the enrollment date.
Genetic information must not be treated as a preexisting condition in the absence of a diagnosis of the condition related to such information (Sec. 23-86-304, as added by Act 997 (H. 1715), L. 1997).
A group health plan and a health insurance issuer offering group health insurance coverage may not impose any preexisting condition exclusion in the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage. This does not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage (Sec. 23-86-304, as added by Act 997 (H. 1715), L. 1997).
A group health plan and a health insurance issuer offering group health insurance coverage may not impose any preexisting condition exclusion in the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This does not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage (Sec. 23-86-304, as added by Act 997 (H. 1715), L. 1997).
A group health plan and health insurance issuer offering group health insurance coverage may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition (Sec. 23-86-304, as added by Act 997 (H. 1715), L. 1997).
Pharmaceutical services. --Open choice. --A health insurance plan, policy, or health maintenance organization (other than an HMO that is both a state-certified and federally qualified and self-insured plan under the Employee Retirement Income Security Act of 1974 (ERISA)) that provides coverage for prescription drugs may not (Sec. 23-79-143):
(1) prohibit or limit in the state of Arkansas any person who is a participant or beneficiary of the policy or plan from selecting a pharmacy or pharmacist of his or her choice who has agreed to participate in the plan according to the terms offered by the insurer; or
(2) deny a pharmacy or pharmacist the right to participate as a contract provider under the policy or plan if the pharmacy or pharmacist agrees to provide pharmacy services, including but not limited to prescription drugs, that meet the terms and requirements set forth by the insurer under the policy or plan and agrees to the terms of reimbursement set forth by the insurer.
Health maintenance organizations that are both state-certified and federally qualified and self-insured plans under the Employee Retirement Income Security Act of 1974 (ERISA) are not covered by Arkansas' open-choice mandate for pharmaceutical services (Sec. 23-79-143).
Prescription drugs. --No insurance policy that provides coverage for prescription drugs may limit or exclude coverage for any drug approved by the United States Food and Drug Administration (FDA) for use in the treatment of cancer on the basis that the drug has not been approved by the FDA for the treatment of the specific type of cancer for which the drug has been prescribed, provided (Sec. 23-79-147, as amended by Act 466 (S. 151), L. 1999):
(1) the drug has been recognized as safe and effective for treatment of that specific type of cancer in any of the following standard reference compendia, unless the use is identified as not indicated in one or more such compendia: (a) the American Hospital Formulary Service drug information; (b) the United States Pharmacopoeia dispensing information; or
(2) the drug has been recognized as safe and effective for treatment of that specific type of cancer in two articles from medical literature that have not had their recognition of the drug's safety and effectiveness contradicted by clear and convincing evidence presented in another article from medical literature.
Contraceptive coverage. --Health benefit policies delivered, issued, executed, or renewed in Arkansas or approved for issuance or renewal in Arkansas by the Insurance Commissioner on or after August 12, 2005, that provide coverage for prescription drugs on an outpatient basis shall provide coverage for prescribed drugs or devices approved by the FDA for use as a contraceptive. Exceptions may be made for religious employers (Act 2217 (H. 2618), L. 2005).
Mammograms. --Every health insurance company, hospital service corporation, health maintenance organization, or other health insurance provider in Arkansas must, after January 1, 1990, offer, to each master group contract holder as an optional benefit, coverage for at least the following mammogram screening of occult breast cancer (Sec. 23-79-140, as amended by Act 508, L. 1995):
(1) a baseline mammogram for a woman covered by such policy who is 35 to 40 years of age;
(2) a mammogram for a woman covered by such policy who is 40 to 49 years of age, inclusive, every one to two years based on the recommendation of such woman's physician;
(3) a mammogram each year for a woman covered by such policy who is at least 50 years of age;
(4) upon recommendation of a woman's physician, without regard to age, where such woman has had a prior history of breast cancer or where such woman's mother or sister has had a history of breast cancer;
(5) insurance coverage for screening mammograms will not prejudice coverage for diagnostic mammograms as recommended by the woman's physician.
