KRS 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 de posit, 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 prov ision 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 termi nated 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 t he 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 pr egnant 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 shal l 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 managed care plan

where the subcontracted provider will bill the managed care plan or subscriber

or enrollee directly for the subcontracted services, the s ubcontract 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.

(2) 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 insurer's oversight and compliance plan regarding the standards and

method of review.

(3) 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 s ubject to KRS

61.872 to 61.884.