2006 Kentucky Revised Statutes - Subtitle 17A. Health Benefit Plans

• .005   Definitions for subtitle.
• .010   Repealed, 1998.
• .020   Repealed, 1998.
• .030   Repealed, 1998.
• .040   Repealed, 1998.
• .050   Repealed, 1998.
• .060   Repealed, 1998.
• .070   Repealed, 1998.
• .071   Discontinuance of operation of Kentucky Health Purchasing Alliance -- Executive director to terminate alliance activities by June 30, 1999.
• .080   Health Insurance Advisory Council -- Powers -- Duties -- Members -- Expenses and supplies.
• .090   Repealed, 1998
• .095   Insurer issuing health benefit plan must file rates and charges -- Executive director's approval -- Policy forms -- Administrative regulations -- Hearing.
• .0952   Premium rate guidelines for individual, small group, and association plans.
• .0954   Definitions for section -- Premium rate guidelines for employer-organized association plans.
• .096   Basic health benefit plans permitted for individual, small group, and association markets -- Required coverage -- Exclusions from coverage.
• .097   Disclosure of coverage levels in basic health benefit plan.
• .100   Repealed, 1998.
• .110   Repealed, 1998.
• .120   Repealed, 1998.
• .130   Repealed, 1998.
• .131   Coverage for cochlear implants.
• .132   Coverage for hearing aids.
• .133   Coverage for mammograms.
• .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.
• .135   Coverage for treatment of breast cancer.
• .137   Repealed, 2002.
• .138   Prohibition against health benefit plan excluding coverage for telehealth -- Benefits subject to deductible, co-payment, or coinsurance -- Payment subject to provider network arrangements -- Administrative regulations.
• .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 -- Exemption.
• .140   Coverage applicable to children to include legally-adopted children.
• .143   Coverage for treatment of autism in children -- Limitation -- Definitions.
• .145   Maternity coverage to include specified amounts of inpatient care for mothers and newly-born children -- Exemption.
• .146   Coverage for registered nurse first assistant.
• .147   Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant.
• .1473   Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant or physician assistant.
• .148   Coverage for diabetes.
• .149   Coverage for anesthesia and services in connection with dental procedures for certain patients.
• .150   Unfair trade practices -- Penalties.
• .155   Prohibition against denial of coverage to victims of domestic violence.
• .160   Repealed, 1998.
• .165   Prescription drug coverage to include exceptions or override policy for refills of covered drugs -- Limitations and exclusions.
• .170   Definitions for KRS 304.17A-170 and 304.17A-171.
• .171   Requirements for health benefit plans that include chiropractic benefits.
• .173   Payment for coverage of services within scope of practice of optometrists.
• .175   Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist.
• .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.
• .210   Repealed, 2000.
• .220   Pre-existing condition exclusion in group coverage -- Definitions for section.
• .230   Pre-existing condition exclusion in individual market -- Prohibition against use of genetic information -- Administrative regulations.
• .240   Renewal or continuation -- Ground for nonrenewal, cancellation, or discontinuance.
• .243   Grace period for unpaid premiums.
• .245   Required notice of cancellation -- Procedure -- Refund of unearned premium.
• .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.
• .252   Health benefit plan not required to include state-mandated benefits enacted after issuance.
• .254   Duties of insurer offering health benefit plan.
• .260   Repealed, 2002.
• .270   Nondiscrimination against provider in geographic coverage area.
• .275   Health benefit plan not to discriminate against physician on basis of degree in medicine or osteopathy.
• .280   Repealed, 2000.
• .290   Prohibition against renewal of nonstate employees and small groups under KRS 18A.2251 or 18A.2281.
• .300   Provider-sponsored integrated health delivery network -- Qualifications -- Fees -- Network subject to provisions of other subtitles.
• .310   Financial solvency requirements for network.
• .320   Certificate of filing for employer-organized association -- Effect -- Revocation.
• .330   Self-insurance reporting requirements -- Exemption.
• .340   Restrictions on use of Kentucky Children's Health Insurance Program allocated funds.
• .350   Repealed, 2002.

Kentucky Guaranteed Acceptance Program

• .400   Repealed, 2000.
• .410   Definitions for KRS 304.17A-400 to 304.17A-480.
• .420   Repealed, 2000.
• .430   Criteria for program plan -- Alternative underwriting.
• .440   Repealed, 2000.
• .450   Cost-containment feature requirement for program plans.
• .460   Repealed, 2000.
• .470   Repealed, 2000.
• .480   Repealed, 2000.
• .500   Definitions for KRS 304.17A-500 to 304.17A-590.
• .505   Disclosure of terms and conditions of health benefit plan -- Filing with office.
• .510   Notification by insurer offering managed care plans of availability of printed document.
• .515   Requirements for managed care plan.
• .520   Enrollee choice of primary care providers.
• .525   Standards for provider participation -- Mechanisms for consideration of provider applications -- Policy for removal or withdrawal.
• .527   Filing of provider agreements, risk-sharing arrangements, and subcontract agreements with executive director -- Contents -- Disclosure of financial information not required.
• .530   Prohibition against contract limiting disclosure to patient of patient medical condition or treatment options.
• .532   Prohibition against contract requiring mandatory use of hospitalist.
• .533   Repealed, 2004.
• .535   Drug utilization waiver program -- Limitations on generic substitution -- Application to drug formulary.
• .540   Disclosure of limitations on coverage -- Denial letter.
• .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.
• .550   Out-of-network benefits.
• .555   Patient's right of privacy regarding mental health or chemical dependency -- Authorized disclosure.
• .560   Most-favored-nation provision.
• .565   Executive director to enforce KRS 304.17A-500 to 304.17A-570 -- Administrative regulations.
• .570   Applicability of KRS 304.17A-500 to 304.17A-570 for health insurance contracts or certificates.
• .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.
• .590   Participating provider directories.