Insurers must pay not less than $50 for each screening mammogram, which includes payment for both the professional and technical components, and no insurer will pay for mammographies performed in an unaccredited facility after January 1, 1990 (Sec. 23-79-140, as amended by Act 508, L. 1995).
Mastectomies. --Health benefit plans providing mastectomy benefits will be required to conform with the mastectomy benefits requirements of the Women's Health and Cancer Rights Act of 1998, as it existed on January 1, 2003 (Sec. 23-99-405, as amended by Act 179 (H. 1280), L. 2003).
Maternity benefits. --A health care insurer may not restrict benefits for any hospital stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery or to less than 96 hours following cesarean section. This requirement does not apply if the decision to discharge the mother or her baby prior to the expiration of the minimum stay is made by the attending physician in consultation with the mother (Sec. 23-99-404).
Infertility. --All accident and health insurance companies doing business in Arkansas must include, as a covered expense, in vitro fertilization (Sec. 23-85-137; and Sec. 23-86-118, as amended by Act 1063 (S. 716), L. 2001).
Coverage must include services performed at a medical facility, licensed or certified by the Arkansas Department of Health, those performed at a facility certified by the Arkansas Department of Health that conforms to the American College of Obstetricians and Gynecologists' guidelines for in vitro fertilization clinics, or those performed at a facility certified by the Arkansas Department of Health that meets the American Fertility Society minimal standards for programs of in vitro fertilization. Continued certification requires that the facility is achieving a reasonable success rate with both fertilization and births (Sec. 23-85-137; and Sec. 23-86-118, as amended by Act 1063 (S. 716), L. 2001).
Phenylketonuria. --All health plans issued, delivered, amended or modified on or after January 1, 2000, must provide benefits for medical foods and low protein modified food products for the treatment of a covered person inflicted with phenylketonuria if (Sec. 23-79-703(a), as added by Act 1113 (H. 1183), L. 1999):
(1) the medical food or low protein modified food products are prescribed as medically necessary for the therapeutic treatment of phenylketonuria;
(2) the products are administered under the direction of a licensed physician; and
(3) the cost of the medical food or low protein modified food products for an individual or a family with a dependent person or persons exceeds the $2,400 per year, per person income tax credit allowed under Arkansas law.
Every health insurance policy, contract, certificate or health care plan issued in Arkansas by an insurance company, hospital medical service corporation, or HMO, other than coverage limited to expenses from accident only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income, or other limited benefit health insurance policies, whether an individual or group policy, contract, certificate or health care plan, which covers the insured and members of the insured's family, must provide coverage for amino acid modified preparations, low protein modified food products and any other special dietary products and formulas prescribed under the direction of a physician for the therapeutic treatment of phenylketonuria (Sec. 23-79-703(b), as amended by Act 1654 (S. 900), L. 2001).
Diabetes: Self-management training. --Health insurance policies must include coverage for one per lifetime training program per insured for diabetes self-management training when medically necessary as determined by a physician, and when provided by an appropriately licensed health care professional, who must certify that the insured has successfully completed the training (Sec. 23-79-602, as added by Act 1249 (H. 1797), L. 1997).
Also, health care insurers must offer additional diabetes self-management training in the event that a physician prescribes additional diabetes self-management training and it is medically necessary because of a significant change in the insured's symptoms or conditions (Sec. 23-79-602, as added by Act 1249 (H. 1797), L. 1997).
Equipment and supplies. --Health insurance policies must include medical coverage for medically necessary equipment, supplies and services for the treatment of Type I, Type II, and gestational diabetes, when prescribed by a licensed physician (Sec. 23-79-603, as added by Act 1249 (H. 1797), L. 1997).
