Limited Health Service Benefit Plans

KRS tit. XXV, ch. 304, subtit. 17C

in effect

KRS 304.17C-010 Definitions for subtitle

304.17C-010. Definitions for subtitle As used in this subtitle, unless the context requires otherwise: (1) "At the time of enrollment" means the same as defined in KRS 304.17A-005(2); (2) "Enrollee" means an individual who is enrolled in a limited health service benefit plan; (3) "Health care provider" or "provider" means the same as defined in KRS 304.17A- 005(23); (4) "Insurer" means any insurance company, health maintenance organization, self- insurer or multiple employer welfare arrangement not exempt from state regulation by ERISA, provider-sponsored integrated health delivery network, self-insured employer-organized association, nonprofit hospital, medical-surgical, dental, health service corporation, or limited health service organization authorized to transact health insurance business in Kentucky who offers a limited health service benefit plan; and (5) "Limited health service benefit plan" means any policy or certificate that provides services for dental, vision, mental health, substance abuse, chiropractic, pharmaceutical, podiatric, or other such services as may be determined by the commissioner to be offered under a limited health service benefit plan. A limited health service benefit plan shall not include hospital, medical, surgical, or emergency services except as these services are provided incidental to the plan. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1289, effective July 15, 2010. -- Amended 2006 Ky. Acts ch. 253, sec. 8, effective July 12, 2006. -- Amended 2005 Ky. Acts ch. 144, sec. 11, effective June 20, 2005. -- Created 2002 Ky. Acts ch. 105, sec. 2, effective July 15, 2002.

KRS 304.17C-020 Discrimination prohibited against willing provider located in area

304.17C-020. Discrimination prohibited against willing provider located in area A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the limited health benefit plan and who is willing to meet the terms and conditions for participation established by the insurer. Effective: July 15, 2002 History: Created 2002 Ky. Acts ch. 105, sec. 3, effective July 15, 2002.

KRS 304.17C-030 Disclosure

304.17C-030. Disclosure (1) An insurer shall disclose in writing to a covered person and an insured or enrollee, in a manner consistent with the provisions of KRS 304.14-420 to 304.14-450, the terms and conditions of its limited health service benefit plan and shall promptly provide the covered person and enrollee with written notification of any change in the terms and conditions prior to the effective date of the change. The insurer shall provide the required information at the time of enrollment and upon request thereafter. (2) The information required to be disclosed under this section shall include a description of: (a) Covered services and benefits to which the enrollee or other covered person is entitled; (b) Restrictions or limitations on covered services and benefits; (c) Financial responsibility of the covered person, including copayments and deductibles; (d) Prior authorization and any other review requirements with respect to accessing covered services; (e) Where and in what manner covered services may be obtained; (f) Changes in covered services or benefits, including any addition, reduction, or elimination of specific services or benefits; (g) The covered person's right to the following: 1. A utilization review and the procedure for initiating a utilization review, if an insurer elects to provide utilization review; and 2. An internal appeal of a utilization review decision made by or on behalf of the insurer with respect to the denial, reduction, or termination of a limited health service benefit plan or the denial of payment for a health care service, and the procedure to initiate an internal appeal; (h) Measures in place to ensure the confidentiality of the relationship between an enrollee and a health care provider; (i) Other information as the commissioner shall require by administrative regulation; (j) A summary of the drug formulary, including but not limited to a listing of the most commonly used drugs, drugs requiring prior authorization, any restrictions, limitations, and procedures for authorization to obtain drugs not on the formulary, and, upon request of an insured or enrollee, a complete drug formulary; and (k) A statement informing the insured or enrollee that if the provider meets the insurer's enrollment criteria and is willing to meet the terms and conditions for participation, the provider has the right to become a provider for the insurer. (3) The insurer shall file the information required under this section with the department. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1290, effective July 15, 2010. -- Created 2002 Ky. Acts ch. 105, sec. 4, effective July 15, 2002.

