Subtitle 304.17A - Health Benefit Plans

304.17A-005 Definitions for subtitle. (Effective until January 1, 2020).
304.17A-005 Definitions for subtitle. (Effective January 1, 2020).
304.17A-010 Repealed, 1998.
304.17A-020 Repealed, 1998.
304.17A-030 Repealed, 1998.
304.17A-040 Repealed, 1998.
304.17A-050 Repealed, 1998.
304.17A-060 Repealed, 1998.
304.17A-070 Repealed, 1998.
304.17A-071 Repealed, 2010.
304.17A-080 Health Insurance Advisory Council -- Powers -- Duties -- Members -- Expenses and supplies.
304.17A-090 Repealed, 1998.
304.17A-095 Insurer issuing health benefit plan must file rates and charges -- Commissioner's approval -- Policy forms -- Administrative regulations -- Hearing.
304.17A-0952 Premium rate guidelines for individual, small group, and association plans.
304.17A-0954 Premium rate guidelines for employer-organized association plans.
304.17A-096 Basic health benefit plans permitted for individual, small group, and association markets -- Required coverage -- Exclusions from coverage.
304.17A-097 Disclosure of coverage levels in basic health benefit plan.
304.17A-098 Rewards or incentives to participate in voluntary wellness or health improvement program.
304.17A-100 Repealed, 1998.
304.17A-110 Repealed, 1998.
304.17A-120 Repealed, 1998.
304.17A-130 Repealed, 1998.
304.17A-131 Coverage for cochlear implants.
304.17A-132 Coverage for hearing aids.
304.17A-133 Coverage for mammograms.
304.17A-134 Coverage for medical and surgical benefits with respect to mastectomy, diagnosis and treatment of endometrioses and endometritis, and bone density testing -- Requirements for health benefit plan.
304.17A-135 Coverage for treatment of breast cancer.
304.17A-136 Coverage for cancer clinical trials.
304.17A-137 Repealed, 2002.
304.17A-138 Telehealth coverage and reimbursement -- Requirements for health benefit plan -- Benefits subject to deductible, copayment, or coinsurance -- Payment subject to provider network arrangements -- Administrative regulations.
304.17A-139 Family or dependents coverage to apply to newly born child from moment of birth and to include inherited metabolic diseases -- Requirement for notification and payment of premium -- Coverage for milk fortifiers to prevent enterocolitis.
304.17A-140 Coverage applicable to children to include legally-adopted children.
304.17A-141 Repealed, 2019. (Effective January 1, 2019).
304.17A-142 Coverage for autism spectrum disorders -- Limitations on coverage -- Utilization review -- Reimbursement not required.
304.17A-143 Repealed, 2019. (Effective January 1, 2019).
304.17A-144 Liaison for autism spectrum disorders treatment benefits.
304.17A-145 Maternity coverage to include specified amounts of inpatient care for mothers and newly-born children -- Exemption.
304.17A-146 Coverage for registered nurse first assistant.
304.17A-147 Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant.
304.17A-1473 Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant or physician assistant.
304.17A-148 Coverage for diabetes.
304.17A-149 Coverage for anesthesia and services in connection with dental procedures for certain patients.
304.17A-150 Unfair trade practices -- Penalties.
304.17A-155 Prohibition against denial of coverage to victims of domestic violence.
304.17A-160 Repealed, 1998.
304.17A-161 Definitions for KRS 304.17A-161, 304.17A-162, 304.17A-163, and 304.17A-165.
304.17A-162 Identification of sources used to calculate drug product reimbursement -- Process to appeal disputes over maximum allowable cost pricing -- Adjustment of maximum allowable cost and drug product reimbursement -- Duties of pharmacy benefit manager.
304.17A-163 Override of restrictions on medication sequence in step therapy or fail-first protocol.
304.17A-164 Limitations on insurers and pharmacy benefit managers regarding cost-sharing for prescription drugs.
304.17A-165 Prescription drug coverage to include exceptions or override policy for refills of covered drugs -- Limitations and exclusions -- Program for synchronization of medications.
304.17A-166 Prescription eye drops coverage to include refills and additional bottle if conditions met.
304.17A-167 Processes and standards for electronic prior authorizations -- Prior authorization of drugs for ongoing medication therapy -- Requirements -- Time span of authorization -- Exemptions. (Effective January 1, 2020).
304.17A-168 Coverage for tobacco cessation medications and services.
304.17A-170 Definitions for KRS 304.17A-170 and 304.17A-171.
304.17A-171 Requirements for health benefit plans that include chiropractic benefits.
304.17A-172 Requirements for health benefit plans that include anticancer medications that are injected or intravenously administered by a health care provider and patient-administered anticancer medications.
