(14) "Managing employee" means an individual who: (a) exercises operational or managerial control over the employing entity's functions, activities, or units; or (b) directly or indirectly conducts the employing entity's day-to-day operations, functions, activities, or units. (15) "Medicaid provider" means a person that furnishes, delivers, supplies, produces, orders, prescribes, administers, or dispenses a covered service. (16) "National drug code identifier" means the same as that term is defined in 21 C.F.R. Sec. 207.33. (17) "Ownership interest" means possession of, in an entity: (a) legal or beneficial ownership; (b) capital interest; (c) profit interest; (d) controlling interest; (e) any combination of the interests described in Subsections (17)(a) through (d); (f) indirect interest through another entity that has an interest described in Subsections (17)(a) through (d) in the entity; or (g) the right to acquire an interest described in Subsections (17)(a) through (d) in the entity upon conversion, exercise, or exchange of a convertible security, option, warrant, or similar instrument. (18) "Parent organization" means an entity that, directly or indirectly, has a majority or greater ownership interest in and control of another entity. (19) "Pass through payment" means the same as that term is defined in 42 C.F.R. Sec. 438. (20) "Protected health information" means the same as that term is defined in 45 C.F.R. Sec. 160.103. (21) "Related party" means: (a) a risk contractor's parent organization; (b) the subordinate holding company, subsidiary, agent, instrumentality, partnership, joint venture, affiliated person, or subordinate business unit of: (i) a risk contractor; (ii) a risk contractor's parent organization; (iii) a subcontractor; (iv) a risk contractor's agent; or (v) a Medicaid provider that is an entity described in Subsections (21)(a), (b)(i) through (iv), (c) (i) through (iv), (d)(i) through (iv), (e)(i) through (iv), Subsection (21)(f), or Subsection (21) (g); (c) an entity that controls, is controlled by, or is in common control with: (i) a risk contractor; (ii) a risk contractor's parent organization; (iii) a subcontractor; (iv) a risk contractor's agent; or (v) a Medicaid provider that is an entity described in Subsections (21)(a), (b)(i) through (iv), (c) (i) through (iv), (d)(i) through (iv), (e)(i) through (iv), Subsection (21)(f), or Subsection (21) (g); (d) an entity that, directly or indirectly, has an ownership interest in: (i) a risk contractor; (ii) a risk contractor's parent organization; (iii) a subcontractor; (iv) a risk contractor's agent; or (v) a Medicaid provider that is an entity described in Subsections (21)(a), (b)(i) through (iv), (c) (i) through (iv), (d)(i) through (iv), (e)(i) through (iv), Subsection (21)(f), or Subsection (21) (g); (e) a Medicaid provider that, directly or indirectly, has an ownership interest in: (i) a risk contractor; (ii) a risk contractor's parent organization; (iii) a subcontractor; (iv) a risk contractor's agent; or (v) a Medicaid provider that is an entity described in Subsections (21)(a), (b)(i) through (iv), (c) (i) through (iv), (d)(i) through (iv), (e)(i) through (iv), Subsection (21)(f), or Subsection (21) (g); (f) a Medicaid provider with a sub-capitation, risk-sharing, or shared-savings payment arrangement with a risk contractor; or (g) an entity described in Subsections (21)(a) through (f) that is identified in: (i) disclosures; (ii) financial statements; (iii) an audit; (iv) regulatory filings; (v) administrative proceedings; (vi) court proceedings; (vii) federal or state: (A) oversight activities; (B) compliance activities; (C) enforcement activities; or (D) investigative activities; or (viii) state legislative oversight activities. (22) "Risk contractor" means a person that has, or is seeking to qualify for, a contract with the department to provide or arrange for covered services to Medicaid program enrollees as: (a) a managed care organization; (b) a health insuring organization, a prepaid ambulatory health plan, or a prepaid inpatient health plan, as those terms are defined in 42 C.F.R. Sec. 438.2; (c) a highly integrated dual eligible special needs plan or a fully integrated dual eligible special needs plan, as those terms are defined in 42 C.F.R. Sec. 422.2; or (d) another type of state-licensed risk-bearing entity that: (i) meets federal and state statutory and regulatory requirements; (ii) assumes full, partial, or shared risk for the cost of covered services; and (iii) may incur loss if the cost of providing the covered services exceeds payments under the entity's agreement with the division to provide goods or services under the Medicaid program. (23) "State directed payment" means a contract arrangement that directs the expenditures of a managed care organization, including to implement value-based purchasing models for: (a) Medicaid provider reimbursement; (b) multi-payer reform; (c) Medicaid-specific delivery system reform; or (d) performance improvement incentives, which may include, for Medicaid providers that provide a specific service under the agreement: (i) a minimum fee schedule; (ii) a uniform dollar amount or percentage increase in reimbursement; or (iii) a maximum fee schedule. (24) "Subcontractor" means a person that contracts with a risk contractor to provide, arrange for, manage, or perform a good or service under the risk contractor's agreement with the division, including: (a) a pharmacy benefit manager; (b) a behavioral health organization; (c) a dental benefit administrator; (d) a transportation broker; (e) a utilization management organization; or (f) an entity that performs: (i) financial management services; (ii) claims processing; (iii) decision support and analytics; (iv) care management; (v) medical policy and utilization review services; (vi) quality improvement activities; (vii) provider network management; (viii) member services; (ix) information systems and technology services; (x) marketing; (xi) staffing services; or (xii) government relations. (25) "Value add benefits" means benefits offered by a managed care organization in addition to standard coverage offered through the Medicaid program. (26) "Value-based purchasing model" means a model for Medicaid provider reimbursement that recognizes value or outcomes over volume of services, including: (a) pay for performance; or (b) bundled payments.
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