KRS 304.17C-040 Availability of provider network

304.17C-040. Availability of provider network An insurer that offers a limited health service benefit plan that utilizes a provider network shall have a provider network that is available to all persons enrolled in the plan within thirty (30) minutes or thirty (30) miles of each enrollee's place of residence or work, to the extent available. Effective: July 15, 2002 History: Created 2002 Ky. Acts ch. 105, sec. 5, effective July 15, 2002.

KRS 304.17C-050 Standards for providers -- Mechanism for acting upon applications -- Policy governing removal of providers from network

304.17C-050. Standards for providers -- Mechanism for acting upon applications -- Policy governing removal of providers from network (1) Insurers shall establish relevant, objective standards for initial consideration of providers and for providers to continue as a participating provider in the plan. Standards shall be reasonably related to services provided. Selection or participation standards based on the economics or capacity of a provider's practice shall be adjusted to account for case mix, severity of illness, patient age, and other features that may account for higher-than-expected or lower-than-expected costs. All data profiling or other data analysis pertaining to participating providers shall be done in a manner which is valid and reasonable. Plans shall not use criteria that would allow an insurer to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations or providers presenting a risk of higher than average claims, losses, or health services utilization, or that would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses, or health services utilization. (2) Each insurer shall establish mechanisms for soliciting and acting upon applications for provider participation in the plan in a fair and systematic manner. These mechanisms shall, at a minimum, include: (a) Allowing all providers who desire to apply for participation in the plan an opportunity to apply at any time during the year, or, where an insurer does not conduct open continuous provider enrollment, conducting a provider enrollment period at least annually with the date publicized to providers located in the geographic service area of the plan at least thirty (30) days in advance of the enrollment period; and (b) Making criteria for provider participation in the plan available to all applicants. (3) An insurer that offers a limited health service benefit plan shall establish a policy governing the removal of and withdrawal by health care providers from the provider network that includes the following: (a) The insurer shall inform a participating health care provider of the insurer's removal and withdrawal policy at the time the insurer contracts with the health care provider to participate in the provider network, and when changed thereafter; (b) If a participating health care provider's participation will be terminated or withdrawn prior to the date of the termination of the contract as a result of a professional review action, the insurer and participating health care provider shall comply with the standards in 42 U.S.C. sec. 11112; and (c) If the insurer finds that a health care provider represents an imminent danger to an individual patient or to the public health, safety, or welfare, the medical director shall promptly notify the appropriate professional state licensing board. Effective: July 15, 2002 History: Created 2002 Ky. Acts ch. 105, sec. 6, effective July 15, 2002.

KRS 304.17C-060 Filing of agreements -- Provisions of agreements -- Procedures for changing agreement -- Filing of risk-sharing arrangements and subcontracts -- Availability of information

304.17C-060. Filing of agreements -- Provisions of agreements -- Procedures for changing agreement -- Filing of risk-sharing arrangements and subcontracts -- Availability of information (1) An insurer shall file with the commissioner sample copies of any agreements it enters into with providers for the provision of health care services. The commissioner shall promulgate administrative regulations prescribing the manner and form of the filings required. The agreements shall include the following: (a) A hold harmless clause that states that the provider may not, under any circumstance, including: 1. Nonpayment of moneys due to providers by the insurer; 2. Insolvency of the insurer; or 3. Breach of the agreement, bill, charge, collect a deposit, seek compensation, remuneration, or reimbursement from, or have any recourse against the subscriber, dependent of subscriber, enrollee, or any persons acting on their behalf, for services provided in accordance with the provider agreement. This provision shall not prohibit collection of deductible amounts, copayment amounts, coinsurance amounts, and amounts for noncovered services; (b) A survivorship clause that states the hold harmless clause and continuity of care clause shall survive the termination of the agreement between the provider and the insurer; and (c) A clause requiring that if a provider enters into any subcontract agreement with another provider to provide health care services to the subscriber, dependent of the subscriber, or enrollee of a limited health service benefit plan, the subcontract agreement must meet all requirements of this subtitle and that all such subcontract agreements shall be filed with the commissioner in accordance with this subsection. (2) Each insurer shall establish procedures for changing an existing agreement with a participating provider, as defined in KRS 304.17A-235, which comply with KRS 304.17A-235. (3) An insurer that enters into any risk-sharing arrangement or subcontract agreement shall file a copy of the arrangement with the commissioner. The insurer shall also file the following information regarding the risk-sharing arrangement: (a) The number of enrollees affected by the risk-sharing arrangement; (b) The health care services to be provided to an enrollee under the risk-sharing arrangement; (c) The nature of the financial risk to be shared between the insurer and entity or provider, including but not limited to the method of compensation; (d) Any administrative functions delegated by the insurer to the entity or provider. The insurer shall describe a plan to ensure that the entity or provider will comply with the requirements of this subtitle in exercising any delegated administrative functions; and (e) The insurer's oversight and compliance plan regarding the standards and method of review. (4) Nothing in this section shall be construed as requiring an insurer to submit the actual financial information agreed to between the insurer and the entity or provider. The commissioner shall have access to a specific risk-sharing arrangement with an entity or provider upon request to the insurer. Financial information obtained by the department shall be considered to be a trade secret and shall not be subject to KRS 61.872 to 61.884. Effective: January 1, 2017 History: Amended 2016 Ky. Acts ch. 143, sec. 3, effective January 1, 2017. -- Amended 2010 Ky. Acts ch. 24, sec. 1291, effective July 15, 2010. -- Created 2002 Ky. Acts ch. 105, sec. 7, effective July 15, 2002.

