| Last Action | 04/04/18: became law without Governor's Signature (Acts, ch. 106) |
|---|---|
| Title | AN ACT relating to service delivery improvements in managed care networks. |
| Bill Documents |
Current/Final
Introduced |
| Bill Request Number | 127 |
| Sponsors | K. Fleming , M. Prunty |
| Summary of Original Version | Create new sections of KRS Chapter 205 to define terms; establish and require that the Department for Medicaid Services designate a single credentialing verification organization to verify credentials for DMS and all contracted Medicaid Managed Care Organizations; submit the credentialing organization to Government Contract Review Committee for comment; require providers to submit a single application to the credentialing organization; require notification within 5 days to the provider if application is complete; require verified packets be sent to the DMS and MCOs within 30 days; require DMS to enroll providers within 15 days and for the MCOs to determine if they will contract with the provider within 15 days; specify that for reimbursement of claims purposes the date of the submission of the credentialing application shall be the date of original enrollment and credentialing; address the written internal appeals process of MCOs; require 24/7 utilization reviews and daily staffing for claims resolution; establish grievance and appeal timeline and written appeal requirements; require reprocessing of incorrectly paid or erroneously denied claims; allow for in-person meetings for unpaid claims beyond 45 days and that individually or in the aggregate exceed $2,500; require consistency and timeliness between physical, behavioral, or other medically necessary services; establish timelines for preauthorization requests; require that substance use disorder be treated as an urgent preauthorization request; require a single nationally recognized clinical review criteria for both physical health and behavioral health services; establish monthly reporting requirements for MCOs relating to claims; require reporting between the DMS and the Department of Insurance; establish penalties for MCOs that fail to comply; prohibit automatic assignment of Medicaid enrollees to an MCO unless there is a participating acute care hospital within the distance requirements; allow for enrollees to change MCOs outside of the open enrollment if their hospital or PCP terminates participation with an MCO; amend KRS 304.17A-515 to require each managed care plan to demonstrate that it offers physically available acute care hospital services; amend KRS 304.17A-576 to require a response about credentialing within 45 instead of 90 days; amend KRS 304.17A-700 to reference Section 1 of the bill. |
| Index Headings of Original Version |
Disabilities and the Disabled - Managed care networks, credentialing, network adequacy, appeals Diseases - Managed care networks, credentialing, network adequacy, appeals Drugs and Medicines - Managed care networks, credentialing, network adequacy, appeals Health and Medical Services - Managed care networks, credentialing, network adequacy, appeals Hospitals and Nursing Homes - Managed care networks, credentialing, network adequacy, appeals Insurance, Health - Managed care networks, credentialing, network adequacy, appeals Medicaid - Managed care networks, credentialing, network adequacy, appeals Mental Health - Managed care networks, credentialing, network adequacy, appeals Pharmacists - Managed care networks, credentialing, network adequacy, appeals Physicians and Practitioners - Managed care networks, credentialing, network adequacy, appeals Public Health - Managed care networks, credentialing, network adequacy, appeals Public Medical Assistance - Managed care networks, credentialing, network adequacy, appeals |
| Jump to Proposed Amendments |
House Committee Substitute 1 House Floor Amendment 1 Senate Committee Substitute 1 Senate Floor Amendment 1 |
| Votes | Vote History |
| 11/29/17 |
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|---|---|
| 01/02/18 |
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| 01/31/18 |
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| 02/15/18 |
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| 02/16/18 |
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| 02/20/18 |
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| 02/21/18 |
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| 02/22/18 |
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| 02/23/18 |
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| 02/26/18 |
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| 03/14/18 |
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| 03/15/18 |
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| 03/16/18 |
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| 03/19/18 |
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| 03/20/18 |
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| 03/21/18 |
