KRS 304.17A-515: Requirements for managed care plan.

(1) 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

physically 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 c are

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, hospit al 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.

(2) A managed care plan shall provide telephone access to the plan during business

hours to ensure plan approval of nonemergen cy care. A managed care plan shall

provide adequate information to enrollees regarding access to urgent and emergency

care.

(3) A managed care plan shall establish reasonable standards for waiting times to obtain

appointments, except as provided for emergency care.