{"data":{"id":"us-ky/krs-304.17a-005","jurisdiction":"us-ky","citation":"KRS 304.17A-005","heading":"Definitions for subtitle.","body":"As used in this subtitle, unless the context requires otherwise:\n(1) \"Association\" means an entity, other than an employer -organized association, that\nhas been organized and is maintained in good faith for purposes other than that of\nobtaining insurance for its members and that has a constitution and bylaws;\n(2) \"At the time of enrollment\" means:\n(a) At the time of application for an individual, an association that actively\nmarkets to individual members, and an employer -organized association that\nactively markets to individual members; and\n(b) During the time of open enrollment or during an insured's initial or special\nenrollment periods for group health insurance;\n(3) \"Base premium rate\" means, for each class of business as to a rating period, the\nlowest pr emium rate charged or that could have been charged under the rating\nsystem for that class of business by the insurer to the individual or small group, or\nemployer as defined in KRS 304.17A -0954, with similar case characteristics for\nhealth benefit plans with the same or similar coverage;\n(4) \"Basic health benefit plan\" means any plan offered to an individual, a small group,\nor employer -organized association that limits coverage to physician, pharmacy,\nhome health, preventive, emergency, and inpatient and ou tpatient hospital services\nin accordance with the requirements of this subtitle. If vision or eye services are\noffered, these services may be provided by an ophthalmologist or optometrist.\nChiropractic benefits may be offered by providers licensed pursuant  to KRS\nChapter 312;\n(5) \"Bona fide association\" means an entity as defined in 42 U.S.C. sec. 300gg -\n91(d)(3);\n(6) \"Church plan\" means a church plan as defined in 29 U.S.C. sec. 1002(33);\n(7) \"COBRA\" means any of the following:\n(a) 26 U.S.C. sec. 4980B other than subsection (f)(1) as it relates to pediatric\nvaccines;\n(b) The Employee Retirement Income Security Act of 1974 (29 U.S.C. sec. 1161\net seq. other than sec. 1169); or\n(c) 42 U.S.C. sec. 300bb;\n(8) \"Creditable coverage\":\n(a) Means, with respect to an individual, coverage of the individual under any of\nthe following:\n1. A group health plan;\n2. Health insurance coverage;\n3. Part A or Part B of Title XVIII of the Social Security Act;\n4. Title XIX of the Social Security Act, other than coverage consisting\nsolely of benefits under section 1928;\n5. Chapter 55 of Title 10, United States Code, including medical and\ndental care for members and certain former members of the uniformed\nservices, and f or their dependents; for purposes of Chapter 55 of Title\n10, United States Code, \"uniformed services\" means the Armed Forces\nand the Commissioned Corps of the National Oceanic and Atmospheric\nAdministration and of the Public Health Service;\n6. A medical ca re program of the Indian Health Service or of a tribal\norganization;\n7. A state health benefits risk pool;\n8. A health plan offered under Chapter 89 of Title 5, United States Code,\nsuch as the Federal Employees Health Benefit Program;\n9. A public health pl an as established or maintained by a state, the United\nStates government, a foreign country, or any political subdivision of a\nstate, the United States government, or a foreign country that provides\nhealth coverage to individuals who are enrolled in the plan;\n10. A health benefit plan under section 5(e) of the Peace Corps Act (22\nU.S.C. sec. 2504(e)); or\n11. Title XXI of the Social Security Act, such as the State Children's Health\nInsurance Program; and\n(b) Does not include coverage consisting solely of cov erage of excepted benefits\nas defined in this section;\n(9) \"Dependent\" means any individual who is or may become eligible for coverage\nunder the terms of an individual or group health benefit plan because of a\nrelationship to a participant;\n(10) \"Employee benefit plan\" means an employee welfare benefit plan or an employee\npension benefit plan or a plan which is both an employee welfare benefit plan and\nan employee pension benefit plan as defined by ERISA;\n(11) \"Eligible individual\" means an individual:\n(a) For whom, as of the date on which the individual seeks coverage, the\naggregate of the periods of creditable coverage is eighteen (18) or more\nmonths and whose most recent prior creditable coverage was under a group\nhealth plan, governmental plan, or church  plan. A period of creditable\ncoverage under this paragraph shall not be counted if, after that period, there\nwas a sixty-three (63) day period of time, excluding any waiting or affiliation\nperiod, during