{"data":{"id":"us-ky/krs-304.17a-220","jurisdiction":"us-ky","citation":"KRS 304.17A-220","heading":"Pre -existing condition exclusion in group coverage -- Definitions for","body":"section.\n(1) All group health plans and insurers offering group health insurance coverage in the\nCommonwealth shall comply with the provisions of this section.\n(2) Subject to subsection (8) of this section, a group health plan, and a health insurance\ninsurer offering group health insurance coverage, may, with respect to a participant\nor beneficiary, impose a pre-existing condition exclusion only if:\n(a) The exclusion relates to a condition, whether physical or mental, regardless of\nthe cause of the condition, for which medical advice, diagnosis, care, or\ntreatment was recommended or received within the six (6) month period\nending on the enrollment date. For purposes of this paragraph:\n1. Medical advice, diagnosis, care, or treatment is taken into account only\nif it is recommended by, or received from, an individual licensed or\nsimilarly authorized to provide such services under state law and\noperating within the scope of practice authorized by state law; and\n2. The six (6) month period ending on the enrollment date begins on the\nsix (6) month anniversary date preceding the enrollment date;\n(b) The exclusion extends for a period of not more than twelve (12) months, or\neighteen (18) months in the case of a late enrollee, after the enrollment date;\n(c) 1. The period of any pre-existing condition exclusion that would otherwise\napply to an individual is reduced by the number of days of creditable\ncoverage the individual has as of the enro llment date, as counted under\nsubsection (3) of this section; and\n2. Except for ineligible individuals who apply for coverage in the\nindividual market, the period of any pre -existing condition exclusion\nthat would otherwise apply to an individual may be re duced by the\nnumber of days of creditable coverage the individual has as of the\neffective date of coverage under the policy; and\n(d) A written notice of the pre -existing condition exclusion is provided to\nparticipants under the plan, and the insurer cannot  impose a pre -existing\ncondition exclusion with respect to a participant or a dependent of the\nparticipant until such notice is provided.\n(3) In reducing the pre-existing condition exclusion period that applies to an individual,\nthe amount of creditable co verage is determined by counting all the days on which\nthe individual has one (1) or more types of creditable coverage. For purposes of\ncounting creditable coverage:\n(a) If on a particular day the individual has creditable coverage from more than\none (1) s ource, all the creditable coverage on that day is counted as one (1)\nday;\n(b) Any days in a waiting period for coverage are not creditable coverage;\n(c) Days of creditable coverage that occur before a significant break in coverage\nare not required to be counted; and\n(d) Days in a waiting period and days in an affiliation period are not taken into\naccount in determining whether a significant break in coverage has occurred.\n(4) An insurer may determine the amount of creditable coverage in another manner than\nestablished in subsection (3) of this section that is at least as favorable to the\nindividual as the method established in subsection (3) of this section.\n(5) If an insurer receives creditable coverage information, the insurer shall make a\ndetermination regarding the amount of the individual's creditable coverage and the\nlength of any pre -existing exclusion period that remains. A written notice of the\nlength of the pre-existing condition exclusion period that remains after offsetting for\nprior creditable coverage shall be issued by the insurer. An insurer may not impose\nany limit on the amount of time that an individual has to present a certificate or\nevidence of creditable coverage.\n(6) For purposes of this section:\n(a) \"Pre-existing condition e xclusion\" means, with respect to coverage, a\nlimitation or exclusion of benefits relating to a condition based on the fact that\nthe condition was present before the effective date of coverage, whether or not\nany medical advice, diagnosis, care, or treatmen t was recommended or\nreceived before that day. A pre -existing condition exclusion includes any\nexclusion applicable to an individual as a result of information relating to an\nindividual's health status before the individual's effective date of coverage\nunder a health benefit plan;\n(b) \"Enrollment date\" means, with respect to an individual covered under a group\nhealth plan or health insurance coverage, the first day of coverage or, if there\nis a waiting period, the first day of the waiting period. If an indi vidual\nreceiving benefits under a group health plan changes benefit packages, or if\nthe employer changes its group health insurer, the individual's enrollment date\ndoes