304.17A-173 Reimbursement for services within scope of practice of optometrists -- Terms and conditions.
304.17A-175 Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist.
304.17A-177 Limitation on amount of copayment or coinsurance charged for services rendered by occupational or physical therapist -- Insurer to clearly state coverage.
304.17A-200 Prohibition against establishing certain rules of eligibility in small group, large group, or association markets -- Limitation on premium -- Participation rules -- Effect of denial of coverage -- Disclosure.
304.17A-210 Repealed, 2000.
304.17A-220 Pre-existing condition exclusion in group coverage -- Definitions for section.
304.17A-230 Pre-existing condition exclusion in individual market -- Prohibition against use of genetic information -- Administrative regulations.
304.17A-235 Notice of proposed material change in health benefit plan's agreement with participating provider.
304.17A-240 Renewal or continuation -- Ground for nonrenewal, cancellation, or discontinuance.
304.17A-243 Grace period for unpaid premiums.
304.17A-245 Required notice of cancellation -- Procedure -- Refund of unearned premium.
304.17A-250 Standard health benefit plan -- Individual or small group markets -- Writing requirement for provider participation -- Time limit for rate quote -- Notice of denial of coverage.
304.17A-252 Health benefit plan not required to include state-mandated benefits enacted after issuance.
304.17A-254 Duties of insurer offering health benefit plan.
304.17A-256 Options for dependent coverage under group health benefit plans -- Disclaimer.
304.17A-257 Coverage under health benefit plan for colorectal cancer examinations and laboratory tests. (Effective until January 1, 2020).
304.17A-257 Coverage under health benefit plan for colorectal cancer examinations and laboratory tests. (Effective January 1, 2020).
304.17A-258 Coverage under health benefit plan for therapeutic food, formulas, supplements, low-protein modified food products, and amino acid-based elemental formula.
304.17A-259 Coverage under health benefit plan for genetic test for cancer risk. (Effective January 1, 2020).
304.17A-260 Repealed, 2002.
304.17A-270 Nondiscrimination against provider in geographic coverage area.
304.17A-275 Health benefit plan not to discriminate against physician on basis of degree in medicine or osteopathy.
304.17A-280 Repealed, 2000.
304.17A-290 Prohibition against renewal of nonstate employees and small groups under KRS 18A.2251 or 18A.2281.
304.17A-300 Provider-sponsored integrated health delivery network -- Qualifications -- Fees -- Network subject to provisions of other subtitles.
304.17A-310 Financial solvency requirements for network.
304.17A-320 Certificate of filing for employer-organized association -- Effect -- Revocation.
304.17A-330 Self-insurance reporting requirements -- Exemption.
304.17A-340 Restrictions on use of Kentucky Children's Health Insurance Program allocated funds.
304.17A-350 Repealed, 2002.
304.17A-400 Repealed, 2000.
304.17A-410 Definitions for KRS 304.17A-400 to 304.17A-480.
304.17A-420 Repealed, 2000.
304.17A-430 Criteria for program plan -- Alternative underwriting. (Effective until January 1, 2020).
304.17A-430 Criteria for program plan -- Alternative underwriting. (Effective January 1, 2020).
304.17A-440 Repealed, 2000.
304.17A-450 Cost-containment feature requirement for program plans.
304.17A-460 Repealed, 2000.
304.17A-470 Repealed, 2000.
304.17A-480 Repealed, 2000.
304.17A-500 Definitions for KRS 304.17A-500 to 304.17A-590.
304.17A-505 Disclosure of terms and conditions of health benefit plan -- Filing with department.
304.17A-510 Notification by insurer offering managed care plans of availability of printed document.
304.17A-515 Requirements for managed care plan.
304.17A-520 Enrollee choice of primary care providers.
304.17A-525 Standards for provider participation -- Mechanisms for consideration of provider applications -- Policy for removal or withdrawal.
304.17A-527 Filing of provider agreements, risk-sharing arrangements, and subcontract agreements with commissioner -- Contents -- Disclosure of financial information not required.
304.17A-530 Prohibition against contract limiting disclosure to patient of patient medical condition or treatment options.
304.17A-532 Prohibition against contract requiring mandatory use of hospitalist.
304.17A-533 Repealed, 2004.
304.17A-535 Drug utilization waiver program -- Limitations on generic substitution -- Application to drug formulary.
304.17A-540 Disclosure of limitations on coverage -- Denial letter.
304.17A-545 Medical director for managed care plan -- Duties -- Quality assurance or improvement standards -- Process to select health care providers -- Uniform application form and guidelines for health care provider evaluations.
304.17A-550 Out-of-network benefits.
