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Arkansas Code Title 23. Public Utilities and Regulated Industries § 23-99-1503. Determination of best interest for enrollee--Billing decision

Current as of March 28, 2024 | Updated by FindLaw Staff

(a) A healthcare provider that provides healthcare services and prescribes prescription medication to an enrollee may make a determination that it is in the best interest of the enrollee to bill the enrollee's:

(1) Healthcare payor; or

(2) Pharmacy benefits carrier.

(b) Every health benefit plan that is issued, renewed, delivered, or extended in this state and every group health benefit plan that is issued, renewed, delivered, or extended outside this state, for an enrollee who is a resident of this state that provides coverage for prescription medication shall allow a healthcare provider to make any appropriate billing decisions concerning healthcare services and administering of prescription medication that is in the best interest of the enrollee.

(c) A healthcare payor shall not require an enrollee to self-administer prescription medication if a healthcare provider determines it is in the best interest of the enrollee for a prescription medication to be administered by a healthcare provider regardless of the formulation or benefit category determination by the health benefit plan.

(d)(1) If a determination is made by a healthcare provider that it is in the enrollee's best interest for the healthcare provider to administer any prescription medication that is ordinarily covered by the healthcare payor regardless of the benefit category determination by the health benefit plan, then a healthcare payor shall reimburse for the cost and administration of the prescription medication through the medical benefit or pharmacy benefit based on the decision of the healthcare provider in consultation with the enrollee.

(2) The healthcare payor shall not impose financial penalties, copayments, coinsurance, or deductibles beyond the ordinary terms required through the enrollee's medical benefit or pharmacy benefit.

(3) This subsection does not apply to:

(A) A risk-based provider organization as established under the Medicaid Provider-Led Organized Care Act, § 20-77-2701 et seq.; or

(B) An individual qualified health insurance plan under the Arkansas Health and Opportunity for Me Act of 2021, § 23-61-1001 et seq.

(e) This section applies to an enrollee who is being evaluated or treated for:

(1) A hematology diagnosis;

(2) An oncology diagnosis; or

(3) Additional disease states or diagnoses that the Insurance Commissioner may include through the promulgation of rules.

(f) This section shall not:

(1) Interfere with the ability of a healthcare payor to create, modify, or maintain a prescription medication formulary; or

(2) Apply to a solid oral dosages form of a prescription medication unless the medication:

(A) Is an oral anticancer prescription medication;

(B) An oral antiemetic prescription medication that is given with chemotherapy treatment; or

(C) Possesses a safety label from the United States Food and Drug Administration that indicates the relevant drug interactions, warnings and precautions, or adverse reactions of the prescription medication that are clinically applicable to the enrollee and determined by a healthcare provider to require supervision during administration of the prescription medication.

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Cite this article: FindLaw.com - Arkansas Code Title 23. Public Utilities and Regulated Industries § 23-99-1503. Determination of best interest for enrollee--Billing decision - last updated March 28, 2024 | https://codes.findlaw.com/ar/title-23-public-utilities-and-regulated-industries/ar-code-sect-23-99-1503/

Read this complete Arkansas Code Title 23. Public Utilities and Regulated Industries § 23-99-1503. Determination of best interest for enrollee--Billing decision on Westlaw

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