not change;\n(c) \"First day of coverage\" means, in the case of an individual covered for\nbenefits under a group health plan, the first day of coverage under the plan\nand, in the case of an individual covered by health insurance coverage in the\nindividual market, the first day of coverage under the policy or contract;\n(d) \"Late enrollee\" means  an individual whose enrollment in a plan is a late\nenrollment;\n(e) \"Late enrollment\" means enrollment of an individual under a group health\nplan other than:\n1. On the earliest date on which coverage can become effective for the\nindividual under the terms of the plan; or\n2. Through special enrollment;\n(f) \"Significant break in coverage\" means a period of sixty-three (63) consecutive\ndays during each of which an individual does not have any creditable\ncoverage; and\n(g) \"Waiting period\" means the period that must pass before coverage for an\nemployee or dependent who is otherwise eligible to enroll under the terms of a\ngroup health plan can become effective. If an employee or dependent enrolls\nas a late enrollee or special enrollee, any period before such late or special\nenrollment is not a waiting period. If an individual seeks coverage in the\nindividual market, a waiting period begins on the date the individual submits a\nsubstantially complete application for coverage and ends on:\n1. If the application results in coverage, the date coverage begins; or\n2. If the application does not result in coverage, the date on which the\napplication is denied by the insurer or the date on which the offer of\ncoverage lapses.\n(7) (a) 1. Except as otherwise provided under subsec tion (3) of this section, for\npurposes of applying subsection (2)(c) of this section, a group health\nplan, and a health insurance insurer offering group health insurance\ncoverage, shall count a period of creditable coverage without regard to\nthe specific benefits covered during the period.\n2. A group health plan, or a health insurance insurer offering group health\ninsurance coverage, may elect to apply subsection (2)(c) of this section\nbased on coverage of benefits within each of several classes or\ncategories of benefits specified in federal regulations. This election shall\nbe made on a uniform basis for all participants and beneficiaries. Under\nthis election, a group health plan or insurer shall count a period of\ncreditable coverage with respect to any clas s or category of benefits if\nany level of benefits is covered within this class or category.\n3. In the case of an election with respect to a group health plan under\nsubparagraph 2. of this paragraph, whether or not health insurance\ncoverage is provided in connection with the plan, the plan shall:\na. Prominently state in any disclosure statements concerning the plan,\nand state to each enrollee at the time of enrollment under the plan,\nthat the plan has made this election; and\nb. Include in these statements a  description of the effect of this\nelection.\n(b) Periods of creditable coverage with respect to an individual shall be\nestablished through presentation of certifications described in subsection (9)\nof this section or in such other manner as may be specifie d in administrative\nregulations.\n(8) (a) Subject to paragraph (e) of this subsection, a group health plan, and a health\ninsurance insurer offering group health insurance coverage, may not impose\nany pre-existing condition exclusion on a child who, within t hirty (30) days\nafter birth, is covered under any creditable coverage. If a child is enrolled in a\ngroup health plan or other creditable coverage within thirty (30) days after\nbirth and subsequently enrolls in another group health plan without a\nsignificant break in coverage, the other group health plan may not impose any\npre-existing condition exclusion on the child.\n(b) Subject to paragraph (e) of this subsection, a group health plan, and a health\ninsurance insurer offering group health insuranc e coverage, may not impose\nany pre-existing condition exclusion on a child who is adopted or placed for\nadoption before attaining eighteen (18) years of age and who, within thirty\n(30) days after the adoption or placement for adoption, is covered under any\ncreditable coverage. If a child is enrolled in a group health plan or other\ncreditable coverage within thirty (30) days after adoption or placement for\nadoption and subsequently enrolls in another group health plan without a\nsignificant break in coverage, the other group health plan may not impose any\npre-existing condition exclusion on the child. This shall not apply to coverage\nbefore the date of the adoption or placement for adoption.\n(c) A group health plan may not impose any pre -existing condition exc lusion\nrelating to pregnancy.