2011 Kentucky Revised Statutes CHAPTER 18A STATE PERSONNEL 18A.225 Health care insurance coverage -- Requirements of prospective carriers -- Analysis of carrier coverage data -- Agency's termination of participation -- Provision of amount of employer contribution -- Lapse of excess flexible spending account funds -- Appeal of formulary change -- Retiree's participation -- Mail order drug option coverage -- Hearing aid coverage for minors -- Coverage for diagnosis and treatment of autism spectrum disorders -- Access to certain services in contiguous counties -- Study of bid variation -- Regional rating bid scenario -- Optometric coverage -- Nondiscrimination against provider in geographic coverage area -- Standards for provider participation -- Utilization review -- Payment of claims -- Uniform health insurance claim forms -- Emergency medical care -- Administrative regulations. (Effective January 1, 2011)
KY Rev Stat § 18A.225 (1996 through Reg Sess) What's This?
18A.225 Health care insurance coverage -- Requirements of prospective carriers -Analysis of carrier coverage data -- Agency's termination of participation -Provision of amount of employer contribution -- Lapse of excess flexible
spending account funds -- Appeal of formulary change -- Retiree's
participation -- Mail order drug option coverage -- Hearing aid coverage for
minors -- Coverage for diagnosis and treatment of autism spectrum disorders - Access to certain services in contiguous counties -- Study of bid variation -Regional rating bid scenario -- Optometric coverage -- Nondiscrimination
against provider in geographic coverage area -- Standards for provider
participation -- Utilization review -- Payment of claims -- Uniform health
insurance claim forms -- Emergency medical care -- Administrative
regulations. (Effective January 1, 2011)
(1)
(a)
(b)
The term "employee" for purposes of this section means:
1.
Any person, including an elected public official, who is regularly
employed by any department, office, board, agency, or branch of state
government; or by a public postsecondary educational institution; or by
any city, urban-county, charter county, county, or consolidated local
government, whose legislative body has opted to participate in the statesponsored health insurance program pursuant to KRS 79.080; and who
is either a contributing member to any one (1) of the retirement systems
administered by the state, including but not limited to the Kentucky
Retirement Systems, Kentucky Teachers' Retirement System, the
Legislators' Retirement Plan, or the Judicial Retirement Plan; or is
receiving a contractual contribution from the state toward a retirement
plan; or, in the case of a public postsecondary education institution, is an
individual participating in an optional retirement plan authorized by
KRS 161.567;
2.
Any certified or classified employee of a local board of education;
3.
Any elected member of a local board of education;
4.
Any person who is a present or future recipient of a retirement
allowance from the Kentucky Retirement Systems, Kentucky Teachers'
Retirement System, the Legislators' Retirement Plan, the Judicial
Retirement Plan, or the Kentucky Community and Technical College
System's optional retirement plan authorized by KRS 161.567, except
that a person who is receiving a retirement allowance and who is age
sixty-five (65) or older shall not be included, with the exception of
persons covered under KRS 61.702(4)(c), unless he or she is actively
employed pursuant to subparagraph 1. of this paragraph; and
5.
Any eligible dependents and beneficiaries of participating employees
and retirees who are entitled to participate in the state-sponsored health
insurance program;
The term "health benefit plan" for the purposes of this section means a health
benefit plan as defined in KRS 304.17A-005;
(c)
(d)
(2)
(a)
(b)
(c)
(d)
The term "insurer" for the purposes of this section means an insurer as defined
in KRS 304.17A-005; and
The term "managed care plan" for the purposes of this section means a
managed care plan as defined in KRS 304.17A-500.