KRS 304.17C-070 Prohibition of contract to limit disclosure to enrollee -- Actions for which provider may not be penalized -- Disclosure of arrangements between plan and providers

304.17C-070. Prohibition of contract to limit disclosure to enrollee -- Actions for which provider may not be penalized -- Disclosure of arrangements between plan and providers (1) An insurer may not contract with a health care provider to limit the provider's disclosure to an enrollee, or to another person on behalf of an enrollee, of any information relating to the enrollee's medical condition or treatment option. (2) A health care provider shall not be penalized, or a health care provider's contract with a limited health service benefit plan terminated, because the provider discusses medically necessary or appropriate care with an enrollee or another person on behalf of an enrollee. (a) The health care provider may not be prohibited by the plan from discussing all treatment options with the enrollee. (b) Other information determined by the health care provider to be in the best interests of the enrollee may be disclosed by the provider to the enrollee or to another person on behalf of an enrollee. (3) (a) A health care provider shall not be penalized for discussing financial incentives and financial arrangements between the provider and the insurer with an enrollee. (b) Upon request, an insurer shall inform its enrollees in writing of the type of financial arrangements between the plan and participating providers if those arrangements include an incentive or bonus. Effective: July 15, 2002 History: Created 2002 Ky. Acts ch. 105, sec. 8, effective July 15, 2002.

KRS 304.17C-080 Plan for selection and reevaluation of providers

304.17C-080. Plan for selection and reevaluation of providers (1) Each insurer shall have a process for the selection of health care providers who will be on the plan's list of participating providers, with written policies and procedures for review and approval used by the plan. (2) The plan shall establish minimum professional requirements for participating health care providers. An insurer may not discriminate against a provider solely on the basis of the provider's license by the state. (3) The plan shall demonstrate that it has consulted with appropriately qualified health care providers to establish the minimum professional requirements. (4) The plan's selection process shall include verification of each health care provider's license, history of license suspension or revocation, and liability claims history. (5) An insurer shall establish a formal written, ongoing process for the reevaluation of each participating health care provider within a specified number of years after the provider's initial acceptance into the plan. The reevaluation shall include an update of the previous review criteria and an assessment of the provider's performance pattern based on criteria such as enrollee clinical outcomes, number of complaints, and malpractice actions. Effective: July 15, 2002 History: Created 2002 Ky. Acts ch. 105, sec. 9, effective July 15, 2002.

