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304.17A-005 Definitions for subtitle.
As used in this subtitle, unless the context requires otherwise:
(1) "Association" means an entity, other than an employer-organized association,
that has been organized and is maintained in good faith for purposes other
than that of obtaining insurance for its members and that has a constitution and
bylaws;
(2) "At the time of enrollment" means:
(a) At the time of application for an individual, an association that actively
markets to individual members, and an employer-organized association
that actively markets to individual members; and
(b) During the time of open enrollment or during an insured's initial or special
enrollment periods for group health insurance;
(3) "Base premium rate" means, for each class of business as to a rating period,
the lowest premium rate charged or that could have been charged under the
rating system for that class of business by the insurer to the individual or small
group, or employer as defined in KRS 304.17A-0954, with similar case
characteristics for health benefit plans with the same or similar coverage;
(4) "Basic health benefit plan" means any plan offered to an individual, a small
group, or employer-organized association that limits coverage to physician,
pharmacy, home health, preventive, emergency, and inpatient and outpatient
hospital services in accordance with the requirements of this subtitle. If vision
or eye services are offered, these services may be provided by an
ophthalmologist or optometrist. Chiropractic benefits may be offered by
providers licensed pursuant to KRS Chapter 312;
(5) "Bona fide association" means an entity as defined in 42 U.S.C. sec.
300gg-91(d)(3);
(6) "Church plan" means a church plan as defined in 29 U.S.C. sec. 1002(33);
(7) "COBRA" means any of the following:
(a) 26 U.S.C. sec. 4980B other than subsection (f)(1) as it relates to pediatric
vaccines;
(b) The Employee Retirement Income Security Act of 1974 (29 U.S.C. sec.
1161 et seq. other than sec. 1169); or
(c) 42 U.S.C. sec. 300bb;
(8) (a) "Creditable coverage" means, with respect to an individual, coverage of
the individual under any of the following:
1.
A group health plan;
2.
Health insurance coverage;
3.
Part A or Part B of Title XVIII of the Social Security Act;
4.
Title XIX of the Social Security Act, other than coverage consisting
solely of benefits under section 1928;
5.
Chapter 55 of Title 10, United States Code, including medical and
dental care for members and certain former members of the
uniformed services, and for their dependents; for purposes of
Chapter 55 of Title 10, United States Code, "uniformed services"
means the Armed Forces and the Commissioned Corps of the
National Oceanic and Atmospheric Administration and of the Public
Health Service;
6.
A medical care program of the Indian Health Service or of a tribal
organization;
7.
A state health benefits risk pool;
8.
A health plan offered under Chapter 89 of Title 5, United States
Code, such as the Federal Employees Health Benefit Program;
9.
A public health plan as established or maintained by a state, the
United States government, a foreign country, or any political
subdivision of a state, the United States government, or a foreign
country that provides health coverage to individuals who are
enrolled in the plan;
10. A health benefit plan under section 5(e) of the Peace Corps Act (22
U.S.C. sec. 2504(e)); or
11. Title XXI of the Social Security Act, such as the State Children's
Health Insurance Program.
(b) This term does not include coverage consisting solely of coverage of
excepted benefits as defined in subsection (14) of this section;
(9) "Dependent" means any individual who is or may become eligible for coverage
under the terms of an individual or group health benefit plan because of a
relationship to a participant;
(10) "Employee benefit plan" means an employee welfare benefit plan or an
employee pension benefit plan or a plan which is both an employee welfare
benefit plan and an employee pension benefit plan as defined by ERISA;
(11) "Eligible individual" means an individual:
(a) For whom, as of the date on which the individual seeks coverage, the
aggregate of the periods of creditable coverage is eighteen (18) or more
months and whose most recent prior creditable coverage was under a
group health plan, governmental plan, or church plan. A period of
creditable coverage under this paragraph shall not be counted if, after that
period, there was a sixty-three (63) day period of time, excluding any
waiting or affiliation period, during all of which the individual was not
covered under any creditable coverage;
(b) Who is not eligible for coverage under a group health plan, Part A or Part
B of Title XVIII of the Social Security Act (42 U.S.C. secs. 1395j et seq.),
or a state plan under Title XIX of the Social Security Act (42 U.S.C. secs.