The secretary of the Finance and Administration Cabinet, upon the
recommendation of the secretary of the Personnel Cabinet, shall procure, in
compliance with the provisions of KRS 45A.080, 45A.085, and 45A.090,
from one (1) or more insurers authorized to do business in this state, a group
health benefit plan that may include but not be limited to health maintenance
organization (HMO), preferred provider organization (PPO), point of service
(POS), and exclusive provider organization (EPO) benefit plans encompassing
all or any class or classes of employees. With the exception of employers
governed by the provisions of KRS Chapters 16, 18A, and 151B, all
employers of any class of employees or former employees shall enter into a
contract with the Personnel Cabinet prior to including that group in the state
health insurance group. The contracts shall include but not be limited to
designating the entity responsible for filing any federal forms, adoption of
policies required for proper plan administration, acceptance of the contractual
provisions with health insurance carriers or third-party administrators, and
adoption of the payment and reimbursement methods necessary for efficient
administration of the health insurance program. Health insurance coverage
provided to state employees under this section shall, at a minimum, contain
the same benefits as provided under Kentucky Kare Standard as of January 1,
1994, and shall include a mail-order drug option as provided in subsection
(13) of this section. All employees and other persons for whom the health care
coverage is provided or made available shall annually be given an option to
elect health care coverage through a self-funded plan offered by the
Commonwealth or, if a self-funded plan is not available, from a list of
coverage options determined by the competitive bid process under the
provisions of KRS 45A.080, 45A.085, and 45A.090 and made available
during annual open enrollment.
The policy or policies shall be approved by the commissioner of insurance and
may contain the provisions the commissioner of insurance approves, whether
or not otherwise permitted by the insurance laws.
Any carrier bidding to offer health care coverage to employees shall agree to
provide coverage to all members of the state group, including active
employees and retirees and their eligible covered dependents and
beneficiaries, within the county or counties specified in its bid. Except as
provided in subsection (19) of this section, any carrier bidding to offer health
care coverage to employees shall also agree to rate all employees as a single
entity, except for those retirees whose former employers insure their active
employees outside the state-sponsored health insurance program.
Any carrier bidding to offer health care coverage to employees shall agree to
provide enrollment, claims, and utilization data to the Commonwealth in a
(3)
format specified by the Personnel Cabinet with the understanding that the data
shall be owned by the Commonwealth; to provide data in an electronic form
and within a time frame specified by the Personnel Cabinet; and to be subject
to penalties for noncompliance with data reporting requirements as specified
by the Personnel Cabinet. The Personnel Cabinet shall take strict precautions
to protect the confidentiality of each individual employee; however,
confidentiality assertions shall not relieve a carrier from the requirement of
providing stipulated data to the Commonwealth.
(e) The Personnel Cabinet shall develop the necessary techniques and capabilities
for timely analysis of data received from carriers and, to the extent possible,
provide in the request-for-proposal specifics relating to data requirements,
electronic reporting, and penalties for noncompliance. The Commonwealth
shall own the enrollment, claims, and utilization data provided by each carrier
and shall develop methods to protect the confidentiality of the individual. The
Personnel Cabinet shall include in the October annual report submitted
pursuant to the provisions of KRS 18A.226 to the Governor, the General
Assembly, and the Chief Justice of the Supreme Court, an analysis of the
financial stability of the program, which shall include but not be limited to
loss ratios, methods of risk adjustment, measurements of carrier quality of
service, prescription coverage and cost management, and statutorially required
mandates. If state self-insurance was available as a carrier option, the report
also shall provide a detailed financial analysis of the self-insurance fund
including but not limited to loss ratios, reserves, and reinsurance agreements.
(f) If any agency participating in the state-sponsored employee health insurance
program for its active employees terminates participation and there is a state
appropriation for the employer's contribution for active employees' health
insurance coverage, then neither the agency nor the employees shall receive
the state-funded contribution after termination from the state-sponsored
employee health insurance program.
(g) Any funds in flexible spending accounts that remain after all reimbursements
have been processed shall be transferred to the credit of the state-sponsored
health insurance plan's appropriation account.
(h) Each entity participating in the state-sponsored health insurance program shall
provide an amount at least equal to the state contribution rate for the employer
portion of the health insurance premium. For any participating entity that used
the state payroll system, the employer contribution amount shall be equal to
but not greater than the state contribution rate.
