Kentucky Statutes 304.17C-060 – Filing of agreements — Provisions of agreements — Procedures for changing agreement — Filing of risk-sharing arrangements and subcontracts — Availability of information
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(1) An insurer shall file with the commissioner sample copies of any agreements it enters into with providers for the provision of health care services. The commissioner shall promulgate administrative regulations prescribing the manner and form of the filings required. The agreements shall include the following:
(a) A hold harmless clause that states that the provider may not, under any circumstance, including:
1. Nonpayment of moneys due to providers by the insurer;
2. Insolvency of the insurer; or
3. Breach of the agreement,
bill, charge, collect a deposit, seek compensation, remuneration, or reimbursement from, or have any recourse against the subscriber, dependent of subscriber, enrollee, or any persons acting on their behalf, for services provided in accordance with the provider agreement. This provision shall not prohibit collection of deductible amounts, copayment amounts, coinsurance amounts, and amounts for noncovered services;
(b) A survivorship clause that states the hold harmless clause and continuity of care clause shall survive the termination of the agreement between the provider and the insurer; and
(c) A clause requiring that if a provider enters into any subcontract agreement with another provider to provide health care services to the subscriber, dependent of the subscriber, or enrollee of a limited health service benefit plan, the subcontract agreement must meet all requirements of this subtitle and that all such subcontract agreements shall be filed with the commissioner in accordance with this subsection.
(2) Each insurer shall establish procedures for changing an existing agreement with a participating provider, as defined in KRS § 304.17A-235, which comply with KRS
304.17A-235.
(3) An insurer that enters into any risk-sharing arrangement or subcontract agreement shall file a copy of the arrangement with the commissioner. The insurer shall also file the following information regarding the risk-sharing arrangement:
(a) The number of enrollees affected by the risk-sharing arrangement;
(b) The health care services to be provided to an enrollee under the risk-sharing arrangement;
(c) The nature of the financial risk to be shared between the insurer and entity or provider, including but not limited to the method of compensation;
(d) Any administrative functions delegated by the insurer to the entity or provider.
The insurer shall describe a plan to ensure that the entity or provider will comply with the requirements of this subtitle in exercising any delegated administrative functions; and
(e) The insurer’s oversight and compliance plan regarding the standards and method of review.
(4) Nothing in this section shall be construed as requiring an insurer to submit the actual financial information agreed to between the insurer and the entity or provider. The commissioner shall have access to a specific risk-sharing arrangement with an entity or provider upon request to the insurer. Financial information obtained by the department shall be considered to be a trade secret and shall not be subject to KRS
61.872 to 61.884.
Effective: January 1, 2017
History: Amended 2016 Ky. Acts ch. 143, sec. 3, effective January 1, 2017. — Amended 2010 Ky. Acts ch. 24, sec. 1291, effective July 15, 2010. — Created 2002
Ky. Acts ch. 105, sec. 7, effective July 15, 2002.
(a) A hold harmless clause that states that the provider may not, under any circumstance, including:
Terms Used In Kentucky Statutes 304.17C-060
- Dependent: A person dependent for support upon another.
- 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
- Oversight: Committee review of the activities of a Federal agency or program.
- provider: means the same as defined in KRS §. See Kentucky Statutes 304.17C-010
- Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. Source: FDIC
1. Nonpayment of moneys due to providers by the insurer;
2. Insolvency of the insurer; or
3. Breach of the agreement,
bill, charge, collect a deposit, seek compensation, remuneration, or reimbursement from, or have any recourse against the subscriber, dependent of subscriber, enrollee, or any persons acting on their behalf, for services provided in accordance with the provider agreement. This provision shall not prohibit collection of deductible amounts, copayment amounts, coinsurance amounts, and amounts for noncovered services;
(b) A survivorship clause that states the hold harmless clause and continuity of care clause shall survive the termination of the agreement between the provider and the insurer; and
(c) A clause requiring that if a provider enters into any subcontract agreement with another provider to provide health care services to the subscriber, dependent of the subscriber, or enrollee of a limited health service benefit plan, the subcontract agreement must meet all requirements of this subtitle and that all such subcontract agreements shall be filed with the commissioner in accordance with this subsection.
(2) Each insurer shall establish procedures for changing an existing agreement with a participating provider, as defined in KRS § 304.17A-235, which comply with KRS
304.17A-235.
(3) An insurer that enters into any risk-sharing arrangement or subcontract agreement shall file a copy of the arrangement with the commissioner. The insurer shall also file the following information regarding the risk-sharing arrangement:
(a) The number of enrollees affected by the risk-sharing arrangement;
(b) The health care services to be provided to an enrollee under the risk-sharing arrangement;
(c) The nature of the financial risk to be shared between the insurer and entity or provider, including but not limited to the method of compensation;
(d) Any administrative functions delegated by the insurer to the entity or provider.
The insurer shall describe a plan to ensure that the entity or provider will comply with the requirements of this subtitle in exercising any delegated administrative functions; and
(e) The insurer’s oversight and compliance plan regarding the standards and method of review.
(4) Nothing in this section shall be construed as requiring an insurer to submit the actual financial information agreed to between the insurer and the entity or provider. The commissioner shall have access to a specific risk-sharing arrangement with an entity or provider upon request to the insurer. Financial information obtained by the department shall be considered to be a trade secret and shall not be subject to KRS
61.872 to 61.884.
Effective: January 1, 2017
History: Amended 2016 Ky. Acts ch. 143, sec. 3, effective January 1, 2017. — Amended 2010 Ky. Acts ch. 24, sec. 1291, effective July 15, 2010. — Created 2002
Ky. Acts ch. 105, sec. 7, effective July 15, 2002.