Kentucky Statutes 304.17B-011 – Third-party administrator to administer Kentucky Access — Selection and duties — Reimbursement for expenses
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(1) The Office of Health Data and Analytics shall select a third-party administrator, through the state competitive bidding process, to administer Kentucky Access. The third-party administrator shall be an administrator licensed by the department. The office shall consider criteria in selecting a third-party administrator that shall include, but not be limited to, the following:
(a) A third-party administrator’s proven ability to demonstrate performance of the operations of an insurer to include the following: enrollee enrollment, eligibility determination, provider enrollment and credentialing, utilization management, quality improvement, drug utilization review, premium billing and collection, claims payment, and data reporting;
(b) The total cost to administer Kentucky Access;
(c) A third-party administrator’s proven ability to demonstrate that Kentucky
Access shall be administered in a cost-efficient manner;
(d) A third-party administrator’s proven ability to demonstrate experience in two (2) or more states administering a risk pool for a minimum of a three (3) year period; and
(e) A third-party administrator’s financial condition and stability.
(2) The office may contract with the third-party administrator for a period of four (4) years with an option for a two (2) year extension as approved by the office on a year-by-year contract basis. At least one (1) year prior to the expiration of the third- party administrator’s contract, the office may solicit third-party administrators, including the current third-party administrator, to submit bids to serve as the third- party administrator for the succeeding four (4) year period.
(3) In addition to any duties and obligations set forth in the contract with the third-party administrator, the third-party administrator shall:
(a) Develop and establish policies and procedures for enrollee enrollment, eligibility determination, provider enrollment and credentialing, utilization management, case management, disease management, quality improvement, drug utilization review, premium billing and collection, data reporting, and other responsibilities determined by the office;
(b) Develop and establish policies and procedures for paying the agent referral fee under KRS § 304.17B-001 to KRS § 304.17B-031;
(c) Develop and establish policies and procedures to ensure timely and efficient payment of claims to include, but not limited to, the following:
1. Develop and provide a claims billing manual to health care providers enrolled in Kentucky Access that includes information relating to the proper billing of a claim and the types of claim forms to use;
2. Payment of all claims in accordance with the provisions of this chapter, KRS § 304.12-237, and the administrative regulations promulgated thereunder; and
3. Notification to an enrollee through an explanation of benefits if a claim is denied or if there is enrollee financial responsibility of a paid claim for deductible or coinsurance amounts;
(d) Issue denial letters under KRS § 304.17A-540 for denial of preauthorization and precertification requests for medical necessity and medical appropriateness determinations;
(e) Submit information to the office and the department under KRS § 304.17A-330; (f) Submit reports to the office regarding the operation and financial condition of
Kentucky Access. The frequency, content, and form of the reports shall be
determined by the office;
(g) Submit an annual report to the office three (3) months after the end of each calendar year. The annual report shall include:
1. Earned premium;
2. Administrative expenses;
3. Incurred losses for the year;
4. Paid losses for the year;
5. Number of enrollees enrolled in Kentucky Access by category of eligibility; and
6. Any other information requested by the office; and
(h) Be subject to examination by the office under Subtitles 2 and 3 of this chapter. (4) The third-party administrator shall be paid for necessary and reasonable expenses,
as provided in the contract between the office and the third-party administrator.
Effective: June 29, 2021
History: Amended 2021 Ky. Acts ch. 30, sec. 4, effective June 29, 2021. — Amended
2019 Ky. Acts ch. 90, sec. 16, effective June 27, 2019. — Amended 2010 Ky. Acts ch. 24, sec. 1278, effective July 15, 2010. — Created 2000 Ky. Acts ch. 476, sec. 6, effective July 14, 2000.
(a) A third-party administrator’s proven ability to demonstrate performance of the operations of an insurer to include the following: enrollee enrollment, eligibility determination, provider enrollment and credentialing, utilization management, quality improvement, drug utilization review, premium billing and collection, claims payment, and data reporting;
Terms Used In Kentucky Statutes 304.17B-011
- agent: includes managing general agent unless the context requires otherwise. See Kentucky Statutes 304.9-085
- Case management: means a process for identifying an enrollee with specific health care needs and interacting with the enrollee and their respective health care providers in order to facilitate the development and implementation of a plan that efficiently uses health care resources to achieve optimum health outcome. See Kentucky Statutes 304.17B-001
- Contract: A legal written agreement that becomes binding when signed.