KRS 304.17C-085 Definitions for section -- Set fees for noncovered services in participating provider agreement prohibited -- Provider charges limited to provider's rate for services and materials -- Contractual discount for covered services -- Reimbursement -- Provisions cannot be waived by contract

304.17C-085. Definitions for section -- Set fees for noncovered services in participating provider agreement prohibited -- Provider charges limited to provider's rate for services and materials -- Contractual discount for covered services -- Reimbursement -- Provisions cannot be waived by contract (1) As used in this section: (a) "Contractual discount" means a percentage reduction from a provider's usual and customary rate for covered services required under a participating provider agreement; and (b) "Covered services": 1. Means services and materials for which: a. Reimbursement from a plan is provided by the enrollee's plan contract; or b. Reimbursement would be available but for the application of the enrollee's contractual limitations of dedu ctibles, copayments, coinsurance, or frequency limitations; and 2. Does not include services and materials for which reimbursement would be available but for the application of the enrollee's contractual limitation of an annual maximum benefit. (2) A participating provider agreement shall not require a participating provider to provide services to an enrollee at a fee set by or subject to the approval of the limited health service benefit plan unless the services are covered services under the participating provider agreement. (3) A provider shall not charge more for services and materials that are noncovered services under a limited health service benefit plan than the provider's rate for the services and materials. (4) The amount of a contractual discount shall not result in a fee that is less than the limited health service benefit plan would pay for covered services but for the application an enrollee's contractual limitations of deductibles, copayments, coinsurance, or frequency limitations. (5) Reimbursement paid by the limited health service benefit plan for covered services: (a) Shall be reasonable; and (b) Shall not provide nominal reimbursement in order to claim that services and materials are covered services. (6) The provisions of this section shall not be waived by contra ct. Any contractual arrangement in conflict with this section or that purports to waive any requirement of this section shall be void. Effective: July 15, 2026 History: Amended 2026 Ky. Acts ch. 131, sec. 18, effective July 15, 2026. -- Amended 2022 Ky. Acts ch. 48, sec. 6, effective July 14, 2022. -- Created 2012 Ky. Acts ch. 116, sec. 10, effective July 12, 2012. Legislative Research Commission Note (7/15/2026). 2026 Ky. Acts ch. 131, sec. 19, provides that the amendments to this statute in that Act shall apply to contracts issued or renewed on or after July 15, 2026. Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was amended by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.

KRS 304.17C-090 Payment of claims of dental-only benefits -- Reports -- Interest

304.17C-090. Payment of claims of dental-only benefits -- Reports -- Interest The provisions of KRS 304.17A-700 to 304.17A-730, relating to payment of claims, shall apply to limited health service benefit plans for the provision of dental-only benefits, except as follows: (1) A limited health service plan for the provision of dental-only benefits, its agent, or designee shall have three (3) business days in which to respond to an original or corrected claim submitted electronically under KRS 304.17A-704(1)(a) or, within three (3) business days, the limited health service benefit plan for the provision of dental-only benefits, its agent, or designee may list the claim and the date it was received on a file that can be accessed electronically by the provider, its agent, or designee. (2) Limited health service benefit plans for the provision of dental-only benefits shall be required to submit the reports required by KRS 304.17A-722 on an annual basis. (3) Limited health service benefit plans for the provision of dental-only benefits shall be required to pay interest required under KRS 304.17A-730 for a claim only if the interest calculated on that claim is equal to or greater than five dollars ($5). Effective: January 1, 2006 History: Created 2005 Ky. Acts ch. 169, sec. 1, effective January 1, 2006.

KRS 304.17C-100 Payment for coverage of services within scope of practice of optometrists

304.17C-100. Payment for coverage of services within scope of practice of optometrists Any limited health service benefit plan issued or renewed on or after July 12, 2006, which provides coverage for services rendered by a physician or osteopath duly licensed under KRS Chapter 311 that are within the scope of practice of an optometrist duly licensed under the provisions of KRS Chapter 320 shall provide the same payment of coverage to optometrists as allowed for those services rendered by physicians or osteopaths. Effective: July 12, 2006 History: Created 2006 Ky. Acts ch. 164, sec. 8, effective July 12, 2006.

