Session of 1999
HOUSE BILL No. 2162
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-
(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.
(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.
(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-
(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
(e) (f) "Insured" means a person who is covered by a health benefit
(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.
(g) (h) "Provider" means a physician, hospital or other person which
56 is licensed, accredited or certified to perform specified health care
(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.
(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.
(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.
(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.