{"data":{"id":"us-ky/krs-304.17c-085","jurisdiction":"us-ky","citation":"KRS 304.17C-085","heading":"Definitions for section -- Set fees for noncovered services in","body":"participating provider agreement prohibited -- Provider charges limited to\nprovider's rate for services and materials -- Contractual discount for covered\nservices -- Reimbursement -- Provisions cannot be waived by contract.\n(1) As used in this section:\n(a) \"Contractual discount\" means a percentage reduction from a provider's usual\nand customary rate for covered services required under a participating\nprovider agreement; and\n(b) \"Covered services\":\n1. Means services and materials for which:\na. Reimbursement from a plan is provided by the enrollee's plan\ncontract; or\nb. Reimbursement would be available but for the application of the\nenrollee's contractual limitations of dedu ctibles, copayments,\ncoinsurance, or frequency limitations; and\n2. Does not include services and materials for which reimbursement would\nbe available but for the application of the enrollee's contractual\nlimitation of an annual maximum benefit.\n(2) A parti cipating provider agreement shall not require a participating provider to\nprovide services to an enrollee at a fee set by or subject to the approval of the\nlimited health service benefit plan unless the services are covered services under the\nparticipating provider agreement.\n(3) A provider shall not charge more for services and materials that are noncovered\nservices under a limited health service benefit plan than the provider's rate for the\nservices and materials.\n(4) The amount of a contractual discount shall not result in a fee  that is less than the\nlimited health service benefit plan would pay for covered services but for the\napplication an enrollee's contractual limitations of deductibles, copayments,\ncoinsurance, or frequency limitations.\n(5) Reimbursement paid by the limited health service benefit plan for covered services:\n(a) Shall be reasonable; and\n(b) Shall not provide nominal reimbursement in order to claim that services and\nmaterials are covered services.\n(6) The provisions of this section shall not be waived by contra ct. Any contractual\narrangement in conflict with this section or that purports to waive any requirement\nof this section shall be void.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57658","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:49Z","sha256":"4c3b7a859e933a93f0f038ef14c5590d9f9e1d4b92473f9ead37a1853f16ddbd","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17c-080","next":"us-ky/krs-304.17c-090"},"notice":"GroundRules: Original legal text. Not legal advice."}