1396 et seq.) and does not have other health insurance coverage;
(c) With respect to whom the most recent coverage within the coverage
period described in paragraph (a) of this subsection was not terminated
based on a factor described in KRS 304.17A-240(2)(a), (b), and (c);
(d) If the individual had been offered the option of continuation coverage
under a COBRA continuation provision or under KRS 304.18-110, who
elected the coverage; and
(e) Who, if the individual elected the continuation coverage, has exhausted
the continuation coverage under the provision or program;
(12) "Employer-organized association" means any of the following:
(a) Any entity that was qualified by the commissioner as an eligible
association prior to April 10, 1998, and that has actively marketed a
health insurance program to its members since September 8, 1996, and
which is not insurer-controlled;
(b) Any entity organized under KRS 247.240 to 247.370 that has actively
marketed health insurance to its members and that is not
insurer-controlled; or
(c) Any entity that is a bona fide association as defined in 42 U.S.C. sec.
300gg-91(d)(3), whose members consist principally of employers, and for
which the entity's health insurance decisions are made by a board or
committee, the majority of which are representatives of employer
members of the entity who obtain group health insurance coverage
through the entity or through a trust or other mechanism established by
the entity, and whose health insurance decisions are reflected in written
minutes or other written documentation.
Except as provided in KRS 304.17A-200, 304.17A.210, and 304.17A-220, and
except as otherwise provided by the definition of "large group" contained in
subsection (30) of this section, an employer-organized association shall not be
treated as an association, small group, or large group under this subtitle,
provided that an employer-organized association that is a bona fide association
as defined in subsection (5) of this section shall be treated as a large group
under this subtitle;
(13) "Employer-organized association health insurance plan" means any health
insurance plan, policy, or contract issued to an employer-organized
association, or to a trust established by one (1) or more employer-organized
associations, or providing coverage solely for the employees, retired
employees, directors and their spouses and dependents of the members of
one (1) or more employer-organized associations;
(14) "Excepted benefits" means benefits under one (1) or more, or any combination
thereof, of the following:
(a) Coverage only for accident, including accidental death and
dismemberment, or disability income insurance, or any combination
thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile
liability insurance;
(d) Workers' compensation or similar insurance;
(e) Automobile medical payment insurance;
(f) Credit-only insurance;
(g) Coverage for on-site medical clinics;
(h) Other similar insurance coverage, specified in administrative regulations,
under which benefits for medical care are secondary or incidental to other
insurance benefits;
(i)
(j)
(15)
(16)
(17)
(18)
(19)
(20)
Limited scope dental or vision benefits;
Benefits for long-term care, nursing home care, home health care,
community-based care, or any combination thereof;
(k) Such other similar, limited benefits as are specified in administrative
regulations;
(l) Coverage only for a specified disease or illness;
(m) Hospital indemnity or other fixed indemnity insurance;
(n) Benefits offered as Medicare supplemental health insurance, as defined
under section 1882(g)(1) of the Social Security Act;
(o) Coverage supplemental to the coverage provided under Chapter 55 of
Title 10, United States Code;
(p) Coverage similar to that in paragraphs (n) and (o) of this subsection that
is supplemental to coverage under a group health plan; and
(q) Health flexible spending arrangements;
"Governmental plan" means a governmental plan as defined in 29 U.S.C. sec.
1002(32);
"Group health plan" means a plan, including a self-insured plan, of or
contributed to by an employer, including a self-employed person, or employee
organization, to provide health care directly or otherwise to the employees,
former employees, the employer, or others associated or formerly associated
with the employer in a business relationship, or their families;
"Guaranteed acceptance program participating insurer" means an insurer that
is required to or has agreed to offer health benefit plans in the individual market
to guaranteed acceptance program qualified individuals under KRS
304.17A-400 to 304.17A-480;
"Guaranteed acceptance program plan" means a health benefit plan in the
individual market issued by an insurer that provides health benefits to a
guaranteed acceptance program qualified individual and is eligible for
assessment and refunds under the guaranteed acceptance program under
KRS 304.17A-400 to 304.17A-480;
"Guaranteed acceptance program" means the Kentucky Guaranteed
Acceptance Program established and operated under KRS 304.17A-400 to
304.17A-480;
"Guaranteed acceptance program qualified individual" means an individual
who, on or before December 31, 2000:
(a) Is not an eligible individual;
(b) Is not eligible for or covered by other health benefit plan coverage or who
is a spouse or a dependent of an individual who:
1.
Waived coverage under KRS 304.17A-210(2); or
2.
Did not elect family coverage that was available through the
association or group market;
(c) Within the previous three (3) years has been diagnosed with or treated for
a high-cost condition or has had benefits paid under a health benefit plan
for a high-cost condition, or is a high risk individual as defined by the
underwriting criteria applied by an insurer under the alternative
underwriting mechanism established in KRS 304.17A-430(3);
(d) Has been a resident of Kentucky for at least twelve (12) months
immediately preceding the effective date of the policy; and
(e) Has not had his or her most recent coverage under any health benefit
plan terminated or nonrenewed because of any of the following:
1.