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| 03/22/18 |
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| 04/02/18 |
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| 04/04/18 |
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| Amendment | House Committee Substitute 1 |
|---|---|
| Summary | Amend original provisions to require DMS to enroll providers within 30 days and for the MCOs to determine if they will contract with the provider within 30 days; specify that for reimbursement of claims purposes the date of the submission of the credentialing application shall be the date of receipt of clean application for credentialing; address the written internal appeals process of MCOs; require telephone line for utilization reviews and staffing for claims resolution; establish grievance and appeal timeline and written appeal requirements; require reprocessing of incorrectly paid or erroneously denied claims; allow for in-person meetings for unpaid clean claims not properly paid and other unpaid claims beyond 45 days and that individually or in the aggregate exceed $2,500; conform definition of timeliness for authorization request to federal regulations; change "urgent preauthorization request" to "expedited authorization request"; modify penalties for MCOs that fail to comply; prohibit automatic assignment of Medicaid enrollees to an MCO; create a new section of KRS Chapter 205 to require Medicaid MCOs to have a utilization review plan and use review criteria selected by the Department of Insurance; amend KRS 205.522 to require Medicaid MCOs to comply with KRS 304.17A-515; amend KRS 304.17A-515 to require each managed care plan to demonstrate that it offers physically available acute care hospital services; amend KRS 304.17A-576 to require a response about credentialing within 45 instead of 90 days; amend KRS 304.17A-700 to reference Section 1 of the bill; Create a new section of Subtitle 38 of KRS Chapter 304 to require the commissioner of insurance to promulgate administrative regulations to select utilization review criteria for use by Medicaid MCOs; amend KRS 304.3-200 to allow revocation of certificate of authority of an insurer offering Medicaid services for failure to comply; amend KRS 304.38-130 to allow revocation of certificate of authority of an HMO offering Medicaid services for failure to comply; amend KRS 304.99-123 to allow the Department of Insurance to assess fines against Medicaid Managed Care organizations for failure to comply. |
| Index Headings |
Insurance - Medicaid managed care organizations, utilization review criteria, selection by the Department Insurance - Insurer, certificate of authority, revocation or suspension of Insurance - HMO, certificate of authority, revocation or suspension of Insurance - Medicaid managed care organizations, prompt pay violations, penalties for Disabilities and the Disabled - Managed care networks, credentialing, network adequacy, appeals Diseases - Managed care networks, credentialing, network adequacy, appeals Drugs and Medicines - Managed care networks, credentialing, network adequacy, appeals Health and Medical Services - Managed care networks, credentialing, network adequacy, appeals Hospitals and Nursing Homes - Managed care networks, credentialing, network adequacy, appeals Insurance, Health - Managed care networks, credentialing, network adequacy, appeals Medicaid - Managed care networks, credentialing, network adequacy, appeals Mental Health - Managed care networks, credentialing, network adequacy, appeals Pharmacists - Managed care networks, credentialing, network adequacy, appeals Physicians and Practitioners - Managed care networks, credentialing, network adequacy, appeals Public Health - Managed care networks, credentialing, network adequacy, appeals Public Medical Assistance - Managed care networks, credentialing, network adequacy, appeals |
| Amendment | House Floor Amendment 1 |
|---|---|
| Sponsor | B. Rowland |
| Summary | Amend original provisions in Section 5 to replace "utilization review determination" with "determinations of medical necessity and clinical appropriateness"; amend Section 10 to require the commissioner of the Department of Insurance to establish a process for designating medical necessity criteria for use by Medicaid managed care organizations; to establish requirements for the process; to require that the criteria designated be nationally recognized, objective and evidence based and not proprietary property of a Medicaid managed care organization; and to require the commissioner to collaborate with the Department for Medicaid Services in the designation process. |
| Index Headings |
