2009 Kentucky Revised Statutes Subtitle 17A. Health Benefit Plans 304.17A.525 Standards for provider participation -- Mechanisms for consideration of provider applications -- Policy for removal or withdrawal.
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304.17A-525 Standards for provider participation -- Mechanisms for consideration
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. <br>Standards shall be reasonably related to services provided. Selection or participation <br>standards based on the economics or capacity of a provider's practice shall be <br>adjusted to account for case mix, severity of illness, patient age and other features <br>that may account for higher-than- or lower-than-expected costs. All data profiling or <br>other data analysis pertaining to participating providers shall be done in a manner <br>which is valid and reasonable. Plans shall not use criteria that would allow an <br>insurer to avoid high-risk populations by excluding providers because they are <br>located in geographic areas that contain populations or providers presenting a risk <br>of higher-than-average claims, losses, or health services utilization or that would <br>exclude providers because they treat or specialize in treating populations presenting <br>a risk of higher-than-average claims, losses, or health services utilization.
(2) Each insurer shall establish mechanisms for soliciting and acting upon applications
for provider participation in the plan in a fair and systematic manner. These <br>mechanisms shall, at a minimum, include: <br>(a) Allowing all providers who desire to apply for participation in the plan an
opportunity to apply at any time during the year or, where an insurer does not <br>conduct open continuous provider enrollment, conducting a provider <br>enrollment period at least annually with the date publicized to providers <br>located in the geographic service area of the plan at least thirty (30) days in <br>advance of the enrollment periods; and
(b) Making criteria for provider participation in the plan available to all
applicants.
(3) If a managed care plan terminates the participation of an enrollee's primary care
provider, the plan shall provide notice to the enrollee and arrange for the enrollee's <br>continuity of care with an approved primary care provider.
(4) An insurer that offers a managed care plan shall establish a policy governing the
removal of and withdrawal by health care providers from the provider network that <br>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
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director shall promptly notify the appropriate professional state licensing <br>board.
Effective: April 10, 1998 <br>History: Created 1998 Ky. Acts ch. 496, sec. 30, effective April 10, 1998.
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