KRS 304.17C-110 Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist

304.17C-110. Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist An insurer shall not impose a copayment or coinsurance amount charged to the insured for services rendered by a chiropractor licensed under KRS Chapter 312 or an optometrist licensed under KRS Chapter 320 that is greater than the copayment or coinsurance amount charged to the insured for the services of a physician or an osteopath licensed under KRS Chapter 311 for the same or similar diagnosed condition, even if different nomenclature is used to describe the condition or complaint. Effective: July 12, 2006 History: Created 2006 Ky. Acts ch. 253, sec. 12, effective July 12, 2006.

KRS 304.17C-120 Prescription eye drops coverage to include refills and additional bottle if conditions met

304.17C-120. Prescription eye drops coverage to include refills and additional bottle if conditions met (1) As used in this section, "practitioner" has the same meaning as in KRS 217.015. (2) Any limited health service benefit plan issued or renewed on or after January 1, 2015, that provides coverage for prescription eye drops shall not deny coverage for a refill of a prescription if: (a) The refill is requested by the insured: 1. For a thirty (30) day supply, between twenty-five (25) days and thirty (30) days from the later of: a. The original date the prescription was distributed to the insured; or b. The date the most recent refill was distributed to the insured; and 2. For a ninety (90) day supply, between eighty (80) days and ninety (90) days from the later of: a. The original date the prescription was distributed to the insured; or b. The date the most recent refill was distributed to the insured; and (b) The prescribing practitioner indicates on the original prescription that additional quantities are needed, and the refill requested by the insured does not exceed the number of additional quantities needed. (3) (a) Any limited health service benefit plan issued or renewed on or after January 1, 2015, that provides coverage for prescription eye drops shall provide coverage for one (1) additional bottle of prescription eye drops, pursuant to KRS 304.17A-165, when: 1. The additional bottle is requested by the insured or the prescribing practitioner at the time the original prescription is distributed to the insured; and 2. The prescribing practitioner indicates on the original prescription that the additional bottle is needed by the insured for use in a day care center or school. (b) Coverage for an additional bottle shall be limited to one (1) bottle every three (3) months. (4) The coverages required by this section shall not be subject to a greater deductible or copayment than other similar health care services provided by the limited health service benefit plan. Effective: January 1, 2015 History: Created 2014 Ky. Acts ch. 47, sec. 2, effective January 1, 2015. Legislative Research Commission Note (1/1/2015). In codification, the Reviser of Statutes has altered the numbering within subsection (3) of this statute from the way it appeared in 2014 Ky. Acts ch. 47, sec. 2, under the authority of KRS 7.136(1)(c).

KRS 304.17C-125 Application of specified sections of Subtitle 17A of KRS Chapter 304 to limited health service benefit plans. (Effective until January 1, 2027)

304.17C-125. Application of specified sections of Subtitle 17A of KRS Chapter 304 to limited health service benefit plans. (Effective until January 1, 2027) The following shall apply to limited health service benefit plans, including any limited health service contract, as defined in KRS 304.38A-010: (1) KRS 304.17A-129; (2) KRS 304.17A-262; and (3) KRS 304.17A-591 to 304.17A-599. Effective: January 1, 2025 History: Amended 2024 Ky. Acts ch. 69, sec. 2, effective January 1, 2025; and ch. 104, sec. 12, effective January 1, 2025. -- Created 2023 Ky. Acts ch. 30, sec. 3, effective January 1, 2025. Legislative Research Commission Note (1/1/2025). 2024 Ky. Acts ch. 69, sec. 7, provides that the amendments to this statute in that Act shall apply to p olicies, certificates, plans, and contracts issued or renewed on or after January 1, 2025. Legislative Research Commission Note (1/1/2025). This statute was amended by 2024 Ky. Acts chs. 69 and 104, which do not appear to be in conflict and have been codified together.

