House Bill 299

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Last Action to Health & Welfare (H)
Title AN ACT relating to an entity with a valid license issued by the Department of Insurance to operate as a health maintenance organization or insurer that operates a Medicaid managed care organization.
Bill Documents Bill
Impact Statements Fiscal Note
Bill Request Number 1185
Sponsors B. Damron, K. Sinnette, J. Bell, R. Benvenuti III, R. Crimm, J. DeCesare, K. Hall, R. Heath, R. Henderson, K. Imes, B. Linder, R. Quarles, B. Rowland, S. Santoro, A. Simpson, D. St. Onge, J. Stewart III, W. Stone, T. Thompson, B. Waide, D. Watkins, G. Watkins, A. Wuchner
Summary of Original Version Create a new section of KRS 205.222 to 205.560 to define "emergency services", "emergency medical conditions", "non-emergency condition", "medical screening fee", and "Medicaid managed care organization"; amend KRS 205.522 to define "Medicaid managed care organization" and to require Medicaid managed care organizations to comply with the provisions of the state health insurance code contained in KRS 304.17A-700 to 304.17A-730, KRS 304.17A-500 to 304.17A-560, KRS 304.17A-575 to 304.17A-590, KRS 304.17A-600, 304.17A-607, 304.17A-609, 304.17A-611, 304.17A-617,304.17A-619, KRS 304.17A-640 to 304.17A-647, and KRS 304.17A-660 to 304.17A-661 relating to patient protections, utilization review and appeals, payment of claims, treatment for emergency conditions, and treatment for mental health conditions for enrollees in Medicaid managed car ein the same manner as required for insureds within the private managed care systems, except where in conflict with the provisions of 42 U.S.C. 1396u-2 or federal regulations promulgated in 42 C.F.R. pt. 438; prohibit specified actions, non-actions or refusals by a Medicaid managed care organization, its agents, representatives and employees; authorizee an enrollee in a Medicaid managed care organization to assign his or her rights to a health care provider to challenge or appeal an adverse determination by the organization concerning health care services, authorize a private cause of action against a Medicaid managed care organization by an enrollee or health care provider aggrieved by an adverse determination concerning coverage or payment for health care services alleged to be in violation of Sections 1 to 5 of this Act, authorize an administrative hearing for an appeal by an enrollee or health care provider of an adverse determination regarding coverage or payment for health care services made by a Medicaid managed care and require the hearing officer to issue a final order within thirty (30) days folowing a hearing, subject to judicial review pursuant to KRS 13B.140; create a new section of KRS 205.222 to 205.560 to provide that a determination of an emergency or non-emergency condition by an emergency treating physician or provider shall be binding on the Medicaid managed care organization, require a Medicaid managed care organization to fully cover emergency services provided to enrollees at any hospital regardless of the hospital's participation status, prohibit a preauthorization requirement by a Medicaid managed care organization for admission of an enrollee with a psychiatric emergency medical condition if inpatient admission is required to stabilize the patient and prohibit coverage or payment for the first twenty-four (24) hours of the inpatient care for a psychiatric medical condition, authorize a medical screening fee, as defined in Section 1 of this Act, be reimbursed to a hospital only for enrolleess who are more than nine (9) years old, and prohibit Medicaid managed care organization reimbursement to an out-of-network provider for emergency serviceat an amount less than he fee-for-service rate promulgated by the Department for Medicaid Services; create a new section ofKRS 205.222 to 205.560 to require the Commissioner of the Deparment for Medicaid Services to monitor and enforce compliance with Sections 1 to 5 of this Act by Medicaid managed care organizations, establish Medicaid managed care reporting requirements for the Department for Medicaid Services including a quarterly report to the Interim Joint Committee on Appropriations and Revenue containing the requirements specified in Section 4 of this Act, a copy of the final audited annual "Healthcare Effectiveness Data and Information Set" to the Interim Joint Committee on Appropriations and Revenue received from each Medicaid managed care organization, and a copy of each audit, performed by the Cabinet for Medicaid Services or its contractor, of each Medicaid managed care organization to the Auditor of Public Accounts for posting on the Auditor's website, and a copy to the Interim Joint Committee on Appropriations and Revenue, and require the Cabinet for Medicaid Services to post a copy of the audit on the agency website; create a new section of KRS 205.222 to 205.560 to require a Medicaid managed care organizationwhich receives a capitation payment for a period of retroactive eligibility to perform a retrospective review of medical necessity, upon a provider's request if received within one (1) year following the date of service, for services rendered to the enrollee during the period of retroactive eligibility, and if a denial is issued by the Medicaid managed care organization based on medical necessity, a telephonic peer-to-peer review between the enrollee's treating provider and the Medicaid managed care organization's health care professional who issued the decision, prior to requiring the hospital or treating provider to file a request for reconsideration with the Medicaid managed care organization; and, repeal KRS 204.6310.
Index Headings of Original Version Health and Medical Services - Medicaid managed care, organization, define
Health and Medical Services - Medicaid Services, Medicaid managed care organization requirements, monitoring and enforcement
Health and Medical Services - Medicaid Services, Medicaid managed care organizations reporting, requirements
Insurance, Health - Patient protections for private health insurance, Medicaid managed care, apply
Fiscal Note - Patient protections, Cabinet for Medicaid Services to monitor and enforce for MCO's, require
Health and Medical Services - Medicaid managed care organization, enrollee's retroactive eligibility coverage, requirements
Health and Medical Services - Medicaid managed care, administrative hearing for adverse determination, authorization
Health and Medical Services - Medicaid managed care, emergency room care and coverage, requirements
Health and Medical Services - Medicaid managed care, emergency room provider determination, binding effect
Health and Medical Services - Medicaid managed care, hearing order appeal to courts, authorization
Health and Medical Services - Medicaid managed care, insurance code patient protection provisions, apply
Medicaid - Managed care, patient protections, establish
Medicaid - Patient protections, Cabinet for Medicaid Services to monitor and enforce for MCO's, require

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02/08/13
  • introduced in House
02/11/13
  • to Health & Welfare (H)


Last updated: 1/16/2019 3:24 PM (EST)