{"data":{"id":"us-ky/krs-304.17a-525","jurisdiction":"us-ky","citation":"KRS 304.17A-525","heading":"Standards for provider participation -- Mechanisms for consideration","body":"of provider applications -- Policy for removal or withdrawal.\n(1) Insurers shall establish relevant, objective standards for initial consideration of\nproviders and for providers to continue as a participating provider in the plan.\nStandards shall be reasonably related to services provided. Selection or participation\nstandards based on the economics or capacity of a provider's practice shall be\nadjusted to account for case mix, sev erity of illness, patient age and other features\nthat may account for higher-than- or lower-than-expected costs. All data profiling or\nother data analysis pertaining to participating providers shall be done in a manner\nwhich is valid and reasonable. Plans shall not use criteria that would allow an\ninsurer to avoid high -risk populations by excluding providers because they are\nlocated in geographic areas that contain populations or providers presenting a risk\nof higher -than-average claims, losses, or health s ervices utilization or that would\nexclude providers because they treat or specialize in treating populations presenting\na risk of higher-than-average claims, losses, or health services utilization.\n(2) Each insurer shall establish mechanisms for soliciting  and acting upon applications\nfor provider participation in the plan in a fair and systematic manner. These\nmechanisms shall, at a minimum, include:\n(a) Allowing all providers who desire to apply for participation in the plan an\nopportunity to apply at any time during the year or, where an insurer does not\nconduct open continuous provider enrollment, conducting a provider\nenrollment period at least annually with the date publicized to providers\nlocated in the geographic service area of the plan at least thi rty (30) days in\nadvance of the enrollment periods; and\n(b) Making criteria for provider participation in the plan available to all\napplicants.\n(3) If a managed care plan terminates the participation of an enrollee's primary care\nprovider, the plan shall p rovide notice to the enrollee and arrange for the enrollee's\ncontinuity of care with an approved primary care provider.\n(4) An insurer that offers a managed care plan shall establish a policy governing the\nremoval of and withdrawal by health care providers  from the provider network that\nincludes the following:\n(a) The insurer shall inform a participating health care provider of the insurer's\nremoval and withdrawal policy at the time the insurer contracts with the health\ncare provider to participate in the p rovider network, and when changed\nthereafter;\n(b) If a participating health care provider's participation will be terminated or\nwithdrawn prior to the date of the termination of the contract as a result of a\nprofessional review action, the insurer and part icipating health care provider\nshall comply with the standards in 42 U.S.C. sec. 11112; and\n(c) If the insurer finds that a health care provider represents an imminent danger\nto an individual patient or to the public health, safety, or welfare, the medical\ndirector shall promptly notify the appropriate professional state licensing\nboard.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=17431","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"9db4e87cc190293e0624a52068af201f2c64b08d99e8ba9e9dd30bd5e5faeff2","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-520","next":"us-ky/krs-304.17a-527"},"notice":"GroundRules: Original legal text. Not legal advice."}