Download as PDF
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. 300gg91(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 insurercontrolled;
(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. 300gg91(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,
(15)
(16)
(17)
(18)
(19)
(20)
under which benefits for medical care are secondary or incidental to other
insurance benefits;
(i) Limited scope dental or vision benefits;
(j) Benefits for long-term care, nursing home care, home health care, communitybased 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 employersponsored 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, a pharmacist as defined pursuant to KRS
Chapter 315, or home medical equipment and services provider as defined pursuant
to KRS 309.402, and any of the following independent practicing practitioners:
(a) Physicians, osteopaths, and podiatrists licensed under KRS Chapter 311;
(b) Chiropractors licensed under KRS Chapter 312;
(c) Dentists licensed under KRS Chapter 313;
(d) Optometrists licensed under KRS Chapter 320;
(e) Physician assistants regulated under KRS Chapter 311;
(f) 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
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
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;
"Insurer" means any insurance company; health maintenance organization; selfinsurer 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;
"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;
"Kentucky Access" has the meaning provided in KRS 304.17B-001(17);
"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;
"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;
"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;
"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;
"Preventive services" means medical services for the early detection of disease that
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
are associated with substantial reduction in morbidity and mortality;
"Provider network" means an affiliated group of varied health care providers that is
established to provide a continuum of health care services to individuals;
"Provider-sponsored integrated health delivery network" means any providersponsored integrated health delivery network created and qualified 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: July 15, 2016
History: Amended 2016 Ky. Acts ch. 103, sec. 17, effective July 15, 2016. -- 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.
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.