Kentucky Statutes 304.17C-030 – Disclosure
Current as of: 2024 | Check for updates
|
Other versions
(1) An insurer shall disclose in writing to a covered person and an insured or enrollee, in a manner consistent with the provisions of KRS § 304.14-420 to KRS § 304.14-450, the terms and conditions of its limited health service benefit plan and shall promptly provide the covered person and enrollee with written notification of any change in the terms and conditions prior to the effective date of the change. The insurer shall provide the required information at the time of enrollment and upon request thereafter.
(2) The information required to be disclosed under this section shall include a description of:
(a) Covered services and benefits to which the enrollee or other covered person is entitled;
(b) Restrictions or limitations on covered services and benefits;
(c) Financial responsibility of the covered person, including copayments and deductibles;
(d) Prior authorization and any other review requirements with respect to accessing covered services;
(e) Where and in what manner covered services may be obtained;
(f) Changes in covered services or benefits, including any addition, reduction, or elimination of specific services or benefits;
(g) The covered person’s right to the following:
1. A utilization review and the procedure for initiating a utilization review, if an insurer elects to provide utilization review; and
2. An internal appeal of a utilization review decision made by or on behalf of the insurer with respect to the denial, reduction, or termination of a limited health service benefit plan or the denial of payment for a health care service, and the procedure to initiate an internal appeal;
(h) Measures in place to ensure the confidentiality of the relationship between an enrollee and a health care provider;
(i) Other information as the commissioner shall require by administrative regulation;
(j) A summary of the drug formulary, including but not limited to a listing of the most commonly used drugs, drugs requiring prior authorization, any restrictions, limitations, and procedures for authorization to obtain drugs not on the formulary, and, upon request of an insured or enrollee, a complete drug formulary; and
(k) A statement informing the insured or enrollee that if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for participation, the provider has the right to become a provider for the insurer.
(3) The insurer shall file the information required under this section with the department.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1290, effective July 15, 2010. — Created
2002 Ky. Acts ch. 105, sec. 4, effective July 15, 2002.
(2) The information required to be disclosed under this section shall include a description of:
Terms Used In Kentucky Statutes 304.17C-030
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- At the time of enrollment: means the same as defined in KRS §. See Kentucky Statutes 304.17C-010
- Enrollee: means an individual who is enrolled in a limited health service benefit plan. See Kentucky Statutes 304.17C-010
- Insurer: means any insurance company, health maintenance organization, self- insurer or multiple employer welfare arrangement not exempt from state regulation by ERISA, provider-sponsored integrated health delivery network, self-insured employer-organized association, nonprofit hospital, medical-surgical, dental, health service corporation, or limited health service organization authorized to transact health insurance business in Kentucky who offers a limited health service benefit plan. See Kentucky Statutes 304.17C-010
- Limited health service benefit plan: means any policy or certificate that provides services for dental, vision, mental health, substance abuse, chiropractic, pharmaceutical, podiatric, or other such services as may be determined by the commissioner to be offered under a limited health service benefit plan. See Kentucky Statutes 304.17C-010
- provider: means the same as defined in KRS §. See Kentucky Statutes 304.17C-010
(a) Covered services and benefits to which the enrollee or other covered person is entitled;
(b) Restrictions or limitations on covered services and benefits;
(c) Financial responsibility of the covered person, including copayments and deductibles;
(d) Prior authorization and any other review requirements with respect to accessing covered services;
(e) Where and in what manner covered services may be obtained;
(f) Changes in covered services or benefits, including any addition, reduction, or elimination of specific services or benefits;
(g) The covered person’s right to the following:
1. A utilization review and the procedure for initiating a utilization review, if an insurer elects to provide utilization review; and
2. An internal appeal of a utilization review decision made by or on behalf of the insurer with respect to the denial, reduction, or termination of a limited health service benefit plan or the denial of payment for a health care service, and the procedure to initiate an internal appeal;
(h) Measures in place to ensure the confidentiality of the relationship between an enrollee and a health care provider;
(i) Other information as the commissioner shall require by administrative regulation;
(j) A summary of the drug formulary, including but not limited to a listing of the most commonly used drugs, drugs requiring prior authorization, any restrictions, limitations, and procedures for authorization to obtain drugs not on the formulary, and, upon request of an insured or enrollee, a complete drug formulary; and
(k) A statement informing the insured or enrollee that if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for participation, the provider has the right to become a provider for the insurer.
(3) The insurer shall file the information required under this section with the department.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1290, effective July 15, 2010. — Created
2002 Ky. Acts ch. 105, sec. 4, effective July 15, 2002.