\n(d) A group health plan may not impose a pre -existing condition exclusion\nrelating to a condition based solely on genetic information. If an individual is\ndiagnosed with a condition, even if the condition relates to genetic\ninformation, the insurer may impose a pre -existing condition exclusion with\nrespect to the condition, subject to other requirements of this section.\n(e) Paragraphs (a) and (b) of this subsection shall no longer apply to an individual\nafter the end of the fir st sixty-three (63) day period during all of which the\nindividual was not covered under any creditable coverage.\n(9) (a) 1. A group health plan, and a health insurance insurer offering group health\ninsurance coverage, shall provide a certificate of credita ble coverage as\ndescribed in subparagraph 2. of this subsection. A certificate of\ncreditable coverage shall be provided, without charge, for participants or\ndependents who are or were covered under a group health plan upon the\noccurrence of any of the following events:\na. At the time an individual ceases to be covered under a health\nbenefit plan or otherwise becomes eligible under a COBRA\ncontinuation provision;\nb. In the case of an individual becoming covered under a COBRA\ncontinuation provision, at the ti me the individual ceases to be\ncovered under the COBRA continuation provision; and\nc. On request on behalf of an individual made not later than twenty -\nfour (24) months after the date of cessation of the coverage\ndescribed in subdivision a. or b. of this su bparagraph, whichever is\nlater.\nThe certificate of creditable coverage as described under subdivision a.\nof this subparagraph may be provided, to the extent practicable, at a time\nconsistent with notices required under any applicable COBRA\ncontinuation provision.\n2. The certification described in this subparagraph is a written certification\nof:\na. The period of creditable coverage of the individual under the\nhealth benefit plan and the coverage, if any, under the COBRA\ncontinuation provision; and\nb. The wa iting period, if any, and affiliation period, if applicable,\nimposed with respect to the individual for any coverage under the\nplan.\n3. To the extent that medical care under a group health plan consists of\ngroup health insurance coverage, the plan is deemed to have satisfied the\ncertification requirement under this paragraph if the health insurance\ninsurer offering the coverage provides for the certification in accordance\nwith this paragraph.\n(b) In the case of an election described in subsection (7)(a)2. o f this section by a\ngroup health plan or health insurance insurer, if the plan or insurer enrolls an\nindividual for coverage under the plan and the individual provides a\ncertification of coverage of the individual under paragraph (a) of this\nsubsection:\n1. Upon request of that plan or insurer, the entity that issued the\ncertification provided by the individual shall promptly disclose to the\nrequesting plan or insurer information on coverage of classes and\ncategories of health benefits available under the en tity's plan or\ncoverage; and\n2. The entity may charge the requesting plan or insurer for the reasonable\ncost of disclosing this information.\n(10) (a) A group health plan, and a health insurance insurer offering group health\ninsurance coverage in connection  with a group health plan, shall permit an\nemployee who is eligible but not enrolled for coverage under the terms of the\nplan, or a dependent of that employee if the dependent is eligible but not\nenrolled for coverage under these terms, to enroll for coverage under the terms\nof the plan if each of the following conditions is met:\n1. The employee or dependent was covered under a group health plan or\nhad health insurance coverage at the time coverage was previously\noffered to the employee or dependent;\n2. The employee stated in writing at that time that coverage under a group\nhealth plan or health insurance coverage was the reason for declining\nenrollment, but only if the plan sponsor or insurer, if applicable, required\nthat statement at that time and provided  the employee with notice of the\nrequirement, and the consequences of the requirement, at that time;\n3. The employee's or dependent's coverage described in subparagraph 1. of\nthis paragraph:\na. Was under a COBRA continuation provision and the coverage\nunder that provision was exhausted; or\nb. Was not under such a provision and either the coverage was\nterminated as a result of loss of eligibility for the coverage,\nincluding as a result of legal separation, divorce, cessation of\ndependent status, such as obta ining the maximum age to be\neligible as a dependent child, death of the employee, termination of\nemployment, reduction in the number of hours of employment,\nemployer contributions toward the coverage were terminated, a\nsituation in which an individual incu rs a claim that would meet or\nexceed a lifetime limit on all benefits, or a situation in which a\nplan no longer offers any benefits to the class of similarly situated\nindividuals that includes the individual; or\nc. Was offered through a health maintenance organization or other\narrangement in the group market that does not provide benefits to\nindividuals who no longer reside, live, or work in a service area\nand, loss of coverage in the group market occurred because an\nindividual no longer resides, lives, or works in the service area,\nwhether or not within the choice of the individual, and no other\nbenefit package is available to the individual; and\n4. An insurer shall allow an employee and dependent a period of at least\nthirty (30) days after an event described in this paragraph has occurred to\nrequest enrollment for the employee or the employee's dependent.