The premiums may be paid by the policyholder:
(a) Wholly from funds contributed by the employee, by payroll deduction or
otherwise;
(b) Wholly from funds contributed by any department, board, agency, public
postsecondary education institution, or branch of state, city, urban-county,
charter county, county, or consolidated local government; or
(c)
(4)
(5)
(6)
(7)
(8)
(9)
Partly from each, except that any premium due for health care coverage or
dental coverage, if any, in excess of the premium amount contributed by any
department, board, agency, postsecondary education institution, or branch of
state, city, urban-county, charter county, county, or consolidated local
government for any other health care coverage shall be paid by the employee.
If an employee moves his place of residence or employment out of the service area
of an insurer offering a managed health care plan, under which he has elected
coverage, into either the service area of another managed health care plan or into an
area of the Commonwealth not within a managed health care plan service area, the
employee shall be given an option, at the time of the move or transfer, to change his
or her coverage to another health benefit plan.
No payment of premium by any department, board, agency, public postsecondary
educational institution, or branch of state, city, urban-county, charter county,
county, or consolidated local government shall constitute compensation to an
insured employee for the purposes of any statute fixing or limiting the
compensation of such an employee. Any premium or other expense incurred by any
department, board, agency, public postsecondary educational institution, or branch
of state, city, urban-county, charter county, county, or consolidated local
government shall be considered a proper cost of administration.
The policy or policies may contain the provisions with respect to the class or classes
of employees covered, amounts of insurance or coverage for designated classes or
groups of employees, policy options, terms of eligibility, and continuation of
insurance or coverage after retirement.
Group rates under this section shall be made available to the disabled child of an
employee regardless of the child's age if the entire premium for the disabled child's
coverage is paid by the state employee. A child shall be considered disabled if he
has been determined to be eligible for federal Social Security disability benefits.
The health care contract or contracts for employees shall be entered into for a period
of not less than one (1) year.
The secretary shall appoint thirty-two (32) persons to an Advisory Committee of
State Health Insurance Subscribers to advise the secretary or his designee regarding
the state-sponsored health insurance program for employees. The secretary shall
appoint, from a list of names submitted by appointing authorities, members
representing school districts from each of the seven (7) Supreme Court districts,
members representing state government from each of the seven (7) Supreme Court
districts, two (2) members representing retirees under age sixty-five (65), one (1)
member representing local health departments, two (2) members representing the
Kentucky Teachers' Retirement System, and three (3) members at large. The
secretary shall also appoint two (2) members from a list of five (5) names submitted
by the Kentucky Education Association, two (2) members from a list of five (5)
names submitted by the largest state employee organization of nonschool state
employees, two (2) members from a list of five (5) names submitted by the
Kentucky Association of Counties, two (2) members from a list of five (5) names
submitted by the Kentucky League of Cities, and two (2) members from a list of
(10)
(11)
(12)
(13)
(14)
(15)
(16)
names consisting of five (5) names submitted by each state employee organization
that has two thousand (2,000) or more members on state payroll deduction. The
advisory committee shall be appointed in January of each year and shall meet
quarterly.
Notwithstanding any other provision of law to the contrary, the policy or policies
provided to employees pursuant to this section shall not provide coverage for
obtaining or performing an abortion, nor shall any state funds be used for the
purpose of obtaining or performing an abortion on behalf of employees or their
dependents.
Interruption of an established treatment regime with maintenance drugs shall be
grounds for an insured to appeal a formulary change through the established appeal
procedures approved by the Department of Insurance, if the physician supervising
the treatment certifies that the change is not in the best interests of the patient.
Any employee who is eligible for and elects to participate in the state health
insurance program as a retiree, or the spouse or beneficiary of a retiree, under any
one (1) of the state-sponsored retirement systems shall not be eligible to receive the
state health insurance contribution toward health care coverage as a result of any
other employment for which there is a public employer contribution. This does not
preclude a retiree and an active employee spouse from using both contributions to
the extent needed for purchase of one (1) state sponsored health insurance policy for
that plan year.
(a) The policies of health insurance coverage procured under subsection (2) of
this section shall include a mail-order drug option for maintenance drugs for
state employees. Maintenance drugs may be dispensed by mail order in
accordance with Kentucky law.
