There is a newer version of the Kentucky Revised Statutes
2009 Kentucky Revised Statutes
Subtitle 17A. Health Benefit Plans
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.
Download pdfNotice of denial of coverage. (1) The commissioner shall, by administrative regulations promulgated under KRS Chapter 13A, define one (1) standard health benefit plan. After July 15, 2004,
insurers may offer the standard health benefit plan in the individual or small group
markets. Except as may be necessary to coordinate with changes in federal law, the
commissioner shall not alter, amend, or replace the standard health benefit plan
more frequently than annually. (2) If offered, the standard health benefit plan may be available in at least one (1) of these four (4) forms of coverage:
(a) A fee-for-service product type;
(b) A health maintenance organization type;
(c) A point-of-service type; and
(d) A preferred provider organization type. (3) The standard health benefit plan shall be defined so that it meets the requirements of KRS 304.17B-021 for inclusion in calculating assessments and refunds under
Kentucky Access. (4) Any health insurer who offers the standard health benefit plan may offer the standard health benefit plan in the individual or small group markets in each and
every form of coverage that the health insurer offers to sell. (5) Nothing in this section shall be construed: (a) To require a health insurer to offer a standard health benefit plan in a form of coverage that the health insurer has not selected; (b) To prohibit a health insurer from offering other health benefit plans in the individual or small group markets in addition to the standard health benefit
plan; or (c) To require that a standard health benefit plan have guaranteed issue, renewability, or pre-existing condition exclusion rights or provisions that are
more generous to the applicant than the health insurer would be required to
provide under KRS 304.17A-200, 304.17A-220, 304.17A.230, and 304.17A-
240. (6) All health benefit plans shall cover hospice care at least equal to the Medicare benefits. (7) All health benefit plans shall coordinate benefits with other health benefit plans in accordance with the guidelines for coordination of benefits prescribed by the
commissioner as provided in KRS 304.18-085. (8) Every health insurer of any kind, nonprofit hospital, medical-surgical, dental and health service corporation, health maintenance organization, or provider-sponsored
health delivery network that issues or delivers an insurance policy in this state that
directs or gives any incentives to insureds to obtain health care services from certain
health care providers shall not imply or otherwise represent that a health care Page 2 of 2 provider is a participant in or an affiliate of an approved or selected provider
network unless the health care provider has agreed in writing to the representation
or there is a written contract between the health care provider and the insurer or an
agreement by the provider to abide by the terms for participation established by the
insurer. This requirement to have written contracts shall apply whenever an insurer
includes a health care provider as a part of a preferred provider network or
otherwise selects, lists, or approves certain health care providers for use by the
insurer's insureds. The obligation set forth in this section for an insurer to have
written contracts with providers selected for use by the insurer shall not apply to
emergency or out-of-area services. (9) A self-insured plan may select any third party administrator licensed under KRS 304.9-052 to adjust or settle claims for persons covered under the self-insured plan. (10) Any health insurer that fails to issue a premium rate quote to an individual within thirty (30) days of receiving a properly completed application request for the quote
shall be required to issue coverage to that individual and shall not impose any pre-
existing conditions exclusion on that individual with respect to the coverage. Each
health insurer offering individual health insurance coverage in the individual market
in the Commonwealth that refuses to issue a health benefit plan to an applicant or
insured with a disclosed high-cost condition as specified in KRS 304.17B-001 or
for any reason, shall provide the individual with a denial letter within twenty (20)
working days of the request for coverage. The letter shall include the name and title
of the person making the decision, a statement setting forth the basis for refusing to
issue a policy, a description of Kentucky Access, and the telephone number for a
contact person who can provide additional information about Kentucky Access. (11) If a standard health benefit plan covers services that the plan's insureds lawfully obtain from health departments established under KRS Chapter 212, the health
insurer shall pay the plan's established rate for those services to the health
department. (12) No individually insured person shall be required to replace an individual policy with group coverage on becoming eligible for group coverage that is not provided by an
employer. In a situation where a person holding individual coverage is offered or
becomes eligible for group coverage not provided by an employer, the person
holding the individual coverage shall have the option of remaining individually
insured, as the policyholder may decide. This shall apply in any such situation that
may arise through an association, an affiliated group, the Kentucky state employee
health insurance plan, or any other entity. Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1221, effective July 15, 2010. -- Amended 2004 Ky. Acts ch. 59, sec. 4, effective July 13, 2004. -- Amended 2000
Ky. Acts ch. 476, sec. 21, effective January 1, 2001. -- Created 1998 Ky. Acts
ch. 496, sec. 7, effective April 10, 1998.
Disclaimer: These codes may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.