all of which the individual was not covered under a ny\ncreditable coverage;\n(b) Who is not eligible for coverage under a group health plan, Part A or Part B of\nTitle XVIII of the Social Security Act (42 U.S.C. secs. 1395j et seq.), or a\nstate plan under Title XIX of the Social Security Act (42 U.S.C. secs. 1396 et\nseq.) and does not have other health insurance coverage;\n(c) With respect to whom the most recent coverage within the coverage period\ndescribed in paragraph (a) of this subsection was not terminated based on a\nfactor described in KRS 304.17A-240(2)(a), (b), and (c);\n(d) If the individual had been offered the option of continuation coverage under a\nCOBRA continuation provision or under KRS 304.18 -110, who elected the\ncoverage; and\n(e) Who, if the individual elected the continuation coverage, has exha usted the\ncontinuation coverage under the provision or program;\n(12) \"Employer-organized association\" means any of the following:\n(a) Any entity that was qualified by the commissioner as an eligible association\nprior to April 10, 1998, and that has actively marketed a health insurance\nprogram to its members since September 8, 1996, and which is not insurer -\ncontrolled;\n(b) Any entity orga nized under KRS 247.240 to 247.370 that has actively\nmarketed health insurance to its members and that is not insurer-controlled;\n(c) Any entity or association of employers, which has been actively in existence\nfor at least two (2) years, formed under the Employee Retirement Income\nSecurity Act, 29 U.S.C. secs. 1001 et seq., to provide an employee welfare\nbenefit plan under guidance issued by the United States Department of Labor\nprior to the issuance of 29 C.F.R. sec. 2510.3 -5, and for which the entity's\nhealth insurance decisions are made by a board or committee, the majority of\nwhich are representatives of employer members of the entity who obtain\ngroup health insurance coverage through the entity or through a trust or other\nmechanism established by the e ntity, and whose health insurance decisions\nare reflected in written minutes or other written documentation; and\n(d) Any entity or association of employers, which has been actively in existence\nfor at least two (2) years, formed under the Employee Retireme nt Income\nSecurity Act, 29 U.S.C. secs. 1001 et seq., to provide an employee welfare\nbenefit plan, whose members consist of employers or a group of employers\nthat satisfy the requirements of 29 C.F.R. sec. 2510.3-5.\nExcept as provided in KRS 304.17A -0954, 304.17A-200, and 304.17A -220, and\nexcept as otherwise provided by the definition of \"large group\" contained in this\nsection, an employer -organized association shall not be treated as an association,\nsmall group, or large group under this subtitle, except that an employer -organized\nassociation as defined under paragraph (c) or (d) of this subsection shall be treated\nas a large group under this subtitle;\n(13) \"Employer-organized association health insurance plan\" means any health\ninsurance plan, policy, or c ontract issued to an employer -organized association, or\nto a trust established by one (1) or more employer -organized associations, or\nproviding coverage solely for the employees, retired employees, directors and their\nspouses and dependents of the members of one (1) or more employer -organized\nassociations;\n(14) \"Excepted benefits\" means benefits under one (1) or more, or any combination of\nthe following:\n(a) Coverage only for accident, including accidental death and dismemberment,\nor disability income insurance, or any combination thereof;\n(b) Coverage issued as a supplement to liability insurance;\n(c) Liability insurance, including general liability insurance and automobile\nliability insurance;\n(d) Workers' compensation or similar insurance;\n(e) Automobile medical payment insurance;\n(f) Credit-only insurance;\n(g) Coverage for on-site medical clinics;\n(h) Other similar insurance coverage, specified in administrative regulations,\nunder which benefits for medical care are secondary or incidental to other\ninsurance benefits;\n(i) Limited scope dental or vision benefits;\n(j) Benefits for long -term care, nursing home care, home health care,\ncommunity-based care, or any combination thereof;\n(k) Such other similar, limited benefits as are specified in administrative\nregulations;\n(l) Coverage only for a specified disease or illness;\n(m) Hospital indemnity or other fixed indemnity insurance;\n(n) Benefits offered as Medicare supplemental health insurance, as defined under\nsection 1882(g)(1) of the Social Security Act;\n(o) Coverage supplemental to the coverage provided under Chapter 55 of Title\n10, United States Code;\n(p) Coverage similar to that in paragraphs (n) and (o) of this subsection that is\nsupplemental to coverage under a group health plan; and\n(q) Health flexible spending arrangements;\n(15) \"Governmental plan\" means a governmental plan as defined in 29 U.S.C. sec.