KRS 304.17C-085: Definitions for section -- Set fees for noncovered services in

participating provider agreement prohibited -- Provider charges limited to

provider's rate for services and materials -- Contractual discount for covered

services -- Reimbursement -- Provisions cannot be waived by contract.

(1) As used in this section:

(a) "Contractual discount" means a percentage reduction from a provider's usual

and customary rate for covered services required under a participating

provider agreement; and

(b) "Covered services":

1. Means services and materials for which:

a. Reimbursement from a plan is provided by the enrollee's plan

contract; or

b. Reimbursement would be available but for the application of the

enrollee's contractual limitations of dedu ctibles, copayments,

coinsurance, or frequency limitations; and

2. Does not include services and materials for which reimbursement would

be available but for the application of the enrollee's contractual

limitation of an annual maximum benefit.

(2) A parti cipating provider agreement shall not require a participating provider to

provide services to an enrollee at a fee set by or subject to the approval of the

limited health service benefit plan unless the services are covered services under the

participating provider agreement.

(3) A provider shall not charge more for services and materials that are noncovered

services under a limited health service benefit plan than the provider's rate for the

services and materials.

(4) The amount of a contractual discount shall not result in a fee that is less than the

limited health service benefit plan would pay for covered services but for the

application an enrollee's contractual limitations of deductibles, copayments,

coinsurance, or frequency limitations.

(5) Reimbursement paid by the limited health service benefit plan for covered services:

(a) Shall be reasonable; and

(b) Shall not provide nominal reimbursement in order to claim that services and

materials are covered services.

(6) The provisions of this section shall not be waived by contra ct. Any contractual

arrangement in conflict with this section or that purports to waive any requirement

of this section shall be void.