KRS 304.17B-015: Eligibility for coverage under Kentucky Access.

(1) 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.

(2) Any individual who is not an eligible in dividual 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.

(3) 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.

(4) 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 require ments 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 s pouse 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

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 office;

(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 -in-

law, sister-in-law, grandchild, guardian, or court-appointed payor.

(5) The coverage of any person who ceases to meet the requirements of this section or

the requirements of any administrative regulation promulga ted under this subtitle

may be terminated.