\n1002(32);\n(16) \"Group health plan\" means a plan, including a self-insured plan, of or contributed to\nby an employer, including a self -employed person, or  employee organization, to\nprovide health care directly or otherwise to the employees, former employees, the\nemployer, or others associated or formerly associated with the employer in a\nbusiness relationship, or their families;\n(17) \"Guaranteed acceptance program participating insurer\" means an insurer that is\nrequired to or has agreed to offer health benefit plans in the individual market to\nguaranteed acceptance program qualified individuals under KRS 304.17A -400 to\n304.17A-480;\n(18) \"Guaranteed acceptance program plan\" means a health benefit plan in the individual\nmarket issued by an insurer that provides health benefits to a guaranteed acceptance\nprogram qualified individual and is eligible for assessment and refunds under the\nguaranteed acceptance program under KRS 304.17A-400 to 304.17A-480;\n(19) \"Guaranteed acceptance program\" means the Kentucky Guaranteed Acceptance\nProgram established and operated under KRS 304.17A-400 to 304.17A-480;\n(20) \"Guaranteed acceptance program qualified individual\" means an individual who, on\nor before December 31, 2000:\n(a) Is not an eligible individual;\n(b) Is not eligible for or covered by other health benefit plan coverage or who is a\nspouse or a dependent of an individual who:\n1. Waived coverage under KRS 304.17A-210(2); or\n2. Did not elect family coverage that was  available through the association\nor group market;\n(c) Within the previous three (3) years has been diagnosed with or treated for a\nhigh-cost condition or has had benefits paid under a health benefit plan for a\nhigh-cost condition, or is a high risk indiv idual as defined by the underwriting\ncriteria applied by an insurer under the alternative underwriting mechanism\nestablished in KRS 304.17A-430(3);\n(d) Has been a resident of Kentucky for at least twelve (12) months immediately\npreceding the effective date of the policy; and\n(e) Has not had his or her most recent coverage under any health benefit plan\nterminated or nonrenewed because of any of the following:\n1. The individual failed to pay premiums or contributions in accordance\nwith the terms of the plan o r the insurer had not received timely\npremium payments;\n2. The individual performed an act or practice that constitutes fraud or\nmade an intentional misrepresentation of material fact under the terms of\nthe coverage; or\n3. The individual engaged in intenti onal and abusive noncompliance with\nhealth benefit plan provisions;\n(21) \"Guaranteed acceptance plan supporting insurer\" means either an insurer, on or\nbefore December 31, 2000, that is not a guaranteed acceptance plan participating\ninsurer or is a stop lo ss carrier, on or before December 31, 2000, provided that a\nguaranteed acceptance plan supporting insurer shall not include an employer -\nsponsored self-insured health benefit plan exempted by ERISA;\n(22) \"Health benefit plan\":\n(a) Shall include any:\n1. Hospital or medical expense policy or certificate;\n2. Nonprofit hospital, medical -surgical, and health service corporation\ncontract or certificate;\n3. Provider sponsored integrated health delivery network;\n4. Self-insured plan or a plan provided by a multiple employer welfare\narrangement, to the extent permitted by ERISA;\n5. Self-insured governmental plan or church plan;\n6. Health maintenance organization contract, except contracts to provide\nMedicaid benefits under KRS Chapter 205; or\n7. Health benefit plan th at affects the rights of a Kentucky insured and\nbears a reasonable relation to Kentucky, whether delivered or issued for\ndelivery in Kentucky; and\n(b) Does not include:\n1. Policies covering only accident, credit, dental, disability income, paid\nfamily leav e, fixed indemnity medical expense reimbursement, long -\nterm care, Medicare supplement, specified disease, or vision care;\n2. Coverage issued as a supplement to liability insurance;\n3. Insurance arising out of a workers' compensation or similar law;\n4. Automobile medical-payment insurance;\n5. Insurance under which benefits are payable with or without regard to\nfault and that is statutorily required to be contained in any liability\ninsurance policy or equivalent self-insurance;\n6. Short-term limited-duration coverage;\n7. Student health insurance  offered by a Kentucky -licensed insurer