2009 Kentucky Revised Statutes Subtitle 17A. Health Benefit Plans 304.17A.505 Disclosure of terms and conditions of health benefit plan -- Filing with department.
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304.17A-505 Disclosure of terms and conditions of health benefit plan -- Filing with
department.
An insurer shall disclose in writing to a covered person and an insured or enrollee, in a <br>manner consistent with the provisions of KRS 304.14-420 to 304.14-450, the terms and <br>conditions of its health benefit plan and shall promptly provide the covered person and <br>enrollee with written notification of any change in the terms and conditions prior to the <br>effective date of the change. The insurer shall provide the required information at the time <br>of enrollment and upon request thereafter. <br>(1) The information required to be disclosed under this section shall include a
description of: <br>(a) Covered services and benefits to which the enrollee or other covered person is
entitled;
(b) Restrictions or limitations on covered services and benefits; <br>(c) Financial responsibility of the covered person, including copayments and
deductibles;
(d) Prior authorization and any other review requirements with respect to
accessing covered services;
(e) Where and in what manner covered services may be obtained; <br>(f) Changes in covered services or benefits, including any addition, reduction, or
elimination of specific services or benefits;
(g) The covered person's right to the following:
1.
A utilization review and the procedure for initiating a utilization review, <br>if an insurer elects to provide utilization review;
2.
An internal appeal of a utilization review made by or on behalf of the <br>insurer with respect to the denial, reduction, or termination of a health <br>care benefit or the denial of payment for a health care service, and the <br>procedure to initiate an internal appeal; and
3.
An external review and the procedure to initiate the external review <br>process;
(h) Measures in place to ensure the confidentiality of the relationship between an
enrollee and a health care provider;
(i) Other information as the commissioner shall require by administrative
regulation;
(j) A summary of the drug formulary, including, but not limited to, a listing of the
most commonly used drugs, drugs requiring prior authorization, any <br>restrictions, limitations, and procedures for authorization to obtain drugs not <br>on the formulary and, upon request of an insured or enrollee, a complete drug <br>formulary; and
(k) A statement informing the insured or enrollee that if the provider meets the
insurer's enrollment criteria and is willing to meet the terms and conditions for <br>participation, the provider has the right to become a provider for the insurer.
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(2) The insurer shall file the information required under this section with the
department.
Effective: July 15, 2010 <br>History: Amended 2010 Ky. Acts ch. 24, sec. 1229, effective July 15, 2010. --
Amended 2000 Ky. Acts ch. 262, sec. 27, effective July 14, 2000; and ch. 500, <br>sec. 2, effective July 14, 2000. -- Created 1998 Ky. Acts ch. 496, sec. 26, effective <br>April 10, 1998.
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