KRS 304.17C-130 Definitions for KRS 304.17C-130 to 304.17C-138

304.17C-130. Definitions for KRS 304.17C-130 to 304.17C-138 As used in KRS 304.17C-130 to 304.17C-138: (1) "Covered person" means an individual who is covered by a dental benefit plan; (2) "Dental benefit plan" means a limited health service benefit plan that provides coverage for dental services; (3) "Dental carrier" means a health insurer that provides coverage for dental services; (4) "Dental services": (a) Means services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease; and (b) Does not include services delivered by a provider that are billed as medical expenses under a health insurance plan; (5) "Dentist" means any dentist licensed or otherwise authorized in this state to furnish dental services; (6) "Health insurer" means any insurance company, health maintenance organization, self-insurer or multiple employer welfare arrangement not exempt from state regulation by ERISA, provider-sponsored integrated health delivery network, self- insured employer-organized association, nonprofit hospital, medical-surgical, dental, and health service corporation, or limited health service organization authorized to transact health insurance business in Kentucky; and (7) "Provider": (a) Means an individual or entity, acting within the scope of the individual or entity's licensure or certification, that provides dental services or supplies defined by the dental benefit plan; and (b) Does not include a physician organization or physician hospital organization that leases or rents its network to a third party. Effective: July 14, 2022 History: Created 2022 Ky. Acts ch. 48, sec. 1, effective July 14, 2022. Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was created by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.

KRS 304.17C-132 Definitions for section -- Third party access to provider network contract -- Prohibition against dental carrier contract cancellation

304.17C-132. Definitions for section -- Third party access to provider network contract -- Prohibition against dental carrier contract cancellation (1) As used in this section: (a) "Contracting entity" means a dental carrier, a third-party administrator, or any other person that enters into direct contracts with providers for the delivery of dental services in the ordinary course of business; (b) "Provider network contract" means a contract between a contracting entity and a provider that: 1. Specifies the rights and responsibilities of the contracting entity; and 2. Provides for the delivery and payment of dental services to a covered person; and (c) "Third party": 1. Means an individual or entity that enters into a contract with a contracting entity or with another person to gain access to the dental services or contractual discounts of a provider network contract; and 2. Does not include an employer or other group for whom the dental carrier or contracting entity provides administrative services. (2) A contracting entity may grant a third party access to a provider network contract or a provider's dental services or contractual discounts provided pursuant to a provider network contract if: (a) At the time the provider network contract is entered into or renewed, or when there are material modifications to the provider network contract relevant to granting a third party access to a provider network contract, the dental carrier allows any provider which is part of the dental carrier's provider network to choose to: 1. Not participate in third-party access to the provider network contract; or 2. Enter into a provider network contract directly with the health insurer that acquired the provider network; (b) The provider network contract includes the following third-party access provisions: 1. That the contracting entity may enter into an agreement with third parties allowing the third parties to obtain the contracting entity's rights and responsibilities as if the third party were the contracting entity; and 2. When the contracting entity is a dental carrier: a. That the provider network contract grants third-party access to the provider network; b. The provider chose to participate in third-party access at the time the provider network contract was entered into or renewed; and c. The provider has the right to choose not to participate in third- party access; (c) The third party accessing the provider network contract agrees to comply with all of the contract's terms; (d) The contracting entity: 1. Identifies all third parties in existence in a list on its Internet Web site, which shall be updated at least once every sixty (60) days; 2. Except for electronic transactions required by the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, requires the third party to identify the source of the discount on all remittance advices or explanations of payment under which a discount is taken; and 3. Makes available a copy of the provider network contract relied on in the adjudication of a claim to a participating provider within thirty (30) days of a request from the provider; and (e) The third party's right to a provider's discounted rate ceases as of the termination date of the provider network contract with the exception of covered dental services that are in progress. (3) A dental carrier: (a) Shall not cancel or otherwise end a contractual relationship with a provider as a result of the provider opting out of third-party access in accordance with subsection (2)(a) of this section; and (b) When initially contracting with a provider, shall accept a qualified provider even if the provider opts out of a third-party access provision. (4) A provider shall not be bound by, or required to provide dental services under, a provider network contract that has been granted to a third party in violation of this section. (5) This section shall not apply: (a) If access to a provider network contract is granted to: 1. A dental carrier or any other entity operating in accordance with the same brand licensee program as the contracting entity; or 2. An entity that is an affiliate of the contracting entity. A contracting entity shall make a list of its affiliates available to providers on its Internet Web site; or (b) To a provider network contract for dental services provided to beneficiaries of state-sponsored public medical assistance programs, including Medicaid and the Kentucky Children's Health Insurance Program. Effective: July 14, 2022 History: Created 2022 Ky. Acts ch. 48, sec. 2, effective July 14, 2022. Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was created by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.