(b) A health insurer shall not discriminate against any retail pharmacy located
within the geographic coverage area of the health benefit plan and that meets
the terms and conditions for participation established by the insurer, including
price, dispensing fee, and copay requirements of a mail-order option. The
retail pharmacy shall not be required to dispense by mail.
(c) The mail-order option shall not permit the dispensing of a controlled
substance classified in Schedule II.
The policy or policies provided to state employees or their dependents pursuant to
this section shall provide coverage for obtaining a hearing aid and acquiring hearing
aid-related services for insured individuals under eighteen (18) years of age, subject
to a cap of one thousand four hundred dollars (,400) every thirty-six (36) months
pursuant to KRS 304.17A-132.
Any policy provided to state employees or their dependents pursuant to this section
shall provide coverage for the diagnosis and treatment of autism spectrum disorders
consistent with KRS 304.17A-142.
If a state employee's residence and place of employment are in the same county, and
if the hospital located within that county does not offer surgical services, intensive
care services, obstetrical services, level II neonatal services, diagnostic cardiac
(17)
(18)
(19)
(20)
catheterization services, and magnetic resonance imaging services, the employee
may select a plan available in a contiguous county that does provide those services,
and the state contribution for the plan shall be the amount available in the county
where the plan selected is located.
If a state employee's residence and place of employment are each located in counties
in which the hospitals do not offer surgical services, intensive care services,
obstetrical services, level II neonatal services, diagnostic cardiac catheterization
services, and magnetic resonance imaging services, the employee may select a plan
available in a county contiguous to the county of residence that does provide those
services, and the state contribution for the plan shall be the amount available in the
county where the plan selected is located.
The Personnel Cabinet is encouraged to study whether it is fair and reasonable and
in the best interests of the state group to allow any carrier bidding to offer health
care coverage under this section to submit bids that may vary county by county or
by larger geographic areas.
Notwithstanding any other provision of this section, the bid for proposals for health
insurance coverage for calendar year 2004 shall include a bid scenario that reflects
the statewide rating structure provided in calendar year 2003 and a bid scenario that
allows for a regional rating structure that allows carriers to submit bids that may
vary by region for a given product offering as described in this subsection:
(a) The regional rating bid scenario shall not include a request for bid on a
statewide option;
(b) The Personnel Cabinet shall divide the state into geographical regions which
shall be the same as the partnership regions designated by the Department for
Medicaid Services for purposes of the Kentucky Health Care Partnership
Program established pursuant to 907 KAR 1:705;
(c) The request for proposal shall require a carrier's bid to include every county
within the region or regions for which the bid is submitted and include but not
be restricted to a preferred provider organization (PPO) option;
(d) If the Personnel Cabinet accepts a carrier's bid, the cabinet shall award the
carrier all of the counties included in its bid within the region. If the Personnel
Cabinet deems the bids submitted in accordance with this subsection to be in
the best interests of state employees in a region, the cabinet may award the
contract for that region to no more than two (2) carriers; and
(e) Nothing in this subsection shall prohibit the Personnel Cabinet from including
other requirements or criteria in the request for proposal.
Any fully insured health benefit plan or self-insured plan issued or renewed on or
after July 12, 2006, to public employees pursuant to this section which provides
coverage for services rendered by a physician or osteopath duly licensed under KRS
Chapter 311 that are within the scope of practice of an optometrist duly licensed
under the provisions of KRS Chapter 320 shall provide the same payment of
coverage to optometrists as allowed for those services rendered by physicians or
osteopaths.
(21) Any fully insured health benefit plan or self-insured plan issued or renewed on or
after July 12, 2006, to public employees pursuant to this section shall comply with
the provisions of KRS 304.17A-270 and 304.17A-525.
(22) Any full insured health benefit plan or self insured plan issued or renewed on or
after July 12, 2006, to public employees shall comply with KRS 304.17A-600 to
304.17A-633 pertaining to utilization review, KRS 205.593 and 304.17A-700 to
304.17A-730 pertaining to payment of claims, KRS 304.14-135 pertaining to
uniform health insurance claim forms, KRS 304.17A-580 and 304.17A-641
pertaining to emergency medical care, KRS 304.99-123, and any administrative
regulations promulgated thereunder.