under\nwritten contract with a university or college whose students it proposes\nto insure;\n8. Medical expense reimbursement policies specifically designed to fill\ngaps in primary coverage, coinsurance, or deductibles and provided\nunder a separate policy, certificate, or contract;\n9. Coverage supplemental to the coverage provided under Chapter 55 of\nTitle 10, United States Code;\n10. Limited health service benefit plans;\n11. Direct primary care agreements established und er KRS 311.6201,\n311.6202, 314.198, and 314.199; or\n12. Coverage provided under KRS Chapter 205;\n(23) \"Health care provider\" or \"provider\" means any:\n(a) Advanced practice registered nurse licensed under KRS Chapter 314;\n(b) Chiropractor licensed under KRS Chapter 312;\n(c) Dentist licensed under KRS Chapter 313;\n(d) Facility or service required to be licensed under KRS Chapter 216B;\n(e) Home medical equipment and services provider licensed under KRS Chapter\n309;\n(f) Optometrist licensed under KRS Chapter 320;\n(g) Pharmacist licensed under KRS Chapter 315;\n(h) Physician, osteopath, or podiatrist licensed under KRS Chapter 311;\n(i) Physician assistant regulated under KRS Chapter 311; and\n(j) Other health care practitioners as determined by the department by\nadministrative regulations promulgated under KRS Chapter 13A;\n(24) (a) \"Health care service\" means health care procedures, treatments, or services\nrendered by a provider within the scope of practice for which the provider is\nlicensed.\n(b) Health care service includes the provision of prescription drugs, as defined in\nKRS 315.010, and home medical equipment, as defined in KRS 309.402;\n(25) \"Health facility\" or \"facility\" has the same meaning as in KRS 216B.015;\n(26) (a) \"High-cost condition,\" pursuant to the K entucky Guaranteed Acceptance\nProgram, means a covered condition in an individual policy as listed in\nparagraph (c) of this subsection or as added by the commissioner in\naccordance with KRS 304.17A -280, but only to the extent that the condition\nexceeds the  numerical score or rating established pursuant to uniform\nunderwriting standards prescribed by the commissioner under paragraph (b)\nof this subsection that account for the severity of the condition and the cost\nassociated with treating that condition.\n(b) The commissioner by administrative regulation shall establish uniform\nunderwriting standards and a score or rating above which a condition is\nconsidered to be high-cost by using:\n1. Codes in the most recent version of the \"International Classification of\nDiseases\" that correspond to the medical conditions in paragraph (c) of\nthis subsection and the costs for administering treatment for the\nconditions represented by those codes; and\n2. The most recent version of the questionnaire incorporated in a national\nunderwriting guide generally accepted in the insurance industry as\ndesignated by the commissioner, the scoring scale for which shall be\nestablished by the commissioner.\n(c) The diagnosed medical conditions are: acquired immune deficiency syndrome\n(AIDS), angina pectoris, ascites, chemical dependency cirrhosis of the liver,\ncoronary insufficiency, coronary occlusion, cystic fibrosis, Friedreich's ataxia,\nhemophilia, Hodgkin's disease, Hu ntington chorea, juvenile diabetes,\nleukemia, metastatic cancer, motor or sensory aphasia, multiple sclerosis,\nmuscular dystrophy, myasthenia gravis, myotonia, open heart surgery,\nParkinson's disease, polycystic kidney, psychotic disorders, quadriplegia,\nstroke, syringomyelia, Wilson's disease, and amyotrophic lateral sclerosis;\n(27) \"Index rate\" means, for each class of business as to a rating period, the arithmetic\naverage of the applicable base premium rate and the corresponding highest\npremium rate;\n(28) \"Individual market\" means the market for the health insurance coverage offered to\nindividuals other than in connection with a group health plan. The individual\nmarket includes an association plan that is not employer -related, issued to\nindividuals on an individually underwritten basis, other than an employer-organized\nassociation or a bona fide association;\n(29) \"Insurer\" means any insurance company; health maintenance organization; self -\ninsurer, including a governmental plan, church plan, or multiple emp loyer welfare\narrangement, not exempt from state regulation by ERISA; provider -sponsored\nintegrated health delivery network; self -insured employer-organized association, or\nnonprofit hospital, medical-surgical, dental, or health service corporation authorized\nto transact health insurance business in Kentucky;\n(30) \"Insurer-controlled\" means that the commissioner has found, in an administrative\nhearing