Speech and hearing impairments. --Every insurer that offers for sale, issue, or delivery in Arkansas any group insurance policy, contract, plan, or agreement for health and accident or medical service or indemnity that covers the insured and members of the insured's family must offer coverage for the necessary care and treatment of loss or impairment of speech or hearing, subject to the same durational limits, dollar limits, deductibles, and coinsurance factors as other covered services in the policies or contracts. This additional coverage does not apply to hearing instruments or devices (Sec. 23-79-130).
TMJ coverage. --Every health carrier must offer optional coverage in its health care plans for the medical treatment of musculoskeletal disorders affecting any bone or joint in the face, neck or head, including temporomandibular joint disorder and craniomandibular disorder. Treatment must include both surgical and nonsurgical procedures. This coverage must be provided for medically necessary diagnosis and treatment of these conditions whether they are the result of accident, trauma, congenital defect, developmental defect, or pathology. This coverage must be the same as that provided for any other musculoskeletal disorder in the body and must be provided whether prescribed or administered by a physician or dentist. An insurer may include such coverage for any or all musculoskeletal disorders affecting any bone or joint in the face, neck or head as part of a policy's basic coverage, in lieu of offering optional coverage (Sec. 1, Act 1470 (H. 2363), L. 2001).
Outpatient services. --Notwithstanding any provisions of any individual or group disability insurance policy, or any provision of a policy, contract, plan, or agreement covering hospital or medical services, in cases where the policy, contract, plan, or agreement provides for payment or reimbursement for any health care service provided by hospitals or related facilities, the person entitled to payment or reimbursement for services under the policy, contract, plan, or agreement is entitled to payment or reimbursement on an equal basis for the service when the service is provided by facilities licensed by the state as outpatient surgery centers (Sec. 23-79-115).
No policy or contract of disability insurance, including contracts issued by hospital and medical service corporations, that provides coverage for any of the following services when delivered on an inpatient basis, may be sold, delivered, or issued for delivery or offered for sale in Arkansas unless the identical coverage for the following services is provided when delivered on an outpatient basis (Sec. 23-85-133):
(1) laboratory and pathological tests;
(2) X rays;
(3) chemotherapy;
(4) radiation treatment; and
(5) renal dialysis.
This mandate for the provision of the above outpatient services also applies to policies and contracts of group accident and health insurance, but such coverage is not required where any policyholder or contract holder rejects the coverage in writing (Sec. 23-86-108, as amended by Act 1063 (S. 716), L. 2001).
Psychiatric care. --Notwithstanding any provisions of any individual or group disability insurance policy, or any provision of a policy, contract, plan, or agreement covering hospital or medical services, in cases where the policy, contract, plan, or agreement provides for payment or reimbursement for any health care service provided by hospitals or related facilities, the person entitled to payment or reimbursement or services under the policy, contract, plan, or agreement is entitled to payment or reimbursement on an equal basis for the service when the service is provided by facilities licensed by the state as outpatient psychiatric centers (Sec. 23-79-115).
Minimum basic benefit policies. --"Minimum basic benefit policies" offered under the authority of Ch. 98 of Title 23 of the Arkansas Code must provide basic levels of primary, preventive, and hospital care, including, but not limited to, the following (Sec. 23-98-106, as amended by Act 1603 (H. 2405), L. 2001):
(1) Fifteen days of inpatient hospitalization coverage per policy year.
(2) As an option, prenatal care, including one prenatal office visit per month during the first two trimesters of pregnancy, two office visits per month during the seventh and eighth months of pregnancy, and one office visit per week during the ninth month until term. Coverage for each such visit must include necessary and appropriate screening, including history, physical examination, and such laboratory and diagnostic procedures as may be deemed appropriate by the physician based upon recognized medical criteria for the risk group of which the patient is a member. Coverage for each office visit must also include such prenatal counseling as the physician deems appropriate.
(3) As an option, obstetrical care, including physicians' services, delivery room, and other medically necessary hospital services.