Disabilities and the Disabled - Managed care networks, credentialing, network adequacy, appeals Diseases - Managed care networks, credentialing, network adequacy, appeals Drugs and Medicines - Managed care networks, credentialing, network adequacy, appeals Health and Medical Services - Managed care networks, credentialing, network adequacy, appeals Hospitals and Nursing Homes - Managed care networks, credentialing, network adequacy, appeals Insurance - HMO, certificate of authority, revocation or suspension of Insurance - Insurer, certificate of authority, revocation or suspension of Insurance - Medicaid managed care organizations, prompt pay violations, penalties for Insurance - Medicaid managed care organizations, medical necessity criteria, selection by the Department Insurance, Health - Managed care networks, credentialing, network adequacy, appeals Medicaid - Managed care networks, credentialing, network adequacy, appeals Mental Health - Managed care networks, credentialing, network adequacy, appeals Pharmacists - Managed care networks, credentialing, network adequacy, appeals Physicians and Practitioners - Managed care networks, credentialing, network adequacy, appeals Public Health - Managed care networks, credentialing, network adequacy, appeals Public Medical Assistance - Managed care networks, credentialing, network adequacy, appeals |
| Amendment | Senate Committee Substitute 1 |
|---|---|
| Summary | Retain provisions of the GA version, except allow for an MCO to have 10 days to update its internal processing systems to include new provider contracts and an additional 15 days if notice is provided; delete a provision which allowed members to change MCOs if a hospital or primary care provider left the MCOs network outside of the open enrollment period; require a willful or frequent, repeated violations of certain provisions before the commissioner of insurance is authorized to subject a Medicaid managed care organization to penalties. |
| Index Headings |
Disabilities and the Disabled - Managed care networks, credentialing, network adequacy, appeals Diseases - Managed care networks, credentialing, network adequacy, appeals Drugs and Medicines - Managed care networks, credentialing, network adequacy, appeals Health and Medical Services - Managed care networks, credentialing, network adequacy, appeals Hospitals and Nursing Homes - Managed care networks, credentialing, network adequacy, appeals Insurance - HMO, certificate of authority, revocation or suspension of Insurance - Insurer, certificate of authority, revocation or suspension of Insurance - Medicaid managed care organizations, prompt pay violations, penalties for Insurance - Medicaid managed care organizations, utilization review criteria, selection by the department Insurance, Health - Managed care networks, credentialing, network adequacy, appeals Medicaid - Managed care networks, credentialing, network adequacy, appeals Mental Health - Managed care networks, credentialing, network adequacy, appeals Pharmacists - Managed care networks, credentialing, network adequacy, appeals Physicians and Practitioners - Managed care networks, credentialing, network adequacy, appeals Public Health - Managed care networks, credentialing, network adequacy, appeals Public Medical Assistance - Managed care networks, credentialing, network adequacy, appeals |
| Amendment | Senate Floor Amendment 1 |
|---|---|
| Sponsor | R. Alvarado |
| Summary | Remove substance abuse services from the behavioral health services medical necessity criteria; require that the commissioner of DMS receive input from healthcare professionals and members of the Advisory Council for Medical Assistance from each category of care when selecting medical necessity criteria. |
| Index Headings |
Disabilities and the Disabled - Managed care networks, credentialing, network adequacy, appeals Diseases - Managed care networks, credentialing, network adequacy, appeals Drugs and Medicines - Managed care networks, credentialing, network adequacy, appeals Health and Medical Services - Managed care networks, credentialing, network adequacy, appeals Hospitals and Nursing Homes - Managed care networks, credentialing, network adequacy, appeals Insurance - HMO, certificate of authority, revocation or suspension of Insurance - Insurer, certificate of authority, revocation or suspension of Insurance - Medicaid managed care organizations, prompt pay violations, penalties for Insurance - Medicaid managed care organizations, utilization review criteria, selection by the department Insurance, Health - Managed care networks, credentialing, network adequacy, appeals Medicaid - Managed care networks, credentialing, network adequacy, appeals Mental Health - Managed care networks, credentialing, network adequacy, appeals Pharmacists - Managed care networks, credentialing, network adequacy, appeals Physicians and Practitioners - Managed care networks, credentialing, network adequacy, appeals Public Health - Managed care networks, credentialing, network adequacy, appeals Public Medical Assistance - Managed care networks, credentialing, network adequacy, appeals |
Last updated: 9/1/2020 2:57 PM (EDT)
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