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HB 69 (BR 127) - K. Fleming

     AN ACT relating to service delivery improvements in managed care networks.
    Create new sections of KRS Chapter 205 to define terms; establish and require that the Department for Medicaid Services designate a single credentialing verification organization to verify credentials for DMS and all contracted Medicaid Managed Care Organizations; submit the credentialing organization to Government Contract Review Committee for comment; require providers to submit a single application to the credentialing organization; require notification within 5 days to the provider if application is complete; require verified packets be sent to the DMS and MCOs within 30 days; require DMS to enroll providers within 15 days and for the MCOs to determine if they will contract with the provider within 15 days; specify that for reimbursement of claims purposes the date of the submission of the credentialing application shall be the date of original enrollment and credentialing; address the written internal appeals process of MCOs; require 24/7 utilization reviews and daily staffing for claims resolution; establish grievance and appeal timeline and written appeal requirements; require reprocessing of incorrectly paid or erroneously denied claims; allow for in-person meetings for unpaid claims beyond 45 days and that individually or in the aggregate exceed $2,500; require consistency and timeliness between physical, behavioral, or other medically necessary services; establish timelines for preauthorization requests; require that substance use disorder be treated as an urgent preauthorization request; require a single nationally recognized clinical review criteria for both physical health and behavioral health services; establish monthly reporting requirements for MCOs relating to claims; require reporting between the DMS and the Department of Insurance; establish penalties for MCOs that fail to comply; prohibit automatic assignment of Medicaid enrollees to an MCO unless there is a participating acute care hospital within the distance requirements; allow for enrollees to change MCOs outside of the open enrollment if their hospital or PCP terminates participation with an MCO; amend KRS 304.17A-515 to require each managed care plan to demonstrate that it offers physically available acute care hospital services; amend KRS 304.17A-576 to require a response about credentialing within 45 instead of 90 days; amend KRS 304.17A-700 to reference Section 1 of the bill.


AMENDMENTS

     HCS1 - Amend original provisions to require DMS to enroll providers within 30 days and for the MCOs to determine if they will contract with the provider within 30 days; specify that for reimbursement of claims purposes the date of the submission of the credentialing application shall be the date of receipt of clean application for credentialing; address the written internal appeals process of MCOs; require telephone line for utilization reviews and staffing for claims resolution; establish grievance and appeal timeline and written appeal requirements; require reprocessing of incorrectly paid or erroneously denied claims; allow for in-person meetings for unpaid clean claims not properly paid and other unpaid claims beyond 45 days and that individually or in the aggregate exceed $2,500; conform definition of timeliness for authorization request to federal regulations; change "urgent preauthorization request" to "expedited authorization request"; modify penalties for MCOs that fail to comply; prohibit automatic assignment of Medicaid enrollees to an MCO; create a new section of KRS Chapter 205 to require Medicaid MCOs to have a utilization review plan and use review criteria selected by the Department of Insurance; amend KRS 205.522 to require Medicaid MCOs to comply with KRS 304.17A-515; amend KRS 304.17A-515 to require each managed care plan to demonstrate that it offers physically available acute care hospital services; amend KRS 304.17A-576 to require a response about credentialing within 45 instead of 90 days; amend KRS 304.17A-700 to reference Section 1 of the bill; Create a new section of Subtitle 38 of KRS Chapter 304 to require the commissioner of insurance to promulgate administrative regulations to select utilization review criteria for use by Medicaid MCOs; amend KRS 304.3-200 to allow revocation of certificate of authority of an insurer offering Medicaid services for failure to comply; amend KRS 304.38-130 to allow revocation of certificate of authority of an HMO offering Medicaid services for failure to comply; amend KRS 304.99-123 to allow the Department of Insurance to assess fines against Medicaid Managed Care organizations for failure to comply.

     Nov 29, 2017 - Prefiled by the sponsor(s).
     Jan 02, 2018 - introduced in House; to Banking & Insurance (H)
     Jan 31, 2018 - posted in committee
     Feb 15, 2018 - reported favorably, 1st reading, to Calendar with Committee Substitute
     Feb 16, 2018 - 2nd reading, to Rules
     Feb 20, 2018 - posted for passage in the Regular Orders of the Day for Wednesday, February 21, 2018