304.17A-555 Patient's right of privacy regarding mental health or chemical dependency -- Authorized disclosure.
304.17A-560 Most-favored-nation provision.
304.17A-565 Commissioner to enforce KRS 304.17A-500 to 304.17A-570 -- Administrative regulations.
304.17A-570 Applicability of KRS 304.17A-500 to 304.17A-570 for health insurance contracts or certificates.
304.17A-575 Definitions for KRS 304.17A-575 to 304.17A-577.
304.17A-576 Notice by managed care plan insurer of health care provider's application for credentialing -- Payments to applicant.
304.17A-577 Disclosure of payment or fee schedule to managed care plan health care provider -- Disclosure of schedule change -- Confidentiality of payment information.
304.17A-578 Renumbered as 304.17A-235, effective 2017. (Effective January 1, 2017).
304.17A-580 Education of insured about appropriate use of emergency and medical services -- Coverage of emergency medical conditions and emergency department services -- Emergency personnel to contact primary care provider or insurer -- Exclusion of limited-benefit health insurance policies. (Effective January 1, 2020).
304.17A-580 Education of insured about appropriate use of emergency and medical services -- Coverage of emergency medical conditions and emergency department services -- Emergency personnel to contact primary care provider or insurer -- Exclusion of limited-benefit health insurance policies. (Effective until January 1, 2020).
304.17A-590 Participating provider directories.
304.17A-600 Definitions for KRS 304.17A-600 to 304.17A-633. (Effective until January 1, 2020).
304.17A-600 Definitions for KRS 304.17A-600 to 304.17A-633. (Effective January 1, 2020).
304.17A-603 Application of KRS 304.17A-600 to 304.17A-633 -- Written procedures for coverage and utilization review determinations to be accessible on insurers' Web sites -- Preauthorization review requirements for insurers. (Effective January 1, 2020).
304.17A-603 Application of KRS 304.17A-600 to 304.17A-633. (Effective until January 1, 2020).
304.17A-605 Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal government.
304.17A-607 Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the department -- Requirement that private review agent provide timely notice of entities for whom it is providing review. (Effective until January 1, 2020).
304.17A-607 Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the department -- Requirement that private review agent provide timely notice of entities for whom it is providing review. (Effective January 1, 2020).
304.17A-609 Emergency administrative regulations governing utilization review and internal appeal to be promulgated by the department.
304.17A-611 Prohibition against retrospective denial of coverage for health care services under certain circumstances.
304.17A-613 Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaints.
304.17A-615 Prohibition against denying or reducing payments under certain circumstances.
304.17A-617 Internal appeals process -- Procedures -- Review of coverage denials.
304.17A-619 Duty of covered person, authorized person, or provider to provide insurer with new information regarding internal appeal -- Time frame for insurer to render a decision based on new information -- Insurer's failure to make timely determination or provide written notice.
304.17A-621 Independent External Review Program established.
304.17A-623 External review of adverse determination -- Who may request -- Criteria for review -- Fee -- Conditions under which covered person not entitled to review -- Resolution of disputes -- Confidentiality -- Expedited external review.
304.17A-625 Factors to be considered by independent review entity conducting external review -- Basis for decision -- Insurer's responsibilities -- Contents, admissibility, and effect of decision -- Consequence of insurer's failure to provide coverage -- Liability -- Written complaints.
304.17A-627 Certification as independent review entity -- Requirements and restrictions.
304.17A-629 Administrative regulations to implement provisions of KRS 304.17A-621, 304.17A-623, 304.17A-625, 304.17A-627, 304.17A-629, and 304.17A-631.
304.17A-631 Time for insurers to comply with administrative regulations.
304.17A-633 Commissioner to report to Interim Joint Committee on Banking and Insurance and to Governor -- Contents of report.
304.17A-640 Definitions for KRS 304.17A-640 et seq.
304.17A-641 Treatment of a stabilized covered person with an emergency medical condition in a nonparticipating hospital's emergency room.
304.17A-643 Treatment of covered person under special circumstances.
304.17A-645 Covered person's access to participating nonprimary care physician specialist.
304.17A-647 Covered person's access to participating obstetrician or gynecologist -- Authorization for annual pap smear without referral.
304.17A-649 Administrative regulations for the implementation of KRS 304.17A-640 et seq.
304.17A-660 Definitions for KRS 304.17A-660 to 304.17A-669.
304.17A-661 Treatment of mental health conditions to be covered under same terms and conditions as treatment of physical health conditions.
304.17A-665 Commissioner to report to Legislative Research Commission on impact of health insurance costs under KRS 304.17A-660 to 304.17A-669.
304.17A-669 KRS 304.17A-660 to 304.17A-669 not to be construed as mandating coverage for mental health conditions -- Exemptions from KRS 304.17A-660 to 304.17A-669.