The individual failed to pay premiums or contributions in accordance
with the terms of the plan or the insurer had not received timely
premium payments;
2.
The individual performed an act or practice that constitutes fraud or
made an intentional misrepresentation of material fact under the
terms of the coverage; or
3.
The individual engaged in intentional and abusive noncompliance
with health benefit plan provisions;
(21) "Guaranteed acceptance plan supporting insurer" means either an insurer, on
or before December 31, 2000, that is not a guaranteed acceptance plan
participating insurer or is a stop loss carrier, on or before December 31, 2000,
provided that a guaranteed acceptance plan supporting insurer shall not
include an employer-sponsored self-insured health benefit plan exempted by
ERISA;
(22) "Health benefit plan" means any hospital or medical expense policy or
certificate; nonprofit hospital, medical-surgical, and health service corporation
contract or certificate; provider sponsored integrated health delivery network; a
self-insured plan or a plan provided by a multiple employer welfare
arrangement, to the extent permitted by ERISA; health maintenance
organization contract; or any health benefit plan that affects the rights of a
Kentucky insured and bears a reasonable relation to Kentucky, whether
delivered or issued for delivery in Kentucky, and does not include policies
covering only accident, credit, dental, disability income, fixed indemnity medical
expense reimbursement policy, long-term care, Medicare supplement,
specified disease, vision care, coverage issued as a supplement to liability
insurance, insurance arising out of a workers' compensation or similar law,
automobile medical-payment insurance, insurance under which benefits are
payable with or without regard to fault and that is statutorily required to be
contained in any liability insurance policy or equivalent self-insurance,
short-term coverage, student health insurance offered by a Kentucky-licensed
insurer under written contract with a university or college whose students it
proposes to insure, medical expense reimbursement policies specifically
designed to fill gaps in primary coverage, coinsurance, or deductibles and
provided under a separate policy, certificate, or contract, or coverage
supplemental to the coverage provided under Chapter 55 of Title 10, United
States Code, or limited health service benefit plans;
(23) "Health care provider" or "provider" means any facility or service required to be
licensed pursuant to KRS Chapter 216B, pharmacist or home medical
equipment and services provider as defined pursuant to KRS Chapter 315, and
any of the following independent practicing practitioners:
(a) Physicians, osteopaths, and podiatrists licensed under KRS Chapter 311;
(b)
(c)
(d)
(e)
(f)
Chiropractors licensed under KRS Chapter 312;
Dentists licensed under KRS Chapter 313;
Optometrists licensed under KRS Chapter 320;
Physician assistants regulated under KRS Chapter 311;
Advanced practice registered nurses licensed under KRS Chapter 314;
and
(g) Other health care practitioners as determined by the department by
administrative regulations promulgated under KRS Chapter 13A;
(24) (a) "High-cost condition," pursuant to the Kentucky Guaranteed Acceptance
Program, means a covered condition in an individual policy as listed in
paragraph (c) of this subsection or as added by the commissioner in
accordance with KRS 304.17A-280, but only to the extent that the
condition exceeds the numerical score or rating established pursuant to
uniform underwriting standards prescribed by the commissioner under
paragraph (b) of this subsection that account for the severity of the
condition and the cost associated with treating that condition.
(b) The commissioner by administrative regulation shall establish uniform
underwriting standards and a score or rating above which a condition is
considered to be high-cost by using:
1.
Codes in the most recent version of the "International Classification
of Diseases" that correspond to the medical conditions in paragraph
(c) of this subsection and the costs for administering treatment for
the conditions represented by those codes; and
2.
The most recent version of the questionnaire incorporated in a
national underwriting guide generally accepted in the insurance
industry as designated by the commissioner, the scoring scale for
which shall be established by the commissioner.