Effective: January 1, 2011
History: Amended 2010 Ky. Acts ch. 24, sec. 28, effective July 15, 2010; and ch. 150,
sec. 19, effective January 1, 2011. -- Amended 2007 Ky. Acts ch. 88, sec. 3, effective
June 26, 2007. -- Amended 2006 Ky. Acts ch. 164, sec. 1, effective July 12, 2006. -Amended 2003 Ky. Acts ch. 12, sec. 1, effective June 24, 2003; and ch. 129, sec. 1,
effective March 18, 2003. -- Amended 2002 Ky. Acts ch. 67, sec. 1, effective July
15, 2002; ch. 106, sec. 2, effective July 15, 2002; ch. 275, sec. 34, effective July 1,
2002; ch. 345, sec. 1, effective July 15, 2002; ch. 351, sec. 17, effective July 15,
2002; and ch. 352, secs. 1 and 4, effective July 15, 2002. -- Amended 2001 Ky. Acts
ch. 70, sec. 3, effective March 15, 2001. -- Amended 2000 Ky. Acts ch. 438, sec. 2,
effective April 21, 2000. -- Amended 1998 Ky. Acts ch. 82, sec. 4, effective July 15,
1998; ch. 154, sec. 45, effective July 15, 1998; and ch. 515, sec. 1, effective July 1,
1998. -- Amended 1996 Ky. Acts ch. 362, sec. 6, effective July 15, 1996; and
ch. 371, sec. 60, effective July 15, 1996. -- Amended 1994 Ky. Acts ch. 350, sec. 1,
effective July 15, 1994; and ch. 512, sec. 94, effective July 15, 1994. -- Amended
1992 Ky. Acts ch. 92, sec. 3, effective July 14, 1992; ch. 219, sec. 1, effective July
14, 1992; and ch. 235, sec. 1, effective July 14, 1992. -- Amended 1990 Ky. Acts
ch. 348, sec. 3, effective July 13, 1990; and ch. 489, sec. 8, effective July 13, 1990. -Amended 1986 Ky. Acts ch. 178, sec. 1, effective July 15, 1986. -- Amended 1984
Ky. Acts ch. 23, sec. 1, effective July 13, 1984. -- Repealed and reenacted as KRS
18A.225, 1982 Ky. Acts ch. 448, sec. 45, effective July 15, 1982. -- Amended 1980
Ky. Acts ch. 132, sec. 6, effective July 15, 1980. -- Created 1976 (1st Extra. Sess.)
Ky. Acts ch. 35, sec. 2.
Formerly codified as KRS 18.470.
Legislative Research Commission Note (1/1/2011). This section was amended by 2010
Ky. Acts chs. 24 and 150, which do not appear to be in conflict and have been
codified together.
Legislative Research Commission Note (7/15/2002). This section was amended by
2002 Ky. Acts chs. 67, 106, 275, 345, 351, and 352. Where these Acts are not in
conflict, they have been codified together. Where a conflict exists between Acts
ch. 275, sec. 34, and ch. 352, sec. 1, Acts ch. 352, which was last enacted by the
General Assembly, prevails under KRS 446.250.
Legislative Research Commission Note (10/19/2004). 2004 (1st Extra. Sess.) Ky. Acts
ch. 1, sec. 2, provides, "Notwithstanding KRS 18A.225, 45A.022, 45A.080,
45A.085, 45A.090, 45A.225 to 45A.290, or any other provision of KRS Chapter 45A
to the contrary, retroactive to August 12, 2004, the Finance and Administration
Cabinet shall implement the provisions of this Act by amending the previously
negotiated contracts for public employee health insurance. The secretary of the
Finance and Administration Cabinet shall provide an actuarial certification that the
self-insured contract amounts are actuarially sound. Any contracts entered into or
modified pursuant to this section shall be forwarded to the Legislative Research
Commission."
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