Kentucky HB 176: AN ACT relating to tax amnesty and declaring an emergency.

Bill Text

CHAPTER 102
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1
CHAPTER 102
( HB 176 )
AN ACT relating to prior authorization.
Be it enacted by the General Assembly of the Commonwealth of Kentucky:
SECTION 1. A NEW SECTION OF KRS 304.17A-600 TO 304.17A-633 IS CREATED TO READ AS
FOLLOWS:
(1) As used in this section:
(a) "Covered health care service" means a health care service furnished or proposed to be furnished to a
covered person that is specifically available or included as a covered benefit in the covered person's
health benefit plan;
(b) "Electronic health record" has the same meaning as in 42 U.S.C. sec. 17921, as amended;
(c) "Evaluation period" means a twelve (12) month period of time for which a health care provider's
prior authorization experience is evaluated by an insurer or private review agent;
(d) "Health care provider" has the same meaning as in KRS 304.17A-005, except for purposes of this
section the term includes, if practicing independently, any:
1. Licensed clinical alcohol and drug counselor licensed under KRS Chapter 309;
2. Licensed psychologist, licensed psychological practitioner, or certified psychologist with
autonomous functioning licensed or certified under the provisions of KRS Chapter 319;
3. Licensed professional clinical counselor licensed under KRS Chapter 335;
4. Licensed marriage and family therapist licensed under KRS Chapter 335;
5. Licensed professional art therapist licensed under KRS Chapter 309; and
6. Licensed clinical social worker licensed under KRS Chapter 335;
(e) "Health care provider group" means two (2) or more health care providers that provide health care
services within an entity that shares a common:
1. Group provider number; or
2. Tax identification number;
(f) "Health care service" has the same meaning as in KRS 304.17A-005, except for purposes of this
section the term:
1. Includes procedures, treatments, and services rendered by a health care provider as defined in
this section; and
2. Does not include the provision of prescription drugs;
(g) "Interoperability standards" means the technical standards set forth in 45 C.F.R. sec. 170.215, as
amended;
(h) "Participating provider":
1. Means a health care provider that has entered into a participating provider contract; and
2. Includes a health care provider group if the insurer has elected to offer an exemption to the
health care provider group under subsection (4)(b)2. of this section;
(i) "Participating provider contract" means a contract between a health care provider, either directly or
through a health care provider group, and an insurer for the provision of health care services under
a health benefit plan;
(j) "Utilization" means the number of claims submitted for a particular health care service under a
health benefit plan by a participating provider; and

ACTS OF THE GENERAL ASSEMBLY 2
(k) "Value-based care agreement" means a contractual agreement between a health care provider,
either directly or through a health care provider group, and an insurer that:
1. Incentivizes or rewards the provider based on one (1) or more of the following:
a. Quality of care;
b. Safety;
c. Patient outcomes;
d. Efficiency;
e. Cost reduction; or
f. Other factors; and
2. May, but is not required to, include shared financial risk and rewards based on performance
metrics.
(2) An insurer or its private review agent shall not require a covered person, authorized person, or participating
provider to obtain a prior authorization for a particular health care service under a health benefit plan if, at
the time the health care service was provided, the provider had a prior authorization exemption for that
particular health care service under a program offered under subsection (3) of this section.
(3) Every insurer shall offer a program under which a participating provider may qualify for an exemption
from the requirement to obtain prior authorization for any covered health care service that requires prior
authorization.
(4) The program offered under subsection (3) of this section:
(a) Shall:
1. Provide that a participating provider, for an evaluation period established by the insurer or
private review agent, receive a prior authorization exemption for a particular health care
service if, during the previous evaluation period, the provider met program terms and
conditions established by the insurer or private review agent that are not in violation of this
section;
2. Not condition a prior authorization exemption upon the provider exceeding a ninety-three
percent (93%) approval rate for prior authorization requests submitted by the provider for that
health care service during an evaluation period;
3. Require the insurer or its private review agent to evaluate, on an annual basis, whether a
participating provider qualifies to receive a prior authorization exemption for each covered
health care service for which the insurer requires prior authorization;
4. Require each annual evaluation required under subparagraph 3. of this paragraph