{"data":{"id":"us-ky/krs-205.5356","jurisdiction":"us-ky","citation":"KRS 205.5356","heading":"Contracts for Medicaid services by managed care organizations --","body":"Required terms and provisions -- Prohibited actions -- Requirements --\nDisenrollment of beneficiary with unknown address -- Penalties.\nAny contract entered into, renewed, or extend ed on or after April 14, 2026, by the\ncabinet, or any subdivision thereof, and any managed care organization for the delivery\nof Medicaid services shall include the following provisions:\n(1) The managed care organization shall be prohibited from:\n(a) Contacting or providing any incentive for Medicaid providers to resubmit\nclaims after an initial submission for the purpose of increasing the managed\ncare organization's risk score;\n(b) Contracting with a vendor or other subcontractor for the purpose of engagin g\nin activities the managed care organization is prohibited from engaging in\nunder paragraph (a) of this subsection;\n(c) Penalizing a primary care provider for the primary care provider's inability to\nmake contact with a Medicaid enrollee that has been ass igned to the primary\ncare provider's roster if the primary care provider has made a good -faith\neffort, as defined by the Department for Medicaid Services in its contract with\na managed care organization, to contact the enrollee;\n(d) Advertising or otherwis e marketing the Medicaid program except to indicate\nthe managed care organization's participation in the Medicaid program; and\n(e) 1. For the purposes of assessing, evaluating, or determining network\nadequacy, counting or otherwise including in any analysi s of network\nadequacy an inactive Medicaid provider.\n2. As used in this paragraph, \"inactive Medicaid provider\" means an\nenrolled Medicaid provider who has submitted fewer than one (1)\nencounter or claim for payment for Medicaid covered services to a given\nmanaged care organization within the previous twelve (12) months;\n(2) The managed care organization shall be required to:\n(a) Notify the Department for Medicaid Services and the Social Security\nAdministration in the appropriate county within five (5) business days of\nreceiving notice from any source of the death of a Medicaid enrollee served\nby the managed care organization;\n(b) Collaborate with the Department for Medicaid Services to implement and\nexecute a value -based payment model that aligns incentives for enrollees,\nproviders, managed care organizations, and the Commonwealth to improve\nquality and health care outcomes. The va lue-based payment model required\nunder this subsection shall include a two percent (2%) withhold from each\nmanaged care organization's capitation amount that can be earned back in full\nor in part by the managed care organization through the achievement of\ndesignated value-based measures that shall include but not be limited to:\n1. Hospital readmission rates;\n2. Cancer screening rates;\n3. Child and adolescent well care visits;\n4. Prenatal and postpartum care;\n5. Emergency department utilization rates;\n6. Behavioral health treatment and counseling services; and\n7. Recovery services; and\n(c) Comply with:\n1. This section and KRS 205.533, 205.534, 205.5355(2), and 205.556;\n2. All terms, conditions, requirements, performance standards, and\nobligations created unde r or included in the contract between the\nmanaged care organization and the cabinet for the delivery of Medicaid\nservices;\n3. KRS 304.17A-708; and\n4. All sections of Subtitle 17A of KRS Chapter 304 listed in KRS 205.522;\n(3) (a) If the Department for Medic aid Services receives mail returned as\nundeliverable following an attempt to contact a Medicaid beneficiary by first -\nclass mail, the department shall make a good -faith effort to obtain the\nbeneficiary's current and correct address. The good-faith effort shall include:\n1. First, requesting the beneficiary's current and correct address from his or\nher managed care organization;\n2. Accessing and reviewing all available state and federal data sources,\nincluding but not limited to the National Change of Address database,\nfrom which the department might obtain the beneficiary's current and\ncorrect address; and\n3. Attempting to obtain the beneficiary's current and correct address\ndirectly from the beneficiary by attempting to contact him or her\nthrough at least two (2) of the following means of communication:\na. Telephone;\nb. Text message; and\nc. Email message.\n(b) 1. The good -faith effort required under paragraph (a) of this subsection\nshall continue for at least thirty (30) days after the date on which the\ndepartment first requested the beneficiary's current and correct address\nfrom his or her managed care organization.\n2. If the department is able to obtain the beneficiary's current and correct\naddress, the department shall resend any mail that was returned to the\ndepartment as undeliverable.\n3. If the department is not able to obtain the beneficiary's current and\ncorrect address within thirty (30) days after the date on which the\ndepartment first requested the beneficiary's current and correct address\nfrom his or her managed care organization, th e department shall, to the\nextent permitted under federal law, disenroll the individual from the\nMedicaid program pending any appeal that may be required or\nguaranteed under federal law;\n(4) The Department for Medicaid Services shall, in all instances, exe rcise its rights\nunder a contract with a Medicaid managed care organization to impose all remedies\navailable to the department under the terms of the contract, at law, or equity if the\ndepartment determines that the managed care organization or a subcontra ctor acting\non behalf of the managed care organization has:\n(a) Violated any provision of the contract between the department and the\nmanaged care organization; or\n(b) Failed to fully comply with any applicable state or federal law or regulation,\ncompliance with which is mandated expressly or implicitly by the contract;\nand\n(5) (a) Penalties for violations of state and federal law related to the Medicaid\nprogram, including but not limited to this section, and any other contract\nrequirements or prohibitions imposed upon the managed care organization by\nthe cabinet, including but not limited to:\n1. The penalty for a violation of subsection (1)(a) or (b) of this section\nshall be at least five hundred dollars ($500) for each claim a managed\ncare organization requests or incentivizes a provider to resubmit;\n2. The penalty for a violation of subsection (1)(c) of this section shall be at\nleast one thousand dollars ($1,000) per violation;\n3. The penalty for a violation of subsection (1)(d) of this section shall be at\nleast five thousand dollars ($5,000) per violation;\n4. The penalty for a violation of subsection (1)(e) of this section shall be at\nleast ten thousand dollars ($10,000) for each inactive provider included\nin an analysis of network adequacy; and\n5. The penalty for a violation of subsection (2)(a) of this section shall be at\nleast one thousand dollars ($1,000) per violation.\n(b) All penalties and fines imposed or assessed against a Medicaid managed care\norganization by the Cabinet for Health and Family Serv ices, including but not\nlimited to those penalties established in paragraph (a) of this subsection, shall\nbe deposited into the Medicaid managed care organization compliance fund\nestablished in KRS 205.5357.","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57030","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:03Z","sha256":"5ad068589c7fcd9513d722eedd0bb341e5500dec6bf94b39ce00d4cf1273f178","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.5355","next":"us-ky/krs-205.5357"},"notice":"GroundRules: Original legal text. Not legal advice."}