Solvency Requirements and Protections. The Contractor will be subject to requirements contained in KRS Chapter 304 and related administrative regulations regarding protection against insolvency and risk-based capital requirements. In addition, pursuant to KRS 304.3-125, the Commissioner has authority to require additional capital and surplus if it appears that an insurer is in a financially hazardous condition. The Contractor shall cover continuation of services to Members during insolvency, for the duration of the period for which payment has been made, as well as for inpatient admissions up until discharge. In the event of the Contractor’s insolvency, the Contractor shall not hold its Members liable, except in instances of Member fraud: A. For the Contractor’s debts; B. For the covered services provided to the Member, for which the Department does not pay the Contractor; C. For the covered services provided to the Member for which the Department or the Contractor does not pay the individual or health care provider that furnishes the services under a contractual, referral, or other arrangement; and D. For covered services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Member would owe if the Contractor provided the services directly.
Appears in 4 contracts
Samples: Managed Care Contract (Wellcare Health Plans, Inc.), Medicaid Managed Care Contract, Medicaid Managed Care Contract
Solvency Requirements and Protections. The Contractor will be subject to requirements contained in KRS Chapter 304 and related administrative regulations regarding protection against insolvency and risk-risk- based capital requirements. In addition, pursuant to KRS 304.3-125, the Commissioner has authority to require additional capital and surplus if it appears that an insurer is in a financially hazardous condition. The Contractor shall cover continuation of services to Members during insolvency, for the duration of the period for which payment has been made, as well as for inpatient admissions up until discharge. In the event of the Contractor’s insolvency, the Contractor shall not hold its Members liable, except in instances of Member fraud:
A. For the Contractor’s debts;
B. For the covered services provided to the Member, for which the Department does not pay the Contractor;
C. For the covered services provided to the Member for which the Department or the Contractor does not pay the individual or health care provider that furnishes the services under a contractual, referral, or other arrangement; and
D. For covered services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Member would owe if the Contractor provided the services directly.
Appears in 2 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract
