KRS 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 ava ilable 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 ba lanced 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 beh alf 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 me dically 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 provisi on 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 schedul es or

other information sufficient to enable the health care provider to determine the

manner and amount of payments under the contract for the 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;

(8) 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 appropriat e professional state licensing

board; and

(9) Meet all requirements provided under KRS 304.17A -600 to 304.17A-633 and KRS

304.17A-700 to 304.17A-730.