Session of 1998
By Senators Brownlee, Harrington, Jordan, Salmans, Steineger and
          10             AN ACT relating to managed care; patient protection act; amending
11             K.S.A. 1997 Supp. 40-4602 and 40-4607 and repealing the existing
12             sections.
14       Be it enacted by the Legislature of the State of Kansas:
15           Section 1. K.S.A. 1997 Supp. 40-4602 is hereby amended to read as
16       follows: 40-4602. As used in this act:
17           (a) ``Emergency medical condition'' means the sudden and, at the
18       time, unexpected onset of a health condition that requires immediate
19       medical attention, where failure to provide medical attention would result
20       in serious or painful impairment to bodily functions or serious dysfunction
21       of a bodily organ or part, or would place the person's health in serious
22       jeopardy.
23           (b) ``Emergency services'' means ambulance services and health care
24       items and services furnished or required to evaluate and treat an emer-
25       gency medical condition, as directed or ordered by a physician.
26           (c) ``Health benefit plan'' means any hospital or medical expense pol-
27       icy, health, hospital or medical service corporation contract, a plan pro-
28       vided by a municipal group-funded pool, a policy or agreement entered
29       into by a health insurer or a health maintenance organization contract
30       offered by an employer or any certificate issued under any such policies,
31       contracts or plans. ``Health benefit plan'' does not include policies or
32       certificates covering only accident, credit, dental, disability income,
33       long-term care, hospital indemnity, medicare supplement, specified dis-
34       ease, vision care, coverage issued as a supplement to liability insurance,
35       insurance arising out of a workers compensation or similar law, automo-
36       bile medical-payment insurance, or insurance under which benefits are
37       payable with or without regard to fault and which is statutorily required
38       to be contained in any liability insurance policy or equivalent self-insur-
39       ance.
40           (d) ``Health insurer'' means any insurance company, nonprofit med-
41       ical and hospital service corporation, municipal group-funded pool, fra-
42       ternal benefit society, health maintenance organization, or any other en-
43       tity which offers a health benefit plan subject to the Kansas Statutes

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  1       Annotated.
  2           (e) ``Insured'' means a person who is covered by a health benefit plan.
  3           (f) ``Participating provider'' means a provider who, under a contract
  4       with the health insurer or with its contractor or subcontractor, has agreed
  5       to provide one or more health care services to insureds with an expec-
  6       tation of receiving payment, other than coinsurance, copayments or de-
  7       ductibles, directly or indirectly from the health insurer.
  8           (g) ``Provider'' means a physician, hospital or other person which is
  9       licensed, accredited or certified to perform specified health care services.
10           (h) ``Provider network'' means those participating providers who have
11       entered into a contract or agreement with a health insurer to provide
12       items or health care services to individuals covered by a health benefit
13       plan offered by such health insurer.
14           (i) ``Physician'' means a person licensed by the state board of healing
15       arts to practice medicine and surgery.
16           Sec. 2. K.S.A. 1997 Supp. 40-4607 is hereby amended to read as
17       follows: 40-4607. (a) A health insurer providing a health benefit plan shall
18       maintain a provider network that is sufficient in numbers and types of
19       providers to assure that all covered services to an insured will be acces-
20       sible without unreasonable delay. Sufficiency of the provider network
21       shall be determined in accordance with the requirements of this section,
22       and may be established by reference to any reasonable criteria used by
23       the health insurer, including but not limited to: provider-insured ratios
24       by specialty; primary care provider-insured ratios; geographic accessibility
25       to the residence or place of employment of the insured; waiting times for
26       appointments with participating providers; hours of operation; and the
27       availability of technological and specialty services to serve the needs of
28       insureds requiring technologically advanced or specialty care. In order to
29       be considered reasonable under this subsection, primary care providers
30       shall be subject to contact for the purpose of referral by the easiest means
31       of communication, including telephone, fax and other electronic means of
32       communication. In the temporary absence of the primary care provider,
33       an alternative provider shall be available 24 hours per day, seven days a
34       week, without a referral required in the case of an acute, nonemergency
35       illness.
36           (b) A health insurer shall have a plan by which an insured with a life-
37       threatening, chronic, degenerative or disabling condition or disease,
38       which requires specialized medical care over a prolonged period of time,
39       may receive a referral to a specialist with expertise in treating such disease
40       or condition who shall be responsible for and capable of providing and
41       coordinating the insured's specialty care. Such a referral shall have a
42       duration of effectiveness of two years, beginning on the day the referral
43       is made.

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  1           (c) Nothing in this section shall require a health insurer to provide
  2       benefits not otherwise covered by the terms of the health benefits plan.
  3           (d) A provider network shall not be determined to be insufficient for
  4       failure to contract with any provider unwilling to contract under the same
  5       terms and conditions, including reimbursement levels, as such health in-
  6       surer offers to other similarly situated health care providers.
  7           New Sec. 3. When a health insurer designates or requires the des-
  8       ignation of a primary care physician such physician, in the case of a female
  9       insured or her female dependent, may be an obstetrician/gynecologist.
10           Sec. 4. K.S.A. 1997 Supp. 40-4602 and 40-4607 are hereby repealed.
11           Sec. 5. This act shall take effect and be in force from and after its
12       publication in the statute book.