40-2123. Same; expenses and services covered under plan; exclusions; plan not subject to coverages mandated by other laws.
40-2123
40-2123. Same; expenses and services covered underplan; exclusions; plan not subject to coverages mandated by otherlaws.(a) The plan shall offer coverage to every eligible personpursuant to which such person's covered expenses shall be indemnified orreimbursed subject to the provisions of K.S.A. 40-2124 andamendments thereto.
(b) Except for those expenses set forth in subsection (c) of this section,expenses covered under the plan shall include expenses for:
(1) Services of persons licensed to practice medicine and surgery which aremedically necessary for the diagnosis or treatment of injuries, illnesses orconditions;
(2) services of advanced registered nurse practitioners who hold acertificate of qualification from the board of nursing to practice in anexpanded role or physicians assistants acting under the direction of aresponsible physician when such services are provided at the direction of aperson licensed to practice medicine and surgery and meet the requirements ofparagraph (b)(1) above;
(3) services of licensed dentistswhen such procedures would otherwise be performed by persons licensed topractice medicine and surgery;
(4) emergency care, surgery and treatment of acute episodes of illness ordisease as defined in the plan and provided in a general hospital or ambulatorysurgical center as such terms are defined in K.S.A. 65-425, and amendmentsthereto;
(5) medically necessary diagnostic laboratory and x-ray services;
(6) drugs and controlled substances prescribed by a practitioner, as definedin K.S.A. 65-1626 and amendments thereto, ordrugs and controlled substances prescribed by a mid-level practitioner asdefined in K.S.A. 65-1626 and amendments thereto.Coverage foroutpatient prescriptions shall be subject to a mandatory 50% coinsuranceprovision, and coverage for prescriptions administered to inpatients shall besubject to a coinsurance provision as established in the plan; and
(7) subject to the approval of the commissioner, the board shall alsoreview and recommend the inclusion of coverage for mental health services andsuch other primary and preventive health care services as the board determineswould not materially impair affordability of the plan.
(c) Expenses not covered under the plan shall include expenses for:
(1) Illness or injury due to an act of war;
(2) services rendered prior to the effective date of coverage under thisplan for the person on whose behalf the expense is incurred;
(3) services for which no charge would be made in the absence ofinsurance or for which the insured bears no legal obligation to pay;
(4) (A) services or charges incurred by the insured which are otherwisecovered by:
(i) Medicare or state law or programs;
(ii) medical services provided for members of the United States armed forcesand their dependents or for employees of such armed forces;
(iii) military service-connected disability benefits;
(iv) other benefit or entitlement programs provided for by the laws of theUnited States (except title XIX of the social security act of 1965);
(v) workers compensation or similar programs addressing injuries, diseases,or conditions incurred in the course of employment covered by such programs;
(vi) benefits payable without regard to fault pursuant to any motor vehicleor other liability insurance policy or equivalent self-insurance.
(B) This exclusion shall not apply to services or charges which exceed thebenefits payable under the applicable programs listed above and which areotherwise eligible for payment under this section.
(5) Services the provision of which is not within the scope of the licenseor certificate of the institution or individual rendering such service;
(6) that part of any charge for services or articles rendered or prescribedwhich exceeds the rate established by K.S.A. 40-2131and amendments thereto for such services;
(7) services or articles not medically necessary;
(8) care which is primarily custodial or domiciliary in nature;
(9) cosmetic surgery unless provided as the result of an injury or medicallynecessary surgical procedure;
(10) eye surgery if corrective lenses would alleviate the problem;
(11) experimental services or supplies not generally recognizedas the normal mode of treatment for the illness or injuryinvolved;
(12) service of a blood donor and any fee for failure of the insured toreplace the first three pints of blood provided in each calendar year; and
(13) personal supplies or services provided by a health care facility or anyother nonmedical or nonprescribed supply or service.
(d) Except as expressly provided for in this act, no law requiring thecoverage or the offer of coverage of a health care service or benefit shallapply to the plan.
(e) A plan may incorporate provisions that will directcovered persons to the most appropriate lowest cost health care provideravailable.
History: L. 1992, ch. 209, § 7;L. 1993, ch. 132, § 5;L. 1997, ch. 184, § 1;L. 1999, ch. 115, § 6;L. 2007, ch. 177, § 28; May 17.