806 KAR 17:100 - Certificate of filing for provider-sponsored networks
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.
Section 4. If any of
the information filed with the department 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 department the correction.
Section 5. Incorporated by Reference.
(1) Form 996, "Application for Certificate of
Filing as a Provider-Sponsored Integrated Health Delivery Network", 08/2021, is
incorporated by reference.
(2) This
material may be inspected, copied, or obtained, subject to applicable copyright
law, at the Kentucky Department of Insurance, The Mayo-Underwood Building, 500
Mero St., Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m.
Forms may also be obtained on the department Web site at
https://insurance.ky.gov/ppc/CHAPTER.aspx.
Notes
STATUTORY AUTHORITY: KRS 304.2-110(1), 304.17A-300, 304.17A-310
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