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HB 566/FN (BR 1650) - T. Thompson, B. DeWeese, J. Jenkins, S. Santoro

     AN ACT relating to managed care organizations that contract with the Department for Medicaid Services.
     Establish KRS Chapter 205A relating to managed care organizations, (MCO) contracting with the Department for Medicaid Services for provision of health care services, and create new sections thereof to define terms; prohibit a MCO from requiring a provider to participate in additional product lines of the MCO as a condition of participation in the MCO; require a MCO to provide chiropractic benefits; prohibit a MCO from discrimination against a provider on the basis of a MD or DO degree; require a MCO to provide written notification of covered services and benefits and any changes to enrollees, establish time frames for notification, information to be included, and require materials to be filed with the Department for Medicaid Services; require a MCO to provide written notification to enrollees of the availability of written documents, establish contents of required documents, provide information about qualifications of a provider to an enrollee upon request, and make annual financial statement available; require a MCO to have a provider network sufficient to meet enrollee needs; require a MCO to provide adequate choice of primary care providers to enrollees, permit enrollee choice of primary care provider, permit women choice of providers for routine and preventive women's health care screenings, and provide enrollee access to providers for second medical opinion; require a MCO to establish standards for provider participation and mechanisms for soliciting and acting upon provider applications, notify enrollees about termination of provider and arrange continuity of care, and establish policy for removal or withdrawal of health care providers; require a MCO to file copies of provider agreements, risk sharing agreements, and subcontract agreements with the department; prohibit against contract provisions limiting disclosure to an enrollee about the enrollee's medical condition or treatment options; prohibit against contract requiring mandatory use of hospitalist; require a MCO to include a drug utilization review program, limit generic drug substitution, and have exceptions policy to use of drug formulary; require a MCO to disclose limitations on coverage and to provide denial letter to enrollee; establish the qualifications and duties of the MCO medical director, require a MCO to adopt national standards and review criteria, develop quality assurance or improvement standards, and establish process to select health care providers; require a MCO to have medical record confidentiality policies and procedures in compliance with HIPAA and ensure protection of medical records from unauthorized disclosure; to prohibit inclusion of a most-favored-nation provision in a MCO contract with a provider; require disclosure of a payment or fee schedule and any changes to MCO health care providers and require confidentiality of provider about payment information; to define the term "material change" and require MCO to notify a health care provider of a material change to the managed care plan; require a MCO to educate enrollees about appropriate use of emergency and other medical services, require payment for in- and out-of-network services without prior approval for emergency care, and require emergency personnel to contact enrollee's primary care provider or MCO; require a MCO to provide a directory of participating providers to enrollees; require a MCO to maintain written policies and procedures for determining covered services, making utilization review determinations, and notifying enrollees about its determinations; prohibit a MCO from providing or performing utilization review without being registered with the Department of Insurance and require findings of noncompliance by the Department for Medicaid Services to be reported to the Department of Insurance for appropriate action; require a MCO to provide written information to the department about the utilization review plan, require the department to establish reporting requirements for the MCO utilization review in accordance with the managed care contract; require timely utilization review decision; define the term "coverage denial", require a MCO to have a grievance and appeals process, establish requirements for expedited review, and require the department to establish and maintain a system for receiving and reviewing requests for state fair hearings; require disclosure of new information regarding internal appeal, establish time frame for rendering decision, and establish that failure of MCO to render decision within required time frame to be deemed as adverse determination by the MCO for the purpose of initiating a state fair hearing; establish process for initiation and notification of state fair hearing; require the department to provide enrollees with a hearing process and establish the time frame for requesting a state fair hearing, documentation, and notification; establish the requirements for stabilization of enrollees with an emergency medical condition in a nonparticipating hospital; prohibit a MCO from preventing referral to a specialist by a primary care provider; prohibit a MCO from preventing authorization of an enrollee's referral to a participating obstetrician or gynecologist and authorize annual pap smear without referral; require a MCO to permit an enrollee to access a dentist or covered dental service an optometrist or ophthalmologist for a covered vision service without a referral; permit an enrollee to disenroll from a MCO as provided by federal law; require a MCO to comply with the Mental Health Parity and Addiction Equity Act of 2008 and federal law; require the department to enforce the provisions of KRS Chapter 205A and to promulgate administrative regulations; amend KRS 304.3-170 to prohibit the Commissioner of Insurance from amending the certificate authority of an insurer also serving as a managed care organization without written notification from the Department of Medicaid Services confirming compliance of the MCO with the provisions of KRS Chapter 205A for at least one year.

     Mar 1-introduced in House
     Mar 5-to Health & Welfare (H)
     Mar 13-posted in committee
     Mar 14-posting withdrawn

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