(c) The diagnosed medical conditions are: acquired immune deficiency
syndrome (AIDS), angina pectoris, ascites, chemical dependency
cirrhosis of the liver, coronary insufficiency, coronary occlusion, cystic
fibrosis, Friedreich's ataxia, hemophilia, Hodgkin's disease, Huntington
chorea, juvenile diabetes, leukemia, metastatic cancer, motor or sensory
aphasia, multiple sclerosis, muscular dystrophy, myasthenia gravis,
myotonia, open heart surgery, Parkinson's disease, polycystic kidney,
psychotic disorders, quadriplegia, stroke, syringomyelia, and Wilson's
disease;
(25) "Index rate" means, for each class of business as to a rating period, the
arithmetic average of the applicable base premium rate and the corresponding
highest premium rate;
(26) "Individual market" means the market for the health insurance coverage
offered to individuals other than in connection with a group health plan. The
individual market includes an association plan that is not employer related,
issued to individuals on an individually underwritten basis, other than an
employer-organized association or a bona fide association, that has been
organized and is maintained in good faith for purposes other than obtaining
insurance for its members and that has a constitution and bylaws;
(27) "Insurer" means any insurance company; health maintenance organization;
self-insurer or multiple employer welfare arrangement not exempt from state
regulation by ERISA; provider-sponsored integrated health delivery network;
self-insured employer-organized association, or nonprofit hospital,
medical-surgical, dental, or health service corporation authorized to transact
health insurance business in Kentucky;
(28) "Insurer-controlled" means that the commissioner has found, in an
administrative hearing called specifically for that purpose, that an insurer has or
had a substantial involvement in the organization or day-to-day operation of the
entity for the principal purpose of creating a device, arrangement, or scheme
by which the insurer segments employer groups according to their actual or
anticipated health status or actual or projected health insurance premiums;
(29) "Kentucky Access" has the meaning provided in KRS 304.17B-001(17);
(30) "Large group" means:
(a) An employer with fifty-one (51) or more employees;
(b) An affiliated group with fifty-one (51) or more eligible members; or
(c) An employer-organized association that is a bona fide association as
defined in subsection (5) of this section;
(31) "Managed care" means systems or techniques generally used by third-party
payors or their agents to affect access to and control payment for health care
services and that integrate the financing and delivery of appropriate health care
services to covered persons by arrangements with participating providers who
are selected to participate on the basis of explicit standards for furnishing a
comprehensive set of health care services and financial incentives for covered
persons using the participating providers and procedures provided for in the
plan;
(32) "Market segment" means the portion of the market covering one (1) of the
following:
(a) Individual;
(b) Small group;
(c) Large group; or
(d) Association;
(33) "Participant" means any employee or former employee of an employer, or any
member or former member of an employee organization, who is or may
become eligible to receive a benefit of any type from an employee benefit plan
which covers employees of the employer or members of the organization, or
whose beneficiaries may be eligible to receive any benefit as established in
Section 3(7) of ERISA;
(34) "Preventive services" means medical services for the early detection of
disease that are associated with substantial reduction in morbidity and
mortality;
(35) "Provider network" means an affiliated group of varied health care providers
that is established to provide a continuum of health care services to individuals;
(36) "Provider-sponsored integrated health delivery network" means any
provider-sponsored integrated health delivery network created and qualified
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
under KRS 304.17A-300 and KRS 304.17A-310;
"Purchaser" means an individual, organization, employer, association, or the
Commonwealth that makes health benefit purchasing decisions on behalf of a
group of individuals;
"Rating period" means the calendar period for which premium rates are in
effect. A rating period shall not be required to be a calendar year;
"Restricted provider network" means a health benefit plan that conditions the
payment of benefits, in whole or in part, on the use of the providers that have
entered into a contractual arrangement with the insurer to provide health care
services to covered individuals;
"Self-insured plan" means a group health insurance plan in which the
sponsoring organization assumes the financial risk of paying for covered
services provided to its enrollees;
"Small employer" means, in connection with a group health plan with respect to
a calendar year and a plan year, an employer who employed an average of at
least two (2) but not more than fifty (50) employees on business days during
the preceding calendar year and who employs at least two (2) employees on
the first day of the plan year;
"Small group" means:
(a) A small employer with two (2) to fifty (50) employees; or
(b) An affiliated group or association with two (2) to fifty (50) eligible
members;
"Standard benefit plan" means the plan identified in KRS 304.17A-250; and
"Telehealth" has the meaning provided in KRS 311.550.
Effective:June 25, 2013
History: Amended 2013 Ky. Acts ch. 123, sec. 4, effective June 25, 2013. -Amended 2012 Ky. Acts ch. 73, sec. 9, effective July 12, 2012. -- Amended
2010 Ky. Acts ch. 24, sec. 1209, effective July 15, 2010; and ch. 85, sec. 46,
effective July 15, 2010. -- Amended 2006 Ky. Acts ch. 253, sec. 1, effective July
12, 2006. -- Amended 2005 Ky. Acts ch. 144, sec. 7, effective June 20, 2005. -Amended 2002 Ky. Acts ch. 351, sec. 1, effective July 15, 2002. -- Amended
2000 Ky. Acts ch. 376, sec. 6, effective July 15, 2001; ch. 476, sec. 17, effective
July 14, 2000; and ch. 521, sec. 1, effective July 14, 2000. -- Created 1998 Ky.
Acts ch. 496, sec. 1, effective April 10, 1998.
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