- Earned premium: means the portion of premium paid by an insured that has been allocated to the insurer's loss experience, expenses, and profit year to date. See Kentucky Statutes 304.17B-001
- Enrollee: means a person who is enrolled in a health benefit plan offered under
Kentucky Access. See Kentucky Statutes 304.17B-001 - Incurred losses: means for Kentucky Access the excess of claims paid over premiums received. See Kentucky Statutes 304.17B-001
- Office: means the Office of Health Data and Analytics in the Cabinet for Health and Family Services. See Kentucky Statutes 304.17B-001
- State: when applied to a part of the United States, includes territories, outlying possessions, and the District of Columbia. See Kentucky Statutes 446.010
- Year: means calendar year. See Kentucky Statutes 446.010
(b) The total cost to administer Kentucky Access;
(c) A third-party administrator’s proven ability to demonstrate that Kentucky
Access shall be administered in a cost-efficient manner;
(d) A third-party administrator’s proven ability to demonstrate experience in two (2) or more states administering a risk pool for a minimum of a three (3) year period; and
(e) A third-party administrator’s financial condition and stability.
(2) The office may contract with the third-party administrator for a period of four (4) years with an option for a two (2) year extension as approved by the office on a year-by-year contract basis. At least one (1) year prior to the expiration of the third- party administrator’s contract, the office may solicit third-party administrators, including the current third-party administrator, to submit bids to serve as the third- party administrator for the succeeding four (4) year period.
(3) In addition to any duties and obligations set forth in the contract with the third-party administrator, the third-party administrator shall:
(a) Develop and establish policies and procedures for enrollee enrollment, eligibility determination, provider enrollment and credentialing, utilization management, case management, disease management, quality improvement, drug utilization review, premium billing and collection, data reporting, and other responsibilities determined by the office;
(b) Develop and establish policies and procedures for paying the agent referral fee under KRS § 304.17B-001 to KRS § 304.17B-031;
(c) Develop and establish policies and procedures to ensure timely and efficient payment of claims to include, but not limited to, the following:
1. Develop and provide a claims billing manual to health care providers enrolled in Kentucky Access that includes information relating to the proper billing of a claim and the types of claim forms to use;
2. Payment of all claims in accordance with the provisions of this chapter, KRS § 304.12-237, and the administrative regulations promulgated thereunder; and
3. Notification to an enrollee through an explanation of benefits if a claim is denied or if there is enrollee financial responsibility of a paid claim for deductible or coinsurance amounts;
(d) Issue denial letters under KRS § 304.17A-540 for denial of preauthorization and precertification requests for medical necessity and medical appropriateness determinations;
(e) Submit information to the office and the department under KRS § 304.17A-330; (f) Submit reports to the office regarding the operation and financial condition of
Kentucky Access. The frequency, content, and form of the reports shall be
determined by the office;
(g) Submit an annual report to the office three (3) months after the end of each calendar year. The annual report shall include:
1. Earned premium;
2. Administrative expenses;
3. Incurred losses for the year;
4. Paid losses for the year;
5. Number of enrollees enrolled in Kentucky Access by category of eligibility; and
6. Any other information requested by the office; and
(h) Be subject to examination by the office under Subtitles 2 and 3 of this chapter. (4) The third-party administrator shall be paid for necessary and reasonable expenses,
as provided in the contract between the office and the third-party administrator.
Effective: June 29, 2021
History: Amended 2021 Ky. Acts ch. 30, sec. 4, effective June 29, 2021. — Amended
2019 Ky. Acts ch. 90, sec. 16, effective June 27, 2019. — Amended 2010 Ky. Acts ch. 24, sec. 1278, effective July 15, 2010. — Created 2000 Ky. Acts ch. 476, sec. 6, effective July 14, 2000.