KRS 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.

(1) 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, th e

commissioner shall not alter, amend, or replace the standard health benefit plan

more frequently than annually.

(2) 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.

(3) The standard health benefit plan shall be defined so that it meets the requirements of

KRS 304.17B -021 for inclusi on in calculating assessments and refunds under

Kentucky Access.

(4) 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.

(5) 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 ri ghts 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.

(6) All health benefit plans shall cover hospice care at least equal to the Me dicare

benefits.

(7) 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.

(8) 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 un der 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 fo r 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 policyh older 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.