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304.17A-254 Duties of insurer offering health benefit plan.
An insurer that offers a health benefit plan that is not a managed care plan but provides <br>financial incentives for a covered person to access a network of providers shall: <br>(1) Notify the covered person, in writing, of the availability of a printed document, in a
manner consistent with KRS 304.14-420 to 304.14-450, containing the following <br>information at the time of enrollment and upon request: <br>(a) A current directory of the in-network providers from which the covered
person may access covered services at a financially beneficial rate. The <br>directory shall, at a minimum, provide the name, type of provider, <br>professional office address, telephone number, and specialty designations of <br>the network provider, if any; and
(b) In addition to making the information available in a printed document, an
insurer may also make the information available in an accessible electronic <br>format;
(2) Assure that contracts with the providers in the network contain a hold harmless
agreement under which the covered person will not be balanced billed by the in-<br>network provider except for deductibles, co-pays, coinsurance amounts, and <br>noncovered benefits;
(3) File with the department a copy of the directory required under subsection (1) of
this section;
(4) Have a process for the selection of health care providers who will be on the insurer's
list of participating providers, with written policies and procedures for review and <br>approval used by the insurer. The insurer shall establish minimum professional <br>requirements for participating health care providers. An insurer may not <br>discriminate against a provider solely on the basis of the provider's license by the <br>state;
(5) Not contract with a health care provider to limit the provider's disclosure to a
covered person, or to another person on behalf of a covered person, of any <br>information relating to the covered person's medical condition or treatment options;
(6) Not penalize a health care provider, or terminate a health care provider's contract
with the insurer, because the provider discusses medically necessary or appropriate <br>care with a covered person or another person on behalf of a covered person. The <br>health care provider may: <br>(a) Not be prohibited by the insurer from discussing all treatment options with the
covered person; and
(b) Disclose to the covered person or to another person on behalf of a covered
person other information determined by the health care provider to be in the <br>best interests of the covered person;
(7) Include in any agreements it enters into with providers for the provision of health
care services a clause stating that the insurer will, upon request of a health care <br>provider, provide or make available to a health care provider, when contracting or <br>renewing an existing contract with such provider, the payment or fee schedules or <br>other information sufficient to enable the health care provider to determine the
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manner and amount of payments under the contract for the health care provider's <br>services prior to the final execution or renewal of the contract and shall provide any <br>change in such schedules at least ninety (90) days prior to the effective date of the <br>amendment pursuant to KRS 304.17A-577;
(8) Establish a policy governing the removal of and withdrawal by health care providers
from the provider network that includes the following: <br>(a) The insurer shall inform a participating health care provider of the insurer's
removal and withdrawal policy at the time the insurer contracts with the health <br>care provider to participate in the provider network, and when changed <br>thereafter;
(b) If a participating health care provider's participation will be terminated or
withdrawn prior to the date of the termination of the contract as a result of a <br>professional review action, the insurer and participating health care provider <br>shall comply with the standards in 42 U.S.C. sec. 11112; and
(c) If the insurer finds that a health care provider represents an imminent danger
to an individual patient or to the public health, safety, or welfare, the medical <br>director shall promptly notify the appropriate professional state licensing <br>board; and
(9) Meet all requirements provided under KRS 304.17A-600 to 304.17A-633 and KRS
304.17A-700 to 304.17A-730.
Effective: July 15, 2008 <br>History: Amended 2008 Ky. Acts ch. 169, sec. 5, effective July 15, 2008. -- Created
2004 Ky. Acts ch. 59, sec. 2, effective July 13, 2004.
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