2014 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 17A.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.
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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.
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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.
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.
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.
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.
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.
All health benefit plans shall cover hospice care at least equal to the Medicare
benefits.
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.
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 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.
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