2011 Kentucky Revised Statutes Subtitle 17C. Limited Health Service Benefit Plans 304.17C.050 Standards for providers -- Mechanism for acting upon applications -- Policy governing removal of providers from network.
KY Rev Stat § 304.17C.050 (1996 through Reg Sess) What's This?
304.17C-050 Standards for providers -- Mechanism for acting upon applications -Policy governing removal of providers from network.
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Insurers shall establish relevant, objective standards for initial consideration of
providers and for providers to continue as a participating provider in the plan.
Standards shall be reasonably related to services provided. Selection or participation
standards based on the economics or capacity of a provider's practice shall be
adjusted to account for case mix, severity of illness, patient age, and other features
that may account for higher-than-expected or lower-than-expected costs. All data
profiling or other data analysis pertaining to participating providers shall be done in
a manner which is valid and reasonable. Plans shall not use criteria that would allow
an insurer to avoid high-risk populations by excluding providers because they are
located in geographic areas that contain populations or providers presenting a risk
of higher than average claims, losses, or health services utilization, or that would
exclude providers because they treat or specialize in treating populations presenting
a risk of higher than average claims, losses, or health services utilization.
Each insurer shall establish mechanisms for soliciting and acting upon applications
for provider participation in the plan in a fair and systematic manner. These
mechanisms shall, at a minimum, include:
(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
conduct open continuous provider enrollment, conducting a provider
enrollment period at least annually with the date publicized to providers
located in the geographic service area of the plan at least thirty (30) days in
advance of the enrollment period; and
(b) Making criteria for provider participation in the plan available to all
applicants.
An insurer that offers a limited health service benefit plan shall establish a policy
governing the removal of and withdrawal by health care providers from the provider
network that includes the following:
(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
care provider to participate in the provider network, and when changed
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
professional review action, the insurer and participating health care provider
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
director shall promptly notify the appropriate professional state licensing
board.
Effective: July 15, 2002
History: Created 2002 Ky. Acts ch. 105, sec. 6, effective July 15, 2002.
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