(4) As an option, coverage for children's preventive health care services on a periodic basis from birth through age six, including 13 visits at approximately the following age intervals: birth, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, three years, four years, five years, and six years.
(5) A basic level of primary and preventive care, including two office visits per calendar year for covered services rendered by a provider licensed to provide the services rendered.
(6) Annual, lifetime, or other benefit limits in amounts not less than that which may be established by the Insurance Commissioner. When first established, limits cannot be not less than $100,000 as an annual benefit and $250,000 as a lifetime benefit.
Minimum basic benefit policies that cover the insured and members of the insured's family must include coverage for newborn infant children of the insured from the moment of birth, and for adopted minors from the date of the interlocutory decree of adoption. The coverage of newborn children or adopted children may not be less than the same as is provided for other members of the insured's family (Sec. 23-98-106, as amended by Act 1603 (H. 2405), L. 2001).
Arkansas Health Insurance Consumer Choice Act. --Every group accident and health insurer, hospital and medical service corporation, or HMO transacting health or accident and health insurance in Arkansas may offer as an option, a group health benefits plan that, either in whole or in part, does not provide state mandated health benefits on group health benefits plans under state law (Sec. 23-79-803, as amended by Act 1359 (H. 1344), L. 2003).
Small Employer Health Insurance Purchasing Group Act of 2001. --The state has passed a law providing purchasing groups for employers employing no more than 100 eligible employees (Act 925 (H. 1660), L. 2001).
Genetic Nondiscrimination in Insurance Act. --No insurer may, for the purpose of determining eligibility of any individual for any insurance coverage, terminating coverage or any other underwriting decision in connection with the offer, sale or renewal or continuation of a policy, except to the extent and in the same fashion as an insurer limits coverage, or increases premiums for loss caused or contributed to by other medical conditions presenting an increased degree of risk (Act 1221 (S. 763), L. 2001):
(1) require or request, directly or indirectly, any individual or a member of the individual's family to obtain a genetic test; and
(2) condition the provision of the policy upon a requirement that an individual take a genetic test.
Genetic Research Studies Nondisclosure Act. --The Genetic Research Studies Nondisclosure Act (Act 1251 (S. 764), L. 2001) provides that no research records of individual subjects in genetic research studies may be disclosed to employers or health insurers without the informed, written consent of the individual.
Colorectal Cancer Act of 2005. --The Colorectal Cancer Act of 2005, which takes effect August 1, 2005, will require employers that offer health care policies to their employees to offer all eligible employees at the time of hiring or policy renewal a policy that includes colorectal cancer exams and lab tests within the coverage of the employee's health care policy (Act 2236 (H. 2781), L. 2005, effective August 1, 2005).
Dental care. --Anesthesia. --Health benefit plans that are issued, renewed, extended or modified on and after January 1, 2006, shall provide coverage for payment of anesthesia and hospital or ambulatory surgical facility charges for services performed in connection with dental procedures in a hospital or ambulatory surgical facility, if the provider treating the patient certifies that, because of the patient's age or condition or problem, hospitalization or general anesthesia is required in order to safely and effectively perform the procedures and the patient is (Sec. 23-86-121, as added by Act 439 (H. 1452), L. 2005):
(1) A child under seven years of age who is determined by two dentists to require, without delay, necessary dental treatment in a hospital or ambulatory surgical center for a significantly complex dental condition;
(2) A person with a diagnosed serious mental or physical condition; or
(3) A person with a significant behavioral problem.
ENFORCEMENT
The Insurance Commission enforces Arkansas' mandated health care law.
WHO TO CONTACT
Contact the Insurance Commission at 1123 S. University Ave., University Tower Building Suite 400, Little Rock, AR 72204-1699. Telephone: (501) 686-2909. Fax: (501) 686-2913.
/resources/state_laws/arkansas/arkansas_health_insurance_benefit_coverage_law_summaries.aspx