304.17A-700 Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
304.17A-702 Claims payment time frames -- Duties of insurer.
304.17A-704 Insurer's acknowledgment of receipt of claim -- Inaccurate or insufficient claim information -- Claim status information.
304.17A-705 Electronic claims submission.
304.17A-706 Contested claims -- Delay of payment -- Conditions -- Procedure.
304.17A-708 Resolution of payment errors -- Retroactive denial of claims -- Conditions.
304.17A-710 Disclosure of claims payment information to provider.
304.17A-712 Claim refunds and overpayments.
304.17A-714 Collection of claim overpayments -- Dispute resolution.
304.17A-716 Prohibition against denial or reduction of payment for covered health benefit -- Conditions.
304.17A-718 Disclosure of claims payment information to covered person.
304.17A-720 Administrative regulations for standardized health claim attachments -- Conformity with federal standards.
304.17A-722 Administrative regulations on claims payment practices.
304.17A-724 Applicability of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
304.17A-726 Exclusive application of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123 to claims incurred and contracts made after July 14, 2000.
304.17A-728 Contract disclosures of discounted fees -- Violation is unfair claims settlement practice.
304.17A-730 Payment of interest for failing to pay, denying, or settling a clean claim as required.
304.17A-740 Definitions for KRS 304.17A-740 to 304.17A-743.
304.17A-741 Audit of pharmacy records -- Conditions.
304.17A-743 Pharmacy audit appeals process.
304.17A-745 KRS 304.17A-740 to 304.17A-743 not applicable to audits conducted by state agency pursuant to KRS Chapter 205.
304.17A-747 KRS 304.17A-740 to 304.17A-743 not applicable when fraud, willful misrepresentation, or abuse alleged.
304.17A-750 Definitions for KRS 304.17A-750 to 304.17A-770 and 304.47-020.
304.17A-752 Registration of insurance purchasing outlets -- Licensed agents -- Administrative regulations.
304.17A-754 Application -- Approval and issuance of certificate -- Information to be filed -- Administrative regulations.
304.17A-756 Denial, suspension, and revocation of application or license -- Civil penalty.
304.17A-758 Activities allowed under administrator license -- Financial statements -- Books and records -- Renewal of certificate -- Nontransferability -- Fees.
304.17A-760 Duties and powers of insurance purchasing outlet.
304.17A-762 Outlet to act as policyholder for member -- Certificate of coverage for each member -- Disclosure to members.
304.17A-764 Determination of premiums -- Restrictions in calculation.
304.17A-766 Coverage deemed group health insurance -- Requirements for health benefit plans -- Member who no longer meets participation requirements.
304.17A-768 Voucher -- Redemption -- Payment of premium amount -- Fee to process voucher -- Administrative regulations.
304.17A-770 Provisions applicable to insurance purchasing outlets.
304.17A-800 Purpose of KRS 304.17A-800 to 304.17A-844.
304.17A-802 Definitions for KRS 304.17A-800 to 304.17A-844.
304.17A-804 Applicability of KRS 304.17A-800 to 304.17A-844 -- Self-insured employer-organized association groups.
304.17A-806 Certificate of filing required.
304.17A-808 Application for certificate of filing -- Fee.
304.17A-810 Conditions for issuance of certificate of filing.
304.17A-812 Initial and continuing financial solvency requirements.
304.17A-814 Notification of change in information.
304.17A-816 Investment of funds.
304.17A-818 Agent of self-insured employer-organized association group -- Licensing -- Continuing education.
304.17A-820 Examination of financial condition, affairs, and management by commissioner.
304.17A-822 Appointment of Secretary of State as attorney to receive legal process.
304.17A-824 Continuing effectiveness of certificate -- Termination of certificate at request of group -- Merger with another group.
304.17A-826 Operation of group by board of trustees -- Powers and duties -- Prohibited acts.
304.17A-828 Membership -- Liability on termination of membership, insolvency, or bankruptcy.
304.17A-830 Trustees, officers, directors, or employees not to have interest in administrator or group.
304.17A-832 Statement of financial condition -- Authority for administrative regulations.
304.17A-834 Filing of rates, underwriting guidelines, evidence of coverage, and changes -- Filing fee.
304.17A-836 Contribution plans to be established.
304.17A-838 Members to receive evidences of coverage -- Contents.
304.17A-840 Suspension or revocation of certificate of filing.
304.17A-842 Authority for administrative regulations.
304.17A-844 Prohibited activities -- Penalties.
304.17A-846 Providing of requested information on insureds by group health benefit plan insurers -- Confidentiality -- Additional information to be provided to large groups.