Utilization Reviews

• .600   Definitions for KRS 304.17A-600 to 304.17A-633.
• .603   Application of KRS 304.17A-600 to 304.17A-633.
• .605   Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal government.
• .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 office -- Requirement that private review agent provide timely notice of entities for whom it is providing review.
• .609   Emergency administrative regulations governing utilization review and internal appeal to be promulgated by the office.
• .611   Prohibition against retrospective denial of coverage for health care services under certain circumstances.
• .613   Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaints.
• .615   Prohibition against denying or reducing payments under certain circumstances.
• .617   Internal appeals process -- Procedures -- Review of coverage denials.
• .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.
• .621   Independent External Review Program established.
• .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.
• .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.
• .627   Certification as independent review entity -- Requirements and restrictions.
• .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.
• .631   Time for insurers to comply with administrative regulations.
• .633   Executive director to report to Interim Joint Committee on Banking and Insurance and to Governor -- Contents of report.

Emergency Medical Conditions

• .640   Definitions for KRS 304.17A-640 et seq.
• .641   Treatment of a stabilized covered person with an emergency medical condition in a nonparticipating hospital's emergency room.
• .643   Treatment of covered person under special circumstances.
• .645   Covered person's access to participating nonprimary care physician specialist.
• .647   Covered person's access to participating obstetrician or gynecologist -- Authorization for annual pap smear without referral.
• .649   Administrative regulations for the implementation of KRS 304.17A-640 et seq.

Mental Health Conditions

• .660   Definitions for KRS 304.17A-660 to 304.17A-669.
• .661   Treatment of mental health conditions to be covered under same terms and conditions as treatment of physical health conditions.
• .665   Executive director to report to Legislative Research Commission on impact of health insurance costs under KRS 304.17A-660 to 304.17A-669.
• .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.

KRS 304.17A-700 to 304.17A-730 Payment of Claims

• .700   Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
• .702   Claims payment time frames -- Duties of insurer.
• .704   Insurer's acknowledgment of receipt of claim -- Inaccurate or insufficient claim information -- Claim status information.
• .706   Contested claims -- Delay of payment -- Conditions -- Procedure.
• .708   Resolution of payment errors -- Retroactive denial of claims -- Conditions.
• .710   Disclosure of claims payment information to provider.
• .712   Claim refunds and overpayments.
• .714   Collection of claim overpayments -- Dispute resolution.
• .716   Prohibition against denial or reduction of payment for covered health benefit -- Conditions.
• .718   Disclosure of claims payment information to covered person.
• .720   Administrative regulations for standardized health claim attachments -- Conformity with federal standards.
• .722   Administrative regulations on claims payment practices.
• .724   Applicability of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
• .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.
• .728   Contract disclosures of discounted fees -- Violation is unfair claims settlement practice.
• .730   Payment of interest for failing to pay, denying, or settling a clean claim as required.

Insurance Purchasing Outlets

• .750   Definitions for KRS 304.17A-750 to 304.17A-770 and 304.47-020.
• .752   Registration of insurance purchasing outlets -- Licensed agents -- Administrative regulations.
• .754   Application -- Approval and issuance of certificate -- Information to be filed -- Administrative regulations.
• .756   Denial, suspension, and revocation of application or license -- Civil penalty.
• .758   Activities allowed under administrator license -- Financial statements -- Books and records -- Renewal of certificate -- Nontransferability -- Fees.
• .760   Duties and powers of insurance purchasing outlet.
• .762   Outlet to act as policyholder for member -- Certificate of coverage for each member -- Disclosure to members.
• .764   Determination of premiums -- Restrictions in calculation.
• .766   Coverage deemed group health insurance -- Requirements for health benefit plans -- Member who no longer meets participation requirements.
• .768   Voucher -- Redemption -- Payment of premium amount -- Fee to process voucher -- Administrative regulations.
• .770   Provisions applicable to insurance purchasing outlets.

Self-Insured Employer-Organized Association Groups

• .800   Purpose of KRS 304.17A-800 to 304.17A-844.
• .802   Definitions for KRS 304.17A-800 to 304.17A-844.
• .804   Applicability of KRS 304.17A-800 to 304.17A-844 -- Self-insured employer-organized association groups.
• .806   Certificate of filing required.
• .808   Application for certificate of filing - Fee.
• .810   Conditions for issuance of certificate of filing.
• .812   Initial and continuing financial solvency requirements.
• .814   Notification of change in information.
• .816   Investment of funds.
• .818   Agent of self-insured employer-organized association group -- Licensing -- Continuing education.
• .820   Examination of financial condition, affairs, and management by executive director.
• .822   Appointment of Secretary of State as attorney to receive legal process.
• .824   Continuing effectiveness of certificate -- Termination of certificate at request of group -- Merger with another group.
• .826   Operation of group by board of trustees -- Powers and duties -- Prohibited acts.
• .828   Membership -- Liability on termination of membership, insolvency, or bankruptcy.
• .830   Trustees, officers, directors, or employees not to have interest in administrator or group.
• .832   Statement of financial condition -- Authority for administrative regulations.
• .834   Filing of rates, underwriting guidelines, evidence of coverage, and changes -- Filing fee.
• .836   Contribution plans to be established.
• .838   Members to receive evidences of coverage -- Contents.
• .840   Suspension or revocation of certificate of filing.
• .842   Authority for administrative regulations.
• .844   Prohibited activities -- Penalties.
• .846   Providing of requested information on insureds by group health benefit plan insurers -- Confidentiality.