Kentucky Statutes 304.17A-550 – Out-of-network benefits
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(1) An insurer that offers a managed care plan shall offer a health benefit plan with out- of-network benefits to every contract holder. The plan with out-of-network benefits shall allow a covered person to receive covered services from out-of-network health care providers without having to obtain a referral. The plan with out-of-network benefits may require that an enrollee pre-certify selected services and pay a higher deductible, copayment, coinsurance, excess charges and higher premium for the out-of-network benefit plan pursuant to limits established by administrative regulations promulgated by the department.
(2) If the contract holder elects the out-of-network offering required under subsection (1) of this section, the insurer shall provide each enrollee with the opportunity at the time of enrollment and during the annual open enrollment period, to enroll in the out-of-network option. If the contract holder elects the out-of-network offering required under subsection (1) of this section, the insurer and the contract holder shall provide written notice of the benefit plan with out-of-network benefits to each enrollee in a plan and shall include in that notice a detailed explanation of the financial costs to be incurred by an enrollee who selects the plan.
(3) The requirement of this section shall not apply to an insurer contract which offers a managed care plan that provides health care services solely to Medicaid or Medicare recipients.
(4) Managed care plans currently licensed and doing business in Kentucky that do not yet offer benefit plans with out-of-network benefits must develop and offer those plans within three hundred sixty-five (365) days of April 10, 1998.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1232, effective July 15, 2010. — Amended 2004 Ky. Acts ch. 59, sec. 10, effective July 13, 2004. — Created 1998 Ky. Acts ch. 496, sec. 35, effective April 10, 1998.
(2) If the contract holder elects the out-of-network offering required under subsection (1) of this section, the insurer shall provide each enrollee with the opportunity at the time of enrollment and during the annual open enrollment period, to enroll in the out-of-network option. If the contract holder elects the out-of-network offering required under subsection (1) of this section, the insurer and the contract holder shall provide written notice of the benefit plan with out-of-network benefits to each enrollee in a plan and shall include in that notice a detailed explanation of the financial costs to be incurred by an enrollee who selects the plan.
Terms Used In Kentucky Statutes 304.17A-550
- At the time of enrollment: means :
(a) At the time of application for an individual, an association that actively markets to individual members, and an employer-organized association that actively markets to individual members. See Kentucky Statutes 304.17A-005 - Contract: A legal written agreement that becomes binding when signed.
- Insurer: means any insurance company. See Kentucky Statutes 304.17A-005
- Managed care: means systems or techniques generally used by third-party payors or their agents to affect access to and control payment for health care services and that integrate the financing and delivery of appropriate health care services to covered persons by arrangements with participating providers who are selected to participate on the basis of explicit standards for furnishing a comprehensive set of health care services and financial incentives for covered persons using the participating providers and procedures provided for in the plan. See Kentucky Statutes 304.17A-005
(3) The requirement of this section shall not apply to an insurer contract which offers a managed care plan that provides health care services solely to Medicaid or Medicare recipients.
(4) Managed care plans currently licensed and doing business in Kentucky that do not yet offer benefit plans with out-of-network benefits must develop and offer those plans within three hundred sixty-five (365) days of April 10, 1998.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1232, effective July 15, 2010. — Amended 2004 Ky. Acts ch. 59, sec. 10, effective July 13, 2004. — Created 1998 Ky. Acts ch. 496, sec. 35, effective April 10, 1998.