Consistent with Ky. Rev. Stat. Xxx. 304.17A-527, the provider agreement contains:
Consistent with Ky. Rev. Stat. Xxx. 304.17A-728 (contract disclosures of discounted fees; violation is unfair claims settlement practice), this amendment identifies below the products and markets applicable to any discount as provided in the contract: The contract is for chiropractic services. In the Participating Practitioner Agreement, the participating physician specifies the particular discount ranging from 10-30% from the published fee schedule to be provided to all HWHN Affinity Program Participants for non-covered services. The disclosure is thus provided in the contract with providers and with their specific consent. The Participating Practitioner Agreement expressly states that if the participating physician chooses not to list a particular discount, then the discount will be set at 20% from the published fee schedule.
Consistent with Ky. Rev. Stat. Xxx. 304.17A-532 (prohibition against contract requiring mandatory use of hospitalist), the agreement between the insurer and the participating practitioner does not require the mandatory use of a hospitalist.
Consistent with Ky. Rev. Stat. Xxx. 304.17A-530 (prohibition against contract limiting disclosure to patient of patient medical condition or treatment options), a managed care plan may not contract with a health care provider to limit the provider's disclosure to an enrollee, or to another person on behalf of an enrollee, of any information relating to the enrollee's medical condition or treatment options. A health care provider shall not be penalized, or a health care provider's contract with a managed care plan terminated, because the provider discusses medically necessary or appropriate care with an enrollee or another person on behalf of an enrollee. The health care provider may not be prohibited by the plan from discussing all treatment options with the enrollee. Other information determined by the health care provider to be in the best interests of the enrollee may be disclosed by the provider to the enrollee or to another person on behalf of an enrollee. A health care provider shall not be penalized for discussing financial incentives and financial arrangements between the provider and the insurer with an enrollee. Upon request, a managed care plan shall inform its enrollees in writing of the type of financial arrangements between the plan and participating providers if those arrangements include an incentive or bonus.
Consistent with Ky. Rev. Stat. Xxx. 304.17A-560 (most-favored nation provision), no insurance contract with a provider shall contain a most-favored-nation provision except where the executive director determines that the market share of the insurer is nominal. Nothing in this provision shall be construed to prohibit a health insurer and a provider from negotiating payment rates and performance-based contract terms that would result in the health insurer receiving a rate that is as favorable, or more favorable, than the rates negotiated between a provider and other health insurance issuers.
Consistent with Ky. Rev. Stat. Xxx. § 304.17A-171, a health benefit plan that includes chiropractic benefits shall comply with Kentucky law, including:
Consistent with Ky. Rev. Stat. Xxx. § 304.17A-545, any utilization management decision to deny, reduce, or terminate a health care benefit or to deny payment for a health care service because that service is not medically necessary shall be made by a physician, except in the case of a health care service rendered by a chiropractor, that decision shall be made respectively by a chiropractor duly licensed in Kentucky.
Consistent with Ky. Rev. Stat. Xxx. 304.17A-150 (unfair trade practices), the insurer and third party administrator involved in this provider agreement, as applicable, shall not engage in unfair trade practices, which are described more fully in 304.17A-150. Specifically, as set forth in 304.17A-150(4), an insurer that offers multiple health benefit plans may not require a health care provider, as a condition of participation in a health benefit plan of the insurer, to participate in any of the insurer‟s other health benefit plans.
Consistent with Ky. Rev. Stat. Xxx. 304.17A-150 (unfair trade practices), the insurer and third party administrator involved in this provider agreement, as applicable, shall not engage in unfair trade practices, which are described more fully in 304.17A-150. Specifically, as set forth in 304.17A-150(4), an insurer that offers multiple health benefit plans may not require a health care provider, as a condition of participation in a health benefit plan of the insurer, to participate in any of the insurer’s other health benefit plans. To the extent the provider agreement states the contrary, this section 5 will control and take precedence as to Participating Providers practicing in and services provided to Members in the Commonwealth of Kentucky. Participating Providers shall be permitted to participate in any of the health benefit plans noted below and shall be asked to select an option(s). To the extent the Participating Provider does not select an option upon request, the Participating Provider shall be advised that the lack of a designation will be treated as an incomplete application. Physician agrees to OPT-IN for all health benefits plan(s) listed below, whether self-funded or fully insured that are offered or administered by Humana ☐ All Lines of Business Physician agrees to OPT-OUT of the health benefits plan(s) selected below, whether self-funded or fully insured that are offered or administered by Humana ☐ Commercial HMO ☐ Commercial POS ☐ Commercial EPO ☐ Commercial PPO ☐ Traditional Plans ☐ Medicare HMO ☐ Medicare POS ☐ Medicare PPO ☐ Affinity Discount Programs Please sign and return this Addendum to Healthways WholeHealth Networks, Inc. (HWHN). Your application is considered incomplete until HWHN has a copy of this signed Addendum. Healthways WholeHealth Networks, Inc 00000 Xxxxxx Xxx Xxxxx Xxxxx 000 Xxxxxxxx, XX 00000 Fax 000-000-0000 Provider Signature Date Provider Printed Name
