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304.17A-254 Duties of insurer offering health benefit plan.
An insurer that offers a health benefit plan that is not a managed care plan but
provides financial incentives for a covered person to access a network of providers
shall:
(1) Notify the covered person, in writing, of the availability of a printed document,
in a manner consistent with KRS 304.14-420 to 304.14-450, containing the
following information at the time of enrollment and upon request:
(a) A current directory of the in-network providers from which the covered
person may access covered services at a financially beneficial rate. The
directory shall, at a minimum, provide the name, type of provider,
professional office address, telephone number, and specialty
designations of the network provider, if any; and
(b) In addition to making the information available in a printed document, an
insurer may also make the information available in an accessible
electronic format;
(2) Assure that contracts with the providers in the network contain a hold harmless
agreement under which the covered person will not be balanced billed by the
in-network provider except for deductibles, co-pays, coinsurance amounts, and
noncovered benefits;
(3) File with the department a copy of the directory required under subsection (1)
of this section;
(4) Have a process for the selection of health care providers who will be on the
insurer's list of participating providers, with written policies and procedures for
review and approval used by the insurer. The insurer shall establish minimum
professional requirements for participating health care providers. An insurer
may not discriminate against a provider solely on the basis of the provider's
license by the state;
(5) Not contract with a health care provider to limit the provider's disclosure to a
covered person, or to another person on behalf of a covered person, of any
information relating to the covered person's medical condition or treatment
options;
(6) Not penalize a health care provider, or terminate a health care provider's
contract with the insurer, because the provider discusses medically necessary
or appropriate care with a covered person or another person on behalf of a
covered person. The health care provider may:
(a) Not be prohibited by the insurer from discussing all treatment options with
the covered person; and
(b) Disclose to the covered person or to another person on behalf of a
covered person other information determined by the health care provider
to be in the best interests of the covered person;
(7) Include in any agreements it enters into with providers for the provision of
health care services a clause stating that the insurer will, upon request of a
health care provider, provide or make available to a health care provider, when
contracting or renewing an existing contract with such provider, the payment or
fee schedules or other information sufficient to enable the health care provider
to determine the manner and amount of payments under the contract for the
(8)
(9)
health care provider's services prior to the final execution or renewal of the
contract and shall provide any change in such schedules at least ninety (90)
days prior to the effective date of the amendment pursuant to KRS
304.17A-577;
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; and
Meet all requirements provided under KRS 304.17A-600 to 304.17A-633 and
KRS 304.17A-700 to 304.17A-730.
Effective:July 15, 2008
History: Amended 2008 Ky. Acts ch. 169, sec. 5, effective July 15, 2008. -Created 2004 Ky. Acts ch. 59, sec. 2, effective July 13, 2004.
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