KRS 304.17C-134 Conditions for dental benefit plan denial of claims requiring prior authorization

304.17C-134. Conditions for dental benefit plan denial of claims requiring prior authorization (1) As used in this section, "prior authorization" means any written communication that: (a) Indicates that a specific procedure is, or multiple procedures are, covered under the covered person's dental benefit plan and reimbursable at a specific amount, subject to applicable cost sharing; and (b) Is issued in response to a request submitted by a dentist using a format prescribed by the dental carrier. (2) A dental benefit plan shall not deny any claim subsequently submitted by a dentist for procedures specifically included in a prior authorization unless at least one (1) of the following circumstances applies for each procedure denied: (a) Benefit limitations, which may include annual maximums and frequency limitations, not applicable at the time of prior authorization are reached due to utilization subsequent to issuance of the prior authorization; (b) Documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized; (c) In accordance with the dental benefit plan, the service: 1. Is not considered medically necessary; or 2. Does not meet any other terms or conditions for coverage that were in effect at the time the prior authorization was issued; (d) Another payer is responsible for payment; (e) The dentist has already been paid for procedures identified on the claim; (f) The covered person was not eligible to receive the procedure on the date of service and the dental carrier did not know, and with the exercise of reasonable care could not have known, of the covered person's eligibility status; or (g) The prior authorization was based upon fraudulent, materially inaccurate, or misrepresented information submitted by the covered person or dentist. Effective: July 14, 2022 History: Created 2022 Ky. Acts ch. 48, sec. 3, effective July 14, 2022. Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was created by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.

KRS 304.17C-136 Definitions for section -- Prohibition against payment method restrictions for dental benefit plan -- Electronic fund transfer payments

304.17C-136. Definitions for section -- Prohibition against payment method restrictions for dental benefit plan -- Electronic fund transfer payments (1) As used in this section: (a) "Credit card payment": 1. Means a type of electronic funds transfer in which a dental benefit plan or its contracted vendor issues a single-use series of numbers associated with the payment of dental services: a. Performed by a dentist and chargeable to a predetermined dollar amount; and b. For which the dentist is responsible for processing the payment by a credit card terminal or Internet portal; and 2. Shall include virtual or online credit card payments for which no physical credit card is presented to the dentist and the single-use credit card expires upon payment processing; (b) "Dentist agent" means a person that establishes an agency relationship contract with a dentist to process bills for services provided by the dentist under terms and conditions established between the agent and dentist. Such contracts may permit the dentist agent to submit bills, request reconsideration, and receive reimbursement; and (c) "Electronic funds transfer payment": 1. Means a payment by any method of electronic funds transfer other than health care electronic fund transfer and remittance advice transactions under 45 C.F.R. secs. 162.1601 and 162.1602; and 2. Shall include virtual credit card payments. (2) A dental benefit plan shall not contain restrictions on methods of payment from the dental benefit plan or its vendors to the dentist in which the only acceptable payment method is a credit card payment. (3) When initiating or changing payments to a dentist using electronic funds transfer payments, a dental benefit plan or its vendors shall: (a) Notify the dentist if any fees are associated with a particular payment method; (b) Advise the dentist of the available methods of payment; and (c) Provide clear instructions to the dentist as to how to select an alternative payment method. (4) (a) A dental benefit plan or its vendor that initiates or changes payments to a dentist for health care electronic fund transfer and remittance advice transactions under 45 C.F.R. secs. 162.1601 and 162.1602 shall not charge a fee solely to transmit the payment to the dentist unless the dentist has consented to the fee. (b) When transmitting health care electronic fund transfer and remittance advice transactions under 45 C.F.R. secs. 162.1601 and 162.1602, a dentist agent may charge reasonable fees for payments related to transaction management, data management, portal services, and other value-added services in addition to the bank transmittal. Effective: July 14, 2022 History: Created 2022 Ky. Acts ch. 48, sec. 4, effective July 14, 2022. Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was created by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.

