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304.17A-300 Provider-sponsored
integrated
health
delivery
network
--
Qualifications -- Fees -- Network subject to provisions of other subtitles.
(1) A provider-sponsored integrated health delivery network may be created by health
care providers for the purpose of providing health care services.
(2) No person shall in this Commonwealth be, act as, or hold itself out as a provider-
sponsored integrated health delivery network unless it holds a certificate of filing <br>from the commissioner. Each provider-sponsored integrated health delivery network <br>that seeks to offer services shall first be certified by the department.
(3) To qualify as a provider-sponsored integrated health delivery network, an applicant
shall submit information acceptable to the department to satisfactorily demonstrate <br>that the provider-sponsored integrated health delivery network: <br>(a) Is licensed and in good standing with the licensure boards for participating
providers;
(b) Has demonstrated the capacity to administer the health plans it is offering; <br>(c) Has the ability, experience, and structure to arrange for the appropriate level
and type of health care services;
(d) Has the ability, policies, and procedures to conduct utilization management
activities;
(e) Has the ability to achieve, monitor, and evaluate the quality and cost
effectiveness of care provided by its provider network;
(f) Is financially solvent; <br>(g) Has the ability to assure enrollees adequate access to providers, including
geographic availability and adequate numbers and types;
(h) Has the ability and procedures to monitor access to its provider network; <br>(i) Has a satisfactory grievance procedure and the ability to respond to enrollees'
inquiries and complaints;
(j) Does not limit the participation of any health care provider in its provider
network in another provider network;
(k) Has the ability and policies that allow patients to receive care in the most
appropriate, least restrictive setting;
(l) Does not discriminate in enrolling members; <br>(m) Participates in coordination of benefits; <br>(n) Uses standardized electronic claims and billing processes and formats; and <br>(o) Discloses to the cooperative reimbursement arrangements with providers.
(4) Fees for the following services shall be paid to the commissioner by every provider-
sponsored integrated health delivery network, and the fees shall be the same as <br>those for insurers as specified in Subtitle 4 of this chapter: <br>(a) For filing an application for a certificate of filing or amendment thereto; <br>(b) For filing an annual statement; and <br>(c) For other services deemed necessary by the commissioner.
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(5) Provider-sponsored integrated health delivery networks shall be subject to the
provisions of this subtitle, and to the following provisions of this chapter, to the <br>extent applicable and not in conflict with the expressed provisions of this subtitle: <br>(a) Subtitle 1 -- Scope of Code; <br>(b) Subtitle 2 -- Commissioner of the Department of Insurance; <br>(c) Subtitle 3 -- Authorization of Insurers and General Requirements; <br>(d) Subtitle 4 -- Fees and Taxes; <br>(e) Subtitle 5 -- Kinds of Insurance--Limits of Risk--Reinsurance; <br>(f) Subtitle 6 -- Assets and Liabilities; <br>(g) Subtitle 7 -- Investments; <br>(h) Subtitle 8 -- Administration of Deposits; <br>(i) Subtitle 9 -- Agents, Consultants, Solicitors, and Adjusters; <br>(j) Subtitle 12 -- Trade Practices and Frauds; <br>(k) Subtitle 14 -- KRS 304.14-120 to 304.14-130 and 304.14-500 to 304.14-560; <br>(l) Subtitle 25 -- Continuity of Management; <br>(m) Subtitle 33 -- Insurers Rehabilitation and Liquidation; <br>(n) Subtitle 37 -- Insurance Holding Company Systems; and <br>(o) Subtitle 99 -- Penalties.
Effective: July 15, 2010 <br>History: Amended 2010 Ky. Acts ch. 24, sec. 1222, effective July 15, 2010. --
Amended 2000 Ky. Acts ch. 521, sec. 2, effective July 14, 2000. -- Amended 1998 <br>Ky. Acts ch. 405, sec. 1, effective July 15, 1998. -- Created 1996 Ky. Acts ch. 371, <br>sec. 18, effective July 15, 1996.
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