806 KAR 17:100.
Certificate of filing for provider-sponsored networks.
RELATES TO: KRS
304.17A-100(6), 304.17A-300, 304.17A-310
STATUTORY AUTHORITY:
KRS 304.2-110(1), 304.17A-300, 304.17A-310
NECESSITY, FUNCTION,
AND CONFORMITY: KRS 304.2-110(1) provides that the executive
director may promulgate reasonable administrative regulations
necessary for or as an aid to the effectuation of any provision of the Kentucky
Insurance Code. KRS 304.17A-300 requires that provider sponsored networks
obtain a certificate of filing before doing business in Kentucky. This
administrative regulation sets forth the requirements for applying for a
certificate of filing.
Section 1.
Definitions. A provider-sponsored network is a provider sponsored integrated
health delivery network as defined in KRS 304.17A-100(6).
Section 2. A
provider-sponsored network shall apply for and obtain a certificate of filing
from the executive director 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 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
provider-sponsored networks.
(b) Address where
books and records of the provider-sponsored network will 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 will:
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 and 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 prescribed or otherwise permitted by the executive
director 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 will 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.
Section 4. If any of
the information filed with the office pursuant to Section 3 of this
administrative regulation changes or becomes incorrect, then the
provider-sponsored network shall immediately notify the office in writing of
the change and immediately give the office the correction.
Section 5. Form
numbered "996", revised June 1996, is prescribed by the office and
incorporated by reference. Copies may be obtained from the Office of Insurance,
P.O. Box 517, 215 West Main Street, Frankfort, Kentucky 40601,
Monday through Friday, 8 a.m. to 4:30 p.m. (ET). (23 Ky.R. 1822; eff. 12-11-96;
TAm eff. 8-9-2007.)