KRS 304.17C-137 Assignment of benefits under a dental insurance plan -- Procedures -- Revocation -- Construction

304.17C-137. Assignment of benefits under a dental insurance plan -- Procedures -- Revocation -- Construction (1) (a) An insurer providing coverage under a dental benefit plan shall honor a written assignment of benefits due under the plan that is: 1. Made: a. By a covered person to a provider for dental services provided to the covered person; and b. On a form established by the commissioner in an administrative regulation promulgated in accordance with KRS Chapter 13A and subsection (2) of this section; and 2. Signed by the covered person and the provider. (b) A provider with a valid assignment under paragraph (a) of this subsection shall provide the following to the insurer when submitting a request for payment pursuant to the assignment: 1. A copy of the dually signed assignment; and 2. Any information or documentation necessary for verifying coverage, or required for claims processing, under the dental benefit plan. (c) 1. Upon a provider's compliance with paragraph (b) of this subsection, the insurer shall make payments for covered serv ices directly to the provider. 2. A payment made to a provider under subparagraph 1. of this paragraph shall be made according to the same criteria and payment schedule under which the insurer would have been required to make the payment to the covered person if the benefits due under the plan had not been assigned. (2) The form established by the commissioner under subsection (1)(a)1.b. of this section shall include a notice informing the covered person that: (a) The provider, as applicable: 1. Is an out-of-network provider; 2. May charge the covered person for noncovered services; and 3. May charge the covered person for any portion of the cost of a covered service that is not reimbursed under the dental benefit plan; (b) Any assignment of benefits is opti onal; and (c) If the covered person has accrued a credit balance on his or her account, the provider shall: 1. Notify the covered person of the credit balance with the provider within thirty (30) days; and 2. a. Except as provided in subdivision b. of this subparagraph, refund any credit balance that has accrued on the covered person's account with the provider within thirty (30) days of receiving a request for refund from the covered person; and b. If, under the assignment, the provider collects payment fr om the covered person and subsequently receives payment from the insurer, refund the covered person within thirty (30) days of receiving the payment from the insurer unless the provider and covered person agree otherwise in writing. (3) (a) An assignment of benefits may be revoked by the covered person, with or without the consent of the provider, by submitting the revocation, in writing, to the insurer. (b) An insurer that receives a revocation referenced in paragraph (a) of this subsection shall promptly send a dated and time-stamped copy of the revocation to the provider. (c) A revocation made in accordance with this subsection shall: 1. Become effective when the insurer receives a copy of the revocation; and 2. Only be effective for any charges incurred on or after the effective date established under subparagraph 1. of this paragraph. (4) This section shall not be construed to limit an insurer's ability to: (a) Determine the scope of a dental benefit plan's benefits, services, or other terms that are not in conflict with this section; or (b) Negotiate any contract with a health care provider regarding reimbursement rates or any other lawful provisions that are not in conflict with this section. Effective: January 1, 2026 History: Created 2025 Ky. Acts ch. 147, sec. 1, effective January 1, 2026. Legislative Research Commission Note (1/1/2026). 2025 Ky. Acts ch. 147, sec. 5, provides that this statute shall apply to policies, plans, and contracts issued or renewed on or after January 1, 2026.

KRS 304.17C-138 Prohibition of contractual waiver of KRS 304.17C-130 to 304.17C- 138

304.17C-138. Prohibition of contractual waiver of KRS 304.17C-130 to 304.17C- 138 The provisions of KRS 304.17C-130 to 304.17C-138 shall not be waived by contract. Any contractual arrangement in conflict with this section or that purports to waive any requirement of this section of shall be null and void. Effective: July 14, 2022 History: Created 2022 Ky. Acts ch. 48, sec. 5, effective July 14, 2022. Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was created by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.

Source: Kentucky Legislative Research Commission (legislature.ky.gov)URL: https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38726Fetched: 10/20/2026