Title XXV, Business and Financial Institutions

A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the health benefit plan and who is willing to meet the terms and conditions for participation established by the health insurer, including the Kentucky state Medicai…

degree in medicine or osteopathy. Notwithstanding any other provision of law, no health benefit plan shall discriminate with respect to employment, staff, privileges, or the provision of professional services against a physician licensed to practice medicine on the basis of wheth…

Catchline at repeal: Additions to high-cost conditions list -- Hearing.

under KRS 18A.2251 or 18A.2281. (1) Coverage of an individual who is not a state employee or a small group which on April 10, 1998, is covered under KRS 18A.2251 or KRS 18A.2281 shall not be renewed after April 10, 1998. (2) The state employee health insurance fund established un…

Qualifications -- Fees -- Network subject to provisions of other subtitles. (1) (a) A provider-sponsored integrated health delivery network may be created before July 14, 2022, by health care providers for the purpose of providing health care services. (b) No person shall be elig…

To qualify as a provider-sponsored integrated health delivery network, the network shall meet the following financial solvency requirements: (1) Maintenance of a fidelity bond or fidelity insurance in an amount not less than two hundred fifty thousand dollars ($250,000) on employ…

Revocation. (1) No employer-organized association shall in this state self-insure in order to provide health benefit plans for its members unless it holds a certificate of filing from the commissioner. (2) To qualify for a certificate of filing and to maintain a certificate of fi…

(1) All insurers authorized to write health insurance in this state and employer- organized associations that self-insure shall transmit at least annually by July 31 to the commissioner the following information, in a format prescribed by the commissioner, on their insurance expe…

Program allocated funds. (1) In no event shall more than ten percent (10%) of federal and state funds allocated to the Kentucky Children's Health Insurance Program be used for: (a) Children's health programs other than those targeted for low-income children as defined under Title…

Catchline at repeal: Payment and contest of claims -- Circumstances under which insurer may delay payment or require additional information from provider.

Catchline at repeal: Guaranteed Acceptance Program -- Nondiscrimination in provider payment -- Participation by insurer as condition to do business.

As used in KRS 304.17A-400 to 304.17A-480, unless the context requires otherwise: (1) "Actual guaranteed acceptance program plan losses" means a dollar amount calculated by subtracting an insurer's guaranteed acceptance program plan claims from that insurer's guaranteed acceptanc…

Catchline at repeal: Participating insurer -- Written notification of program status -- Program participating insurer requirements -- Exemptions.

(1) A health benefit plan shall be considered a program plan and is eligible for inclusion in calculating assessments and refunds under the program risk adjustment process if it meets all of the following criteria: (a) The health benefit plan was purchased by an individual to pro…

Catchline at repeal: Premium -- Limitations.

Notwithstanding any other provision of this chapter, program plans shall contain cost containment features, which may include managed care and utilization management, to control the amount of high-cost policy losses without creating excessive adverse health care outcomes.

Catchline at repeal: Insurer annual reports -- Department calculations and notification to insurer -- Assessments and refunds -- Stop-loss carrier -- Examinations of participating insurers.

Catchline at repeal: Risk adjustment process -- Program account -- Funding -- Calculation of losses -- Assessments.

Catchline at repeal: Report to Legislative Research Commission -- Audit.

As used in KRS 304.17A-500 to 304.17A-590, unless the context requires otherwise: (1) "Areas other than urban areas" means a classification code that does not meet the definition of urban area; (2) "Contract holder" means an employer or organization that purchases a health benefi…

department. An insurer shall disclose in writing to a covered person and an insured or enrollee, in a manner consistent with the provisions of KRS 304.14-420 to 304.14-450, the terms and conditions of its health benefit plan and shall promptly provide the covered person and enrol…

printed document. (1) In addition to the disclosure requirements provided in KRS 304.17A-505, an insurer that offers a managed care plan shall notify an enrollee, in writing, of the availability of a printed document, in a manner consistent with KRS 304.14-420 to 304.14-450, cont…

(1) A managed care plan shall arrange for a sufficient number and type of primary care providers and specialists throughout the plan's service area to meet the needs of enrollees. Each managed care plan shall demonstrate that it offers: (a) An adequate number of accessible acute …

(1) An enrollee shall have adequate choice among participating primary care providers in a managed care plan who are accessible and qualified. (2) A managed care plan shall permit enrollees to choose their own primary care provider from a list of health care providers within the …

of provider applications -- Policy for removal or withdrawal. (1) Insurers shall establish relevant, objective standards for initial consideration of providers and for providers to continue as a participating provider in the plan. Standards shall be reasonably related to services…

subcontract agreements with commissioner -- Contents -- Disclosure of financial information not required. (1) A managed care plan shall file with the commissioner sample copies of any agreements it enters into with providers for the provision of health care services. The commissi…

medical condition or treatment options. (1) A managed care plan may not contract with a health care provider to limit the provider's disclosure to an enrollee, or to another person on behalf of an enrollee, of any information relating to the enrollee's medical condition or treatm…

