Kentucky Statutes 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 …
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(1) As used in this section:
(a) “Contractual discount” means a percentage reduction from a provider‘s usual and customary rate for covered services and material required under a participating provider agreement; and
(b) “Covered services” means services and materials for which:
1. Reimbursement from a plan is provided by the enrollee‘s plan contract;
or
2. Reimbursement would be available but for the application of the enrollee’s contractual limitations of deductibles, copayments, coinsurance, or frequency limitations.
(2) A participating 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 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.
Effective: July 14, 2022
History: Amended 2022 Ky. Acts ch. 48, sec. 6, effective July 14, 2022. — Created
2012 Ky. Acts ch. 116, sec. 10, effective July 12, 2012.
Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was amended by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.
(a) “Contractual discount” means a percentage reduction from a provider‘s usual and customary rate for covered services and material required under a participating provider agreement; and
Terms Used In Kentucky Statutes 304.17C-085
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means an individual who is enrolled in 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
- Statute: A law passed by a legislature.
(b) “Covered services” means services and materials for which:
1. Reimbursement from a plan is provided by the enrollee‘s plan contract;
or
2. Reimbursement would be available but for the application of the enrollee’s contractual limitations of deductibles, copayments, coinsurance, or frequency limitations.
(2) A participating 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 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.
Effective: July 14, 2022
History: Amended 2022 Ky. Acts ch. 48, sec. 6, effective July 14, 2022. — Created
2012 Ky. Acts ch. 116, sec. 10, effective July 12, 2012.
Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was amended by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.