Kentucky Statutes 304.17A-515 – Requirements for managed care plan
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(1) A managed care plan shall arrange for a sufficient number and type of primary care providers and specialists throughout the plan’s service area to meet the needs of enrollees. Each managed care plan shall demonstrate that it offers:
(a) An adequate number of accessible acute care hospital services, where physically available;
(b) An adequate number of accessible primary care providers, including family practice and general practice physicians, internists, obstetricians/gynecologists, and pediatricians, where available;
(c) An adequate number of accessible specialists and subspecialists, and when the specialist needed for a specific condition is not represented on the plan’s list of participating specialists, enrollees have access to nonparticipating health care providers with prior plan approval;
(d) The availability of specialty services; and
(e) A provider network that meets the following accessibility requirements:
1. For urban areas, a provider network that is available to all persons enrolled in the plan within thirty (30) miles or thirty (30) minutes of each person’s place of residence or work, to the extent that services are available; or
2. For areas other than urban areas, a provider network that makes available primary care physician services, hospital services, and pharmacy services within thirty (30) minutes or thirty (30) miles of each enrollee’s place of residence or work, to the extent those services are available. All other providers shall be available to all persons enrolled in the plan within fifty (50) minutes or fifty (50) miles of each enrollee’s place of residence or work, to the extent those services are available.
(2) A managed care plan shall provide telephone access to the plan during business hours to ensure plan approval of nonemergency care. A managed care plan shall provide adequate information to enrollees regarding access to urgent and emergency care.
(3) A managed care plan shall establish reasonable standards for waiting times to obtain appointments, except as provided for emergency care.
Effective: January 1, 2019
History: Amended 2018 Ky. Acts ch. 106, sec. 7, effective January 1, 2019. — Amended 2000 Ky. Acts ch. 476, sec. 31, effective July 14, 2000; and ch. 500, sec.
4, effective July 14, 2000. — Created 1998 Ky. Acts ch. 496, sec. 28, effective April
10, 1998, as amended by 1998 Ky. Acts ch. 585, sec. 1, effective April 14, 1998.
(a) An adequate number of accessible acute care hospital services, where physically available;
Terms Used In Kentucky Statutes 304.17A-515
- 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
- provider: means any:
(a) Advanced practice registered nurse licensed under KRS Chapter 314. See Kentucky Statutes 304.17A-005 - Provider network: means an affiliated group of varied health care providers that is established to provide a continuum of health care services to individuals. See Kentucky Statutes 304.17A-005
(b) An adequate number of accessible primary care providers, including family practice and general practice physicians, internists, obstetricians/gynecologists, and pediatricians, where available;
(c) An adequate number of accessible specialists and subspecialists, and when the specialist needed for a specific condition is not represented on the plan’s list of participating specialists, enrollees have access to nonparticipating health care providers with prior plan approval;
(d) The availability of specialty services; and
(e) A provider network that meets the following accessibility requirements:
1. For urban areas, a provider network that is available to all persons enrolled in the plan within thirty (30) miles or thirty (30) minutes of each person’s place of residence or work, to the extent that services are available; or
2. For areas other than urban areas, a provider network that makes available primary care physician services, hospital services, and pharmacy services within thirty (30) minutes or thirty (30) miles of each enrollee’s place of residence or work, to the extent those services are available. All other providers shall be available to all persons enrolled in the plan within fifty (50) minutes or fifty (50) miles of each enrollee’s place of residence or work, to the extent those services are available.
(2) A managed care plan shall provide telephone access to the plan during business hours to ensure plan approval of nonemergency care. A managed care plan shall provide adequate information to enrollees regarding access to urgent and emergency care.
(3) A managed care plan shall establish reasonable standards for waiting times to obtain appointments, except as provided for emergency care.
Effective: January 1, 2019
History: Amended 2018 Ky. Acts ch. 106, sec. 7, effective January 1, 2019. — Amended 2000 Ky. Acts ch. 476, sec. 31, effective July 14, 2000; and ch. 500, sec.
4, effective July 14, 2000. — Created 1998 Ky. Acts ch. 496, sec. 28, effective April
10, 1998, as amended by 1998 Ky. Acts ch. 585, sec. 1, effective April 14, 1998.