called specifically for that purpose, that an insurer has or had a substantial\ninvolvement in the organizat ion or day -to-day operation of the entity for the\nprincipal purpose of creating a device, arrangement, or scheme by which the insurer\nsegments employer groups according to their actual or anticipated health status or\nactual or projected health insurance premiums;\n(31) \"Kentucky Access\" has the meaning provided in KRS 304.17B-001;\n(32) \"Large group\" means:\n(a) An employer with fifty-one (51) or more employees;\n(b) An affiliated group with fifty-one (51) or more eligible members; or\n(c) A fully insured employ er-organized association as defined in subsection\n(12)(c) or (d) of this section that:\n1. Covers at least fifty-one (51) employee members; and\n2. Is registered with the department pursuant to administrative regulations\npromulgated by the commissioner;\n(33) \"Managed care\" means systems or techniques generally used by third -party payors\nor their agents to affect access to and control payment for health care services and\nthat integrate the financing and delivery of appropriate health care services to\ncovered persons by arrangements with participating providers who are selected to\nparticipate on the basis of explicit standards for furnishing a comprehensive set of\nhealth care services and financial incentives for covered persons using the\nparticipating providers and procedures provided for in the plan;\n(34) \"Market segment\" means the portion of the market covering one (1) of the\nfollowing:\n(a) Individual;\n(b) Small group;\n(c) Large group; or\n(d) Association;\n(35) \"Medically necessary health care services\" means h ealth care services that a\nprovider would render to a patient for the purpose of preventing, diagnosing, or\ntreating an illness, injury, disease, or its symptoms in a manner that is:\n(a) In accordance with generally accepted standards of medical practice; and\n(b) Clinically appropriate in terms of type, frequency, extent, and duration;\n(36) \"Participant\" means any employee or former employee of an employer, or any\nmember or former member of an employee organization, who is or may become\neligible to receive a benefit of any type from an employee benefit plan which covers\nemployees of the employer or members of the organization, or whose beneficiaries\nmay be eligible to receive any benefit as established in Section 3(7) of ERISA;\n(37) \"Preventive services\" means medical services for the early detection of disease that\nare associated with substantial reduction in morbidity and mortality;\n(38) \"Provider network\" means an affiliated group of varied health care providers that is\nestablished to provide a continuum of health care services to individuals;\n(39) \"Provider-sponsored integrated health delivery network\" means any provider -\nsponsored integrated health delivery network created and qualified under KRS\n304.17A-300 and KRS 304.17A-310;\n(40) \"Purchaser\" means an i ndividual, organization, employer, association, or the\nCommonwealth that makes health benefit purchasing decisions on behalf of a group\nof individuals;\n(41) \"Rating period\" means the calendar period for which premium rates are in effect. A\nrating period shall not be required to be a calendar year;\n(42) \"Restricted provider network\" means a health benefit plan that conditions the\npayment of benefits, in whole o r in part, on the use of the providers that have\nentered into a contractual arrangement with the insurer to provide health care\nservices to covered individuals;\n(43) \"Self-insured plan\" means a group health insurance plan in which the sponsoring\norganization assumes the financial risk of paying for covered services provided to\nits enrollees;\n(44) \"Small employer\" means, in connection with a group health plan with respect to a\ncalendar year and a plan year, an employer who employed an average of at least\ntwo (2) but not more than fifty (50) employees on business days during the\npreceding calendar year and who employs at least two (2) employees on the first\nday of the plan year;\n(45) \"Small group\" means:\n(a) A small employer with two (2) to fifty (50) employees; or\n(b) An affiliated group or association with two (2) to fifty (50) eligible members;\nand\n(46) \"Standard benefit plan\" means the plan identified in KRS 304.17A-250.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=54530","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:46Z","sha256":"af1923bbf744703467d5d1fe88c82925be1d8caf1dee94aa68ebf228b7f1f3f8","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.179","next":"us-ky/krs-304.17a-008"},"notice":"GroundRules: Original legal text. Not legal advice."}