\nCoverage shall begin no later than the first day of the first calendar\nmonth beginning after the date the insurer receives the request for\nspecial enrollment.\n(b) A dependent of a current employee, including the employee's spouse, and the\nemployee each are eligible for enrollment in the group health plan subject to\nplan eligibility rules conditioning depen dent enrollment on enrollment of the\nemployee if the requirements of paragraph (a) of this subsection are satisfied.\n(c) 1. If:\na. A group health plan makes coverage available with respect to a\ndependent of an individual;\nb. The individual is a participant  under the plan, or has met any\nwaiting period applicable to becoming a participant under the plan\nand is eligible to be enrolled under the plan but for a failure to\nenroll during a previous enrollment period; and\nc. A person becomes such a dependent of th e individual through\nmarriage, birth, or adoption or placement for adoption;\nthe group health plan shall provide for a dependent special enrollment\nperiod described in subparagraph 2. of this paragraph during which the\nperson or, if not otherwise enrolled , the individual, may be enrolled\nunder the plan as a dependent of the individual, and in the case of the\nbirth or adoption of a child, the spouse of the individual may be enrolled\nas a dependent of the individual if the spouse is otherwise eligible for\ncoverage.\n2. A dependent special enrollment period under this subparagraph shall be\na period of at least thirty (30) days and shall begin on the later of:\na. The date dependent coverage is made available; or\nb. The date of the marriage, birth, or adoption or  placement for\nadoption, as the case may be, described in subparagraph 1.c. of this\nparagraph.\n3. If an individual seeks to enroll a dependent during the first thirty (30)\ndays of the dependent special enrollment period, the coverage of the\ndependent shall become effective:\na. In the case of marriage, not later than the first day of the first\nmonth beginning after the date the completed request for\nenrollment is received;\nb. In the case of a dependent's birth, as of the date of the birth; or\nc. In the case of a dependent's adoption or placement for adoption,\nthe date of the adoption or placement for adoption.\n(d) At or before the time an employee is initially offered the opportunity to enroll\nin a group health plan, the employer shall provide the employee wi th a notice\nof special enrollment rights.\n(11) (a) In the case of a group health plan that offers medical care through health\ninsurance coverage offered by a health maintenance organization, the plan\nmay provide for an affiliation period with respect to co verage through the\norganization only if:\n1. No pre-existing condition exclusion is imposed with respect to coverage\nthrough the organization;\n2. The period is applied uniformly without regard to any health status -\nrelated factors; and\n3. The period does not  exceed two (2) months, or three (3) months in the\ncase of a late enrollee.\n(b) 1. For purposes of this section, the term \"affiliation period\" means a period\nwhich, under the terms of the health insurance coverage offered by the\nhealth maintenance organiza tion, must expire before the health\ninsurance coverage becomes effective. The organization is not required\nto provide health care services or benefits during this period and no\npremium shall be charged to the participant or beneficiary for any\ncoverage during the period.\n2. This period shall begin on the enrollment date.\n3. An affiliation period under a plan shall run concurrently with any\nwaiting period under the plan.\n(c) A health maintenance organization described in paragraph (a) of this\nsubsection may use alternative methods other than those described in that\nparagraph to address adverse selection as approved by the commissioner.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=17395","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:46Z","sha256":"6fb8f13412944d6d0eadb34e17c814ee83b3e66ca97c67b6424ff19bd1acd7c5","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-210","next":"us-ky/krs-304.17a-230"},"notice":"GroundRules: Original legal text. Not legal advice."}