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304.17A-527 Filing of provider agreements, risk-sharing arrangements, and
subcontract agreements with commissioner -- Contents -- Disclosure of
financial information not required.
(1)
A managed care plan shall file with the commissioner sample copies of any
agreements it enters into with providers for the provision of health care
services. The commissioner shall promulgate administrative regulations
prescribing the manner and form of the filings required. The agreements shall
include the following:
(a) A hold harmless clause that states that the provider may not, under any
circumstance, including:
1.
Nonpayment of moneys due the providers by the managed care
plan,
2.
Insolvency of the managed care plan, or
3.
Breach of the agreement,
bill, charge, collect a deposit, seek compensation, remuneration, or
reimbursement from, or have any recourse against the subscriber,
dependent of subscriber, enrollee, or any persons acting on their behalf,
for services provided in accordance with the provider agreement. This
provision shall not prohibit collection of deductible amounts, copayment
amounts, coinsurance amounts, and amounts for noncovered services;
(b) A continuity of care clause that states that if an agreement between the
provider and the managed care plan is terminated for any reason, other
than a quality of care issue or fraud, the insurer shall continue to provide
services and the plan shall continue to reimburse the provider in
accordance with the agreement until the subscriber, dependent of the
subscriber, or the enrollee is discharged from an inpatient facility, or the
active course of treatment is completed, whichever time is greater, and in
the case of a pregnant woman, services shall continue to be provided
through the end of the post-partum period if the pregnant woman is in her
fourth or later month of pregnancy at the time the agreement is
terminated;
(c) A survivorship clause that states the hold harmless clause and continuity
of care clause shall survive the termination of the agreement between the
provider and the managed care plan;
(d) A clause stating that the insurer issuing a managed care plan will, upon
request of a participating provider, provide or make available to a
participating provider, when contracting or renewing an existing contract
with such provider, the payment or fee schedules or other information
sufficient to enable the provider to determine the manner and amount of
payments under the contract for the 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; and
(e) A clause requiring that if a provider enters into any subcontract
agreement with another provider to provide their licensed health care
services to the subscriber, dependent of the subscriber, or enrollee of a
(2)
(3)
managed care plan where the subcontracted provider will bill the
managed care plan or subscriber or enrollee directly for the subcontracted
services, the subcontract agreement must meet all requirements of this
subtitle and that all such subcontract agreements shall be filed with the
commissioner in accordance with this subsection.
An insurer that offers a health benefit plan that enters into any risk-sharing
arrangement or subcontract agreement shall file a copy of the arrangement
with the commissioner. The insurer shall also file the following information
regarding the risk-sharing arrangement:
(a) The number of enrollees affected by the risk-sharing arrangement;
(b) The health care services to be provided to an enrollee under the
risk-sharing arrangement;
(c) The nature of the financial risk to be shared between the insurer and
entity or provider, including but not limited to the method of compensation;
(d) Any administrative functions delegated by the insurer to the entity or
provider. The insurer shall describe a plan to ensure that the entity or
provider will comply with KRS 304.17A-500 to 304.17A-590 in exercising
any delegated administrative functions; and
(e) The insurers oversight and compliance plan regarding the standards
and method of review.
Nothing in this section shall be construed as requiring an insurer to submit the
actual financial information agreed to between the insurer and the entity or
provider. The commissioner shall have access to a specific risk sharing
arrangement with an entity or provider upon request to the insurer. Financial
information obtained by the department shall be considered to be a trade
secret and shall not be subject to KRS 61.872 to 61.884.
Effective:July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1230, effective July 15, 2010. -Amended 2008 Ky. Acts ch. 169, sec. 6, effective July 15, 2008. -- Amended
2004 Ky. Acts ch. 157, sec. 3, effective July 13, 2004; and ch. 59, sec. 8,
effective July 13, 2004. -- Amended 2002 Ky. Acts ch. 181, sec. 3, effective July
15, 2002. -- Created 2000 Ky. Acts ch. 500, sec. 1, effective July 14, 2000.
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