(1) As used in this section, "hospitalist" means a physician of record at a hospital for a patient of a participating physician and who may return the care of the patient to that physician at the end of the hospitalization. (2) A contract between an insurer and a physician shall …

Catchline at repeal: Prohibition against contract requiring mandatory use of hospitalist.

substitution -- Application to drug formulary. (1) A managed care plan shall include a drug utilization review program, the primary emphasis of which shall be to enhance quality of care for enrollees by assuring appropriate drug therapy within the health care provider's legally a…

(1) Any insurer that limits coverage for any treatment, procedure, a drug, or device shall define the limitations and fully disclose those limits in the health insurance policy or certificate coverage. (2) (a) Any insurer that denies coverage for a treatment, procedure, a drug th…

or improvement standards -- Process to select health care providers -- Uniform application form and guidelines for health care provider evaluations. (1) A managed care plan shall appoint a medical director who: (a) Is a physician licensed to practice in this state; (b) Is in good…

(1) An insurer that offers a managed care plan shall offer a health benefit plan with out- of-network benefits to every contract holder. The plan with out-of-network benefits shall allow a covered person to receive covered services from out-of-network health care providers withou…

dependency -- Authorized disclosure. There is hereby recognized a patient's right of privacy in the content of a patient's record and communications between a patient and a health care provider with regard to mental health or chemical dependency. (1) An insurer may request the pr…

(1) No insurance contract with a provider shall contain a most-favored-nation provision except where the commissioner determines that the market share of the insurer is nominal. (2) Nothing in this section shall be construed to prohibit a health insurer and a provider from negoti…

Administrative regulations. The commissioner shall enforce the provisions of KRS 304.17A-500 to 304.17A-570 and shall adopt administrative regulations necessary to carry out the provisions of KRS 304.17A-500 to 304.17A-570.

insurance contracts or certificates. No health insurance contract or certificate subject to the provisions of this subtitle shall be delivered, issued, executed, or renewed on or after the date ninety (90) days after April 10, 1998, unless it and the insurer meet the requirements…

As used in KRS 304.17A-575 to 304.17A-577, unless the context requires otherwise: (1) "Applicant" means a physician licensed under KRS Chapter 311, an advanced practice registered nurse licensed under KRS Chapter 314, a psychologist licensed under KRS Chapter 319, or an optometri…

application for credentialing -- Payments to applicant. (1) An insurer issuing a managed care plan shall notify an applicant of its determination regarding a properly submitted application for credentialing within forty-five (45) days of receipt of an application containing all i…

care provider -- Disclosure of schedule change -- Confidentiality of payment information. (1) (a) An insurer issuing a managed care plan shall, upon request of a health care provider, provide or make available to the health care provider, when contracting or renewing an existing …

medical services -- Coverage of emergency medical conditions and emergency department services -- Emergency personnel to contact primary care provider or insurer -- Exclusion of limited-benefit health insurance policies. (1) An insurer offering health benefit plans shall educate …

(1) An insurer that offers a managed care plan or a risk-bearing managed care plan shall notify an enrollee, in writing, of the availability, in a manner consistent with KRS 304.14-420 to 304.14-450, in writing, at the time of enrollment and thereafter upon request, and as new pr…

As used in KRS 304.17A-591 to 304.17A.599: (1) "Cost sharing" means the cost to an insured under a health plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan; (2) "Health plan": (a) Except as pr…

pharmacy networks -- Annual report to commissioner -- Confidential information not subject to disclosure. To the extent permitted under federal law: (1) (a) An insurer, a pharmacy benefit manager, or any other administrator of pharmacy benefits that utilizes a network to provide …

pharmacy services -- Minimum reimbursements -- Administrative regulations. (1) As used in this section: (a) "Actual overpayment" means the portion of any amount paid for pharmacy or pharmacist services that: 1. Is duplicative because the pharmacy or pharmacist has already been pa…

benefits against pharmacy -- Right of pharmacist to provide information about lower cost alternatives to insured. To the extent permitted under federal law and except as provided in KRS 304.17A-595: (1) With respect to the provision of pharmacy or pharmacist services under a heal…

304.17A-595, or 304.17A-597. (1) Any insured, pharmacy, or pharmacist impacted by an alleged violation of KRS 304.17A-593, 304.17A-595, or 304.17A-597 may file a complaint with the commissioner. (2) The commissioner shall: (a) Review and investigate all complaints filed under thi…

As used in KRS 304.17A-600 to 304.17A-633: (1) "Adverse benefit determination": (a) Has the same meaning as in 29 C.F.R. sec. 2560.503-1, as amended; and (b) Includes: 1. A determination by an insurer or its designee that the health care services furnished or proposed to be furni…

procedures for coverage and utilization review determinations to be accessible on insurers' Web sites -- Preauthorization review requirements for insurers. (1) KRS 304.17A-600 to 304.17A-633 shall apply to any insurer that covers citizens of the Commonwealth under a health benefi…