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304.17B-015 Eligibility for coverage under Kentucky Access.
(1)
(2)
(3)
(4)
Any individual who is an eligible individual and a resident of Kentucky is eligible
for coverage under Kentucky Access, except as specified in paragraphs (a), (b), (d),
and (e) of subsection (4) of this section.
Any individual who is not an eligible individual who has been a resident of the
Commonwealth for at least twelve (12) months immediately preceding the
application for Kentucky Access coverage is eligible for coverage under Kentucky
Access if one (1) of the following conditions is met:
(a) The individual has been rejected by at least one (1) insurer for coverage of a
health benefit plan that is substantially similar to Kentucky Access coverage;
(b) The individual has been offered coverage substantially similar to Kentucky
Access coverage at a premium rate greater than the Kentucky Access premium
rate at the time of enrollment or upon renewal; or
(c) The individual has a high-cost condition listed in KRS 304.17B-001.
A Kentucky Access enrollee whose premium rates exceed claims for a three (3) year
period shall be issued a notice of insurability. The notice shall indicate that the
Kentucky Access enrollee has not had claims exceed premium rates for a three (3)
year period and may be used by the enrollee to obtain insurance in the regular
individual market.
An individual shall not be eligible for coverage under Kentucky Access if:
(a) 1.
The individual has, or is eligible for, on the effective date of coverage
under Kentucky Access, substantially similar coverage under another
contract or policy, unless the individual was issued coverage from a
GAP participating insurer as a GAP qualified individual prior to January
1, 2001. A GAP qualified individual shall be automatically eligible for
coverage under Kentucky Access without regard to the requirements of
subsection (2) of this section; or
2.
For individuals meeting the requirements of KRS 304.17A-005(11), the
individual has, or is eligible for, on the effective date of coverage under
Kentucky Access, coverage under a group health plan.
An individual who is ineligible for coverage pursuant to this paragraph shall
not preclude the individual's spouse or dependents from being eligible for
Kentucky Access coverage. As used in this paragraph, "eligible for" includes
any individual and an individual's spouse or dependent who was eligible for
coverage but waived that coverage. That individual and the individual's
spouse or dependent shall be ineligible for Kentucky Access coverage through
the period of waived coverage;
(b) The individual is eligible for coverage under Medicaid or Medicare;
(c) The individual previously terminated Kentucky Access coverage and twelve
(12) months have not elapsed since the coverage was terminated, unless the
individual demonstrates a good faith reason for the termination;
(d) Except for covered benefits paid under the standard health benefit plan as
(5)
specified in KRS 304.17B-019, Kentucky Access has paid two million dollars
($2,000,000) in covered benefits per individual. The maximum limit under
this paragraph may be increased by the department;
(e) The individual is confined to a public institution or incarcerated in a federal,
state, or local penal institution or in the custody of federal, state, or local law
enforcement authorities, including work release programs; or
(f) The individual's premium, deductible, coinsurance, or copayment is partially
or entirely paid or reimbursed by an individual or entity other than the
individual or the individual's parent, grandparent, spouse, child, stepchild,
father-in-law, mother-in-law, son-in-law, daughter-in-law, sibling, brother-inlaw, sister-in-law, grandchild, guardian, or court-appointed payor.
The coverage of any person who ceases to meet the requirements of this section or
the requirements of any administrative regulation promulgated under this subtitle
may be terminated.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1280, effective July 15, 2010; and ch.
126, sec. 1, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 351, sec. 8,
effective July 15, 2002. -- Created 2000 Ky. Acts ch. 476, sec. 8, effective July 14,
2000.
Legislative Research Commission Note (7/15/2010). This section was amended by
2010 Ky. Acts chs. 24 and 126, which do not appear to be in conflict and have been
codified together.
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