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304.17A-515 Requirements for managed care plan.
(1)
(2)
(3)
A managed care plan shall arrange for a sufficient number and type of primary care
providers and specialists throughout the plan's service area to meet the needs of
enrollees. Each managed care plan shall demonstrate that it offers:
(a) An adequate number of accessible acute care hospital services, where
available;
(b) An adequate number of accessible primary care providers, including family
practice
and
general
practice
physicians,
internists,
obstetricians/gynecologists, and pediatricians, where available;
(c) An adequate number of accessible specialists and subspecialists, and when the
specialist needed for a specific condition is not represented on the plan's list of
participating specialists, enrollees have access to nonparticipating health care
providers with prior plan approval;
(d) The availability of specialty services; and
(e) A provider network that meets the following accessibility requirements:
1.
For urban areas, a provider network that is available to all persons
enrolled in the plan within thirty (30) miles or thirty (30) minutes of
each person's place of residence or work, to the extent that services are
available; or
2.
For areas other than urban areas, a provider network that makes
available primary care physician services, hospital services, and
pharmacy services within thirty (30) minutes or thirty (30) miles of each
enrollee's place of residence or work, to the extent those services are
available. All other providers shall be available to all persons enrolled in
the plan within fifty (50) minutes or fifty (50) miles of each enrollee's
place of residence or work, to the extent those services are available.
A managed care plan shall provide telephone access to the plan during business
hours to ensure plan approval of nonemergency care. A managed care plan shall
provide adequate information to enrollees regarding access to urgent and emergency
care.
A managed care plan shall establish reasonable standards for waiting times to obtain
appointments, except as provided for emergency care.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 476, sec. 31, effective July 14, 2000; and ch.
500, sec. 4, effective July 14, 2000. -- Created 1998 Ky. Acts ch. 496, sec. 28,
effective April 10, 1998, as amended by 1998 Ky. Acts ch. 585, sec. 1, effective
April 14, 1998.
Legislative Research Commission Note (7/14/2000). This section was amended by
2000 Ky. Acts chs. 476 and 500, which do not appear to be in conflict and have been
codified together.
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