Session of 1999
By Representative Franklin

  9             AN  ACT concerning accident and health insurance; relating to coverage
10             of health care services outside of provider networks; amending K.S.A.
11             1998 Supp. 40-4602 and 40-4607 and repealing the existing sections.
13       Be it enacted by the Legislature of the State of Kansas:
14             Section  1. K.S.A. 1998 Supp. 40-4602 is hereby amended to read as
15       follows: 40-4602. As used in this act:
16             (a) "Chronic illness" means any illness that requires continual treat-
17       ment or maintenance including, but not limited to: heart disease, diabetes,
18       multiple sclerosis, scoliosis, cancer, asthma, lupus, developmental illness,
19       Alzheimer's disease, degenerative arthritis, sickle-cell anemia and endom-
20       etriosis.
21             (a) (b) "Emergency medical condition" means the sudden and, at the
22       time, unexpected onset of a health condition that requires immediate
23       medical attention, where failure to provide medical attention would result
24       in serious impairment to bodily functions or serious dysfunction of a bod-
25       ily organ or part, or would place the person's health in serious jeopardy.
26             (b) (c) "Emergency services" means ambulance services and health
27       care items and services furnished or required to evaluate and treat an
28       emergency medical condition, as directed or ordered by a physician.
29             (c) (d) "Health benefit plan" means any hospital or medical expense
30       policy, health, hospital or medical service corporation contract, a plan
31       provided by a municipal group-funded pool, a policy or agreement en-
32       tered into by a health insurer or a health maintenance organization con-
33       tract offered by an employer or any certificate issued under any such
34       policies, contracts or plans. "Health benefit plan" does not include poli-
35       cies or certificates covering only accident, credit, dental, disability income,
36       long-term care, hospital indemnity, medicare supplement, specified dis-
37       ease, vision care, coverage issued as a supplement to liability insurance,
38       insurance arising out of a workers compensation or similar law, automo-
39       bile medical-payment insurance, or insurance under which benefits are
40       payable with or without regard to fault and which is statutorily required
41       to be contained in any liability insurance policy or equivalent self-
42       insurance.
43             (d) (e) "Health insurer" means any insurance company, nonprofit
44       medical and hospital service corporation, municipal group-funded pool,
45       fraternal benefit society, health maintenance organization, or any other
46       entity which offers a health benefit plan subject to the Kansas Statutes
47       Annotated.
48             (e) (f) "Insured" means a person who is covered by a health benefit
49       plan.
50             (f) (g) "Participating provider" means a provider who, under a con-
51       tract with the health insurer or with its contractor or subcontractor, has
52       agreed to provide one or more health care services to insureds with an
53       expectation of receiving payment, other than coinsurance, copayments or
54       deductibles, directly or indirectly from the health insurer.
55             (g) (h) "Provider" means a physician, hospital or other person which
56       is licensed, accredited or certified to perform specified health care
57       services.
58             (h) (i) "Provider network" means those participating providers who
59       have entered into a contract or agreement with a health insurer to provide
60       items or health care services to individuals covered by a health benefit
61       plan offered by such health insurer.
62             (i) (j) "Physician" means a person licensed by the state board of heal-
63       ing arts to practice medicine and surgery.
64             Sec.  2. K.S.A. 1998 Supp. 40-4607 is hereby amended to read as
65       follows: 40-4607. (a) A health insurer providing a health benefit plan shall
66       maintain a provider network that is sufficient in numbers and types of
67       providers to assure that all covered services to an insured will be acces-
68       sible without unreasonable delay. Sufficiency of the provider network
69       shall be determined in accordance with the requirements of this section,
70       and may be established by reference to any reasonable criteria used by
71       the health insurer, including but not limited to: provider-insured ratios
72       by specialty; primary care provider-insured ratios; geographic accessibil-
73       ity; waiting times for appointments with participating providers; hours of
74       operation; and the availability of technological and specialty services to
75       serve the needs of insureds requiring technologically advanced or spe-
76       cialty care.
77             (b) A health insurer shall have a plan by which an insured with a life-
78       threatening, chronic, degenerative or disabling condition or disease,
79       which requires specialized medical care over a prolonged period of time,
80       may receive a referral to a specialist with expertise in treating such disease
81       or condition who shall be responsible for and capable of providing and
82       coordinating the insured's specialty care.
83             (c) A health insurer shall provide optional benefits that provide for
84       reimbursement to an insured who seeks service outside the insurer's pro-
85       vider network for health care services for the treatment of chronic illness.
86       Such services must be rendered by board-certified medical and surgical
87       specialists recognized by the American board of medical specialties. Any
88       additional premium charged for such benefits shall be limited to 50% of
89       actuarially determined cost due to lost network volume. Reimbursement
90       to providers outside the insurer's provider network shall be limited to the
91       reasonable amount paid for the same services if rendered by a provider
92       within the provider network.
93             (c) (d) Nothing in this section shall require a health insurer to provide
94       benefits not otherwise covered by the terms of the health benefits plan.
95             (d) (e) A provider network shall not be determined to be insufficient
96       for failure to contract with any provider unwilling to contract under the
97       same terms and conditions, including reimbursement levels, as such
98       health insurer offers to other similarly situated health care providers. 
99       Sec.  3. K.S.A. 1998 Supp. 40-4602 and 40-4607 are hereby repealed.
100        Sec.  4. This act shall take effect and be in force from and after its
101       publication in the statute book.