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304.17B-007
Access.
Department's duties in operation and administration of Kentucky
In its duties to operate and administer Kentucky Access, the department shall, through
itself or designated agents:
(1) Establish administrative and accounting procedures for the operation of Kentucky
Access;
(2) Enter into contracts as necessary;
(3) Take legal action necessary:
(a) To avoid the payment of improper claims against Kentucky Access or the
coverage provided by or through Kentucky Access;
(b) To recover any amounts erroneously or improperly paid by Kentucky Access;
(c) To recover any amounts paid by the Kentucky Access as a result of mistake of
fact or law;
(d) To recover other amounts due Kentucky Access; or
(e) To operate and administer its obligations under the provisions of KRS
304.17B-001 to 304.17B-031;
(4) Establish, and modify as appropriate, rates, rate schedules, rate adjustments,
premium rates, expense allowances, claim reserve formulas, and any other actuarial
function appropriate to the administration and operation of Kentucky Access.
Premium rates and rate schedules may be adjusted for appropriate factors,
including, but not limited to, age and sex, and shall take into consideration
appropriate factors in accordance with established actuarial and underwriting
practices;
(5) Establish procedures under which applicants and participants in Kentucky Access
shall have an internal grievance process and a mechanism for external review
through an independent review organization in accordance with this chapter;
(6) Select a third-party administrator in accordance with KRS 304.17B-011;
(7) Require that all health benefit plans, riders, endorsements, or other forms and
documents used to administer Kentucky Access meet the requirements of Subtitles
12, 14, 17, 17A, and 38 of this chapter;
(8) Adopt nationally recognized uniform claim forms in accordance with this chapter;
(9) Develop and implement a marketing strategy to publicize the existence of Kentucky
Access, including, but not limited to, eligibility requirements, procedures for
enrollment, premium rates, and a toll–free telephone number to call for questions;
(10) Establish and review annually provider reimbursement rates that ensure that
payments are consistent with efficiency, economy, and quality of care and are
sufficient to enlist enough providers so that care and services are available under
Kentucky Access at least to the extent that such care and services are available to
the general population. The department shall only authorize contracts with health
care providers that prohibit the provider from collecting from the enrollee any
amounts in excess of copayment amounts, coinsurance amounts, deductible
amounts, and amounts for noncovered services;
(11) Conduct periodic audits to assure the general accuracy of the financial and claims
data submitted to the department and be subject to an annual audit of its operations;
(12) Issue health benefit plans January 1, 2001, or thereafter, in accordance with the
requirements of KRS 304.17B-001 to 304.17B-031;
(13) Require a referral fee of fifty dollars ($50) to be paid to agents who refer applicants
who are subsequently enrolled in Kentucky Access. The referral fee shall be paid
only on the initial enrollment of an applicant. Referral fees shall not be paid on any
enrollments of enrollees who have been previously enrolled in Kentucky Access, or
for renewals for enrollees;
(14) Bill and collect premiums from enrollees in the amount determined by the
department;
(15) Assess insurers and stop-loss carriers in accordance with KRS 304.17B-021;
(16) Reimburse GAP participating insurers for GAP losses pursuant to KRS 304.17B021;
(17) Establish a provider network for Kentucky Access by developing a statewide
provider network or by contracting with an insurer for a statewide provider network.
In the event the department contracts with an insurer, the department may take into
consideration factors including, but not limited to, the size of the provider network,
the composition of the provider network, and the current market rate of the provider
network. The provider network shall be made available to the third-party
administrator specified in KRS 304.17B-011 and shall be limited to Kentucky
Access enrollees.
(18) Be audited by the Auditor of Public Accounts;
(19) By administrative regulation, amend the definition of high-cost conditions provided
in KRS 304.17B-001 by adding other high-cost conditions;
(20) The department shall report on an annual basis to the Interim Joint Committee on
Banking and Insurance the separation plan pursuant to KRS 304.17A-080 for the
division of duties and responsibilities between the operation of the Department of
Insurance and the operation of Kentucky Access; and
(21) Any other actions as may be necessary and proper for the execution of the
department's powers, duties, and obligations under KRS 304.17B-001 to 304.17B031.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1276, effective July 15, 2010. -- Created
2000 Ky. Acts ch. 476, sec. 4, effective July 14, 2000.
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