Kansas Statutes 40-4607. Same; provider network required to be sufficient to ensure covered services accessible without unreasonable delay; determination of sufficiency of provider network; plan to provide for referral of insured to specialists under…
(a) A health insurer providing a health benefit plan shall maintain a provider network that is sufficient in numbers and types of providers to assure that all covered services to an insured will be accessible without unreasonable delay. Sufficiency of the provider network shall be determined in accordance with the requirements of this section, and may be established by reference to any reasonable criteria used by the health insurer, including but not limited to: provider-insured ratios by specialty; primary care provider-insured ratios; geographic accessibility; waiting times for appointments with participating providers; hours of operation; and the availability of technological and specialty services to serve the needs of insureds requiring technologically advanced or specialty care.
(b) A health insurer shall have a plan by which an insured with a life-threatening, chronic, degenerative or disabling condition or disease, which requires specialized medical care over a prolonged period of time, may receive a referral to a specialist with expertise in treating such disease or condition who shall be responsible for and capable of providing and coordinating the insured’s specialty care.
Terms Used In Kansas Statutes 40-4607
- Contract: A legal written agreement that becomes binding when signed.
- Health benefit plan: means any hospital or medical expense policy, health, hospital or medical service corporation contract, a plan provided by a municipal group-funded pool, a policy or agreement entered into by a health insurer or a health maintenance organization contract offered by an employer or any certificate issued under any such policies, contracts or plans. See Kansas Statutes 40-4602
- Health insurer: means any insurance company, nonprofit medical and hospital service corporation, municipal group-funded pool, fraternal benefit society, health maintenance organization, or any other entity which offers a health benefit plan subject to the Kansas Statutes Annotated. See Kansas Statutes 40-4602
- Insured: means a person who is covered by a health benefit plan. See Kansas Statutes 40-4602
- Provider: means a physician, hospital or other person which is licensed, accredited or certified to perform specified health care services. See Kansas Statutes 40-4602
- Provider network: means those participating providers who have entered into a contract or agreement with a health insurer to provide items or health care services to individuals covered by a health benefit plan offered by such health insurer. See Kansas Statutes 40-4602
(c) Nothing in this section shall require a health insurer to provide benefits not otherwise covered by the terms of the health benefits plan.
(d) A provider network shall not be determined to be insufficient for failure to contract with any provider unwilling to contract under the same terms and conditions, including reimbursement levels, as such health insurer offers to other similarly situated health care providers.