304.17C-030 Disclosure.
(1)
(2)
(3)
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 limited health service benefit plan and shall promptly
provide the covered person and enrollee with written notification of any change in
the terms and conditions prior to the effective date of the change. The insurer shall
provide the required information at the time of enrollment and upon request
thereafter.
The information required to be disclosed under this section shall include a
description of:
(a) Covered services and benefits to which the enrollee or other covered person is
entitled;
(b) Restrictions or limitations on covered services and benefits;
(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;
(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,
if an insurer elects to provide utilization review; and
2.
An internal appeal of a utilization review decision made by or on behalf
of the insurer with respect to the denial, reduction, or termination of a
limited health service benefit plan or the denial of payment for a health
care service, and the procedure to initiate an internal appeal;
(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
restrictions, limitations, and procedures for authorization to obtain drugs not
on the formulary, and, upon request of an insured or enrollee, a complete drug
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
participation, the provider has the right to become a provider for the insurer.
The insurer shall file the information required under this section with the
department.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1290, effective July 15, 2010. -- Created
2002 Ky. Acts ch. 105, sec. 4, effective July 15, 2002.
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