Kentucky Administrative Regulations › Title 806 - PUBLIC PROTECTION CABINET - DEPARTMENT OF INSURANCE › Chapter 17 - Health Insurance Contracts › Section 806 KAR 17:100 - Certificate of filing for provider-sponsored networks

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				304.17A-005(39),
				304.17A-300,
				304.17A-310
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				304.2-110(1) authorizes the
				commissioner to promulgate reasonable administrative regulations necessary for
				or as an aid to the effectuation of any provision of the Kentucky Insurance
				Code, established in
				KRS
				304.1-010.
				KRS
				304.17A-300 requires provider sponsored
				networks to obtain a certificate of filing before doing business in Kentucky.
				This administrative regulation establishes the requirements for a provider
				sponsored network applying for a certificate of filing.
Section 1. Definitions. A provider-sponsored
			 network is a provider sponsored integrated health delivery network as defined
			 in 304.17A-005(39).
Section 2. A
			 provider-sponsored network shall apply for and obtain a certificate of filing
			 from the commissioner in order to provide, directly or through arrangements
			 with others, a health benefit plan to consumers voluntarily enrolled with the
			 organization on a per capita or a predetermined, fixed prepayment
			 basis.
Section 3.
(1) Each application for a certificate of
			 filing for a provider-sponsored network shall be filed on a Form 996 and
			 verified by an officer or authorized representative of the applicant.
(2) Each application shall set forth or be
			 accompanied by the following:
(a) Name,
			 address, principal place of business, owners, officers, managers, and sponsors
			 of the provider-sponsored network.
(b) Address where books and records of the
			 provider-sponsored network shall be maintained at all times.
(c) The providers who sponsor, own, govern,
			 or manage the provider-sponsored network shall provide a copy of their licenses
			 and affidavit confirming good standing with their licensure board.
(d) A copy of the organizational documents of
			 the applicant including:
1. Articles of
			 incorporation;
2. Articles of
			 association;
3. Partnership
			 agreement;
4. Trust
			 agreement;
5. Bylaws;
6. Organizational chart; and
7. Other applicable documents and
			 amendments.
(e) A copy
			 of the policies, procedures, and other documents explaining how the provider
			 sponsored network shall:
1. Administer health
			 plans;
2. Have ability, experience,
			 and structure to arrange for appropriate level and type of health care
			 services;
3. Conduct utilization
			 management activities;
4. Achieve,
			 monitor, and evaluate the quality and cost effectiveness of care
			 provided;
5. Monitor access to its
			 provider network; and
6. Use
			 standardized electronic claims, billing processes, and formats.
(f) Names, addresses, and
			 biographical information of the following:
1.
			 Board of directors;
2. Board of
			 trustees;
3. Executive committee or
			 other governing body;
4. Each owner
			 of five (5) percent or more of the provider-sponsored network;
5. Principal officers;
6. Partners; and
7. Persons responsible for the conduct of the
			 applicants affairs and day to day operations.
(g) Financial statements audited by an
			 independent certified public accountant in conformity with statutory accounting
			 practices that reflect the following:
1.
			 Financial position of the applicant;
2. Results of its operation;
3. Cash flows; and
4. Changes in capital and surplus.
(h) If the "as of" date of the
			 financial statements filed pursuant to paragraph (f) of this subsection is more
			 than ninety (90) days from the date of the application, interim financial
			 statements compiled by an independent certified public accountant as of a date
			 less than ninety (90) days from the application containing the same information
			 as the audited financial statements.
(i) List of providers including name,
			 address, license number, and health services provided.
(j) A statement or map reasonably describing
			 the counties to be served and written assurance that health services shall be
			 provided to enrollees within fifty (50) miles of their residences.
(k) Proposed contracts and agreements
			 including the following:
1. Applications or
			 individual enrollment forms;
2.
			 Master contract forms for group enrollment;
3. Evidence of coverage or
			 handbook;
4. Riders or
			 endorsements; and
5. Rates with
			 actuarial justifications.
(l) A copy of the following professional
			 agreements:
1. Provider agreements;
2. Third party administrators
			 agreements;
3. Service
			 agreements;
4. Administrative
			 agreements; and
5. Reinsurance
			 agreements.
(m) A copy
			 of grievance procedures to be utilized for the investigation and resolution of
			 enrollee and provider complaints and grievances.
(n) A copy of the applicant's plan for
			 handling insolvency as required by
			 KRS
			 304.17A-310(6).
(o) Financial program setting forth a three
			 (3) year projection of operations on a quarterly basis which shall include the
			 following:
1. Detailed enrollment
			 projections;
2. Projection of
			 balance sheets;
3. Projection of
			 cash flow statements showing any capital expenditures;
4. Projection of purchase and sale of
			 investments and deposits;
5.
			 Projection of income and expense statements anticipated from the start of
			 operation until the organization has had net income for one (1) year;
			 and
6. Statement of the sources of
			 working capital as well as other sources of funding.