{"data":{"id":"us-ky/krs-304.17a-430","jurisdiction":"us-ky","citation":"KRS 304.17A-430","heading":"Criteria for program plan -- Alternative underwriting.","body":"(1) A health benefit plan shall be considered a program plan and is eligible for\ninclusion in calculating assessments and refunds under the program risk adjustment\nprocess if it meets all of the following criteria:\n(a) The health benefit plan was purchased by an individual to provide benefits for\nonly one (1) or more of the following: the individual, the individual's spouse,\nor the individual's children. Health insurance coverage provided to an\nindividual in the group market or otherwise in connection with a gr oup health\nplan does not satisfy this criteria even if the individual, or the individual's\nspouse or parent, pays some or all of the cost of the coverage unless the\ncoverage is offered in connection with a group health plan that has fewer than\ntwo (2) participants as current employees on the first day of the plan year;\n(b) An individual entitled to benefits under the health benefit plan has been\ndiagnosed with a high -cost condition on or before the effective date of the\nindividual's coverage for coverage issued on a guarantee-issue basis after July\n15, 1995;\n(c) The health benefit plan imposes the maximum pre -existing condition\nexclusion permitted under KRS 304.17A-200;\n(d) The individual purchasing the health benefit plan is not eligible for or covered\nby other coverage; and\n(e) The individual is not a state employee eligible for or covered by the state\nemployee health insurance plan under KRS Chapter 18A.\n(2) Notwithstanding the provisions of subsection (1) of this section, if the total claims\npaid for the high-cost condition under a program plan for any three (3) consecutive\nyears are less than the premiums paid under the program plan for those three (3)\nconsecutive years, then the following shall occur:\n(a) The policy shall not be considered to be a progra m plan thereafter until the\nfirst renewal of the policy after there are three (3) consecutive years in which\nthe total claims paid under the policy have exceeded the total premiums paid\nfor the policy and at the time of the renewal the policy also qualifie s under\nsubsection (1) as a program plan; and\n(b) Within the last six (6) months of the third year, the insurer shall provide each\nperson entitled to benefits under the policy who has a high-cost condition with\na written notice of insurability. The notice shall state that the recipient may be\nable to purchase a health benefit plan other than a program plan and shall also\nstate that neither the notice nor the individual's actions to purchase a health\nbenefit plan other than a program plan shall affect the in dividual's eligibility\nfor plan coverage. The notice shall be valid for six (6) months.\n(3) (a) There is established within the guaranteed acceptance program the alternative\nunderwriting mechanism that a participating insurer may elect to use. An\ninsurer that elects this mechanism shall use the underwriting criteria that the\ninsurer has used for the past twelve (12) months for purposes of the program\nplan requirement in paragraph (b) of subsection (1) of this section for high -\nrisk individuals rather than using the criteria established in KRS 304.17A -005\nand 304.17A-280 for high-cost conditions.\n(b) An insurer that elects to use the alternative underwriting mechanism shall\nmake written application to the commissioner. Before the insurer may\nimplement the mech anism, the insurer shall obtain approval of the\ncommissioner. Annually thereafter, the insurer shall obtain the commissioner's\napproval of the underwriting criteria of the insurer before the insurer may\ncontinue to use the alternative underwriting mechanism.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=49561","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"df62a02de438b491738355cea2621c1e5a1e63625b3a06ee59c62ff3570b9c06","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-420","next":"us-ky/krs-304.17a-440"},"notice":"GroundRules: Original legal text. Not legal advice."}