Health Maintenance Organizations

KRS tit. XXV, ch. 304, subtit. 38

in effect

KRS 304.38-010 Title

304.38-010. Title This subtitle may be cited as the Health Maintenance Organization Act. Effective: June 21, 1974 History: Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 1, effective June 21, 1974.

304.38-020. Purpose (1) The purpose of this subtitle is to encourage and guarantee the development of health maintenance organizations by licensing and regulating their operation to insure that they provide high quality health care services through state licensed organizations meeting reasonable standards as to administration, services, and financial soundness. (2) It is the intent of this subtitle to complement the provisions of the certificate of need and licensure provisions of KRS Chapter 216B. (3) It is the intent of this subtitle to complement the Federal Health Maintenance Organization Act of 1973, as amended (P.L. 93-222), and nothing in this subtitle is intended to be in conflict with the federal statutes and regulations promulgated thereunder. Effective: July 15, 1980 History: Amended 1980 Ky. Acts ch. 135, sec. 30, effective July 15, 1980. -- Created 1974 Ky. Acts ch. 357, subtit. 38, secs. 2 and 23, effective June 21, 1974.

KRS 304.38-030 Definitions for subtitle

304.38-030. Definitions for subtitle As used in this subtitle, unless the context otherwise requires: (1) "Commissioner" means the commissioner of the Department of Insurance; (2) "Enrollee" means a person who has been enrolled in a health maintenance organization; (3) "Evidence of coverage" means any certificate, agreement, contract, or other document issued to an enrollee stating the health care services to which the enrollee is entitled. All coverages described in an evidence of coverage issued by a health maintenance organization are deemed to be "health benefit plans" to the extent defined in KRS 304.17A-005 unless exempted by the commissioner; (4) "Health care services" means any services included in the furnishing to any individual of medical, optometric, or dental care, or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services and goods for the purpose of preventing, alleviating, curing, or healing human illness, physical disability, or injury; (5) "Health maintenance organization" means any person who undertakes to provide, directly or through arrangements with others, health care services to individuals enrolled with such an organization on a per capita or a predetermined, fixed prepayment basis. A health maintenance organization is authorized to provide all health care services; (6) "Person" includes but is not limited to any individual, partnership, association, trust, or corporation; and (7) "Provider" means a person or group of persons licensed to practice medicine, osteopathy, dentistry, podiatry, optometry, or another health profession in a state or licensed to act as a hospital or another health care facility. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1498, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 105, sec. 22, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 427, sec. 1, effective July 14, 2000. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 3, effective June 21, 1974.

KRS 304.38-035 Certificate required for health maintenance organization

304.38-035. Certificate required for health maintenance organization No person shall in this state be, act as, or hold himself or herself out as a health maintenance organization unless he or she holds a certificate of authority as a health maintenance organization from the commissioner. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1499, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 105, sec. 23, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 427, sec. 2, effective July 14, 2000. -- Created 1986 Ky. Acts ch. 437, sec. 25, effective July 15, 1986.

KRS 304.38-040 Establishment of health maintenance organizations

304.38-040. Establishment of health maintenance organizations (1) A corporation, limited liability company, or partnership may apply to the commissioner for and obtain a certificate of authority to establish and operate a health maintenance organization in compliance with this subtitle. (2) Health maintenance organizations which are corporations may be organized by applying the provisions of KRS Chapter 271B, if for profit, and KRS Chapter 273, if for nonstock, nonprofit, to the extent that the same are not inconsistent with the express provisions of this subtitle. (3) Each application for a certificate of authority shall be submitted to the commissioner upon a form prescribed by the commissioner and shall set forth or be accompanied by: (a) Evidence that the applicant has been issued a certificate of need in accordance with the provisions of KRS Chapter 216B or evidence that no certificate of need is required by KRS Chapter 216B; (b) Articles of incorporation, articles of organization, partnership agreement, or other applicable documents in quadruplicate, acknowledged and verified by the applicant; (c) The initial bylaws, operating agreement, or other equivalent documents of the organization in triplicate, or any other similar documents; (d) A statement which shall include describing the health maintenance organization: 1. The health services to be offered; 2. The financial risks to be assumed; 3. The initial geographic area to be served; 4. Pro forma financial projections for the first three (3) years of operations including the assumptions the projections are based upon; 5. The sources of working capital and funding; 6. A description of the persons to be covered by the health maintenance organization; 7. Any proposed reinsurance arrangements; 8. Any proposed management, administrative, or cost-sharing arrangements; and 9. A description of the health maintenance organization's proposed method of marketing; (e) The names, addresses, and positions of the initial board of directors, board of trustees, or other governing body responsible for the conduct of the affairs of the applicant; (f) Any proposed evidence of coverage to be issued by the applicant to individuals, enrollees, groups, or other contract holders; and (g) Evidence of financial responsibility as provided in KRS 304.38-060. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1500, effective July 15, 2010; and repealed and reenacted ch. 51, sec. 136, effective July 15, 2010. -- Amended 2007 Ky. Acts ch. 137, sec. 136, effective June 26, 2007. -- Amended 2002 Ky. Acts ch. 105, sec. 32, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 427, sec. 3, effective July 14, 2000. -- Amended 1986 Ky. Acts ch. 437, sec. 26, effective July 15, 1986. -- Amended 1980 Ky. Acts ch. 135, sec. 31, effective July 15, 1980. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 4, effective June 21, 1974. Legislative Research Commission Note (7/15/2010). This section was amended by 2010 Ky. Acts ch. 24 and repealed and reenacted by 2010 Ky. Acts ch. 51. These Acts do not appear to be in conflict and have been codified together pursuant to 2010 Ky. Acts ch. 51, sec. 184. Legislative Research Commission Note (7/15/2010). 2010 Ky. Acts ch. 51, sec. 183, provides, "The specific textual provisions of Sections 1 to 178 of this Act which reflect amendments made to those sections by 2007 Ky. Acts ch. 137 shall be deemed effective as of June 26, 2007, and those provisions are hereby made expressly retroactive to that date, with the remainder of the text of those sections being unaffected by the provisions of this section."

KRS 304.38-042 Requirements for provider-sponsored integrated health networks to convert to health maintenance organization

304.38-042. Requirements for provider-sponsored integrated health networks to convert to health maintenance organization (1) As used in this section, "provider-sponsored integrated health delivery network" has the same meaning as in KRS 304.17A-005. (2) A provider-sponsored integrated health delivery network may elect to convert to a health maintenance organization under KRS 304.38-070(5) by filing an election to convert with the commissioner that contains a notification of the network's effective date of conversion. (3) Within thirty (30) days of the date of an election filing under subsection (2) of this section, the commissioner shall issue a certificate of authority as a health maintenance organization under KRS 304.38-070(5) to the provider-sponsored integrated health delivery network unless the commissioner: (a) Finds that, at the time of the election, the provider-sponsored integrated health delivery network fails to meet the net worth requirements of KRS 304.38- 070(5)(b); and (b) Provides the provider-sponsored integrated health delivery network with a written notice of the determination that contains a notice of the network's rights under KRS 304.2-310. Effective: July 14, 2022 History: Created 2022 Ky. Acts ch. 133, sec. 11, effective July 14, 2022. Legislative Research Commission Note (7/14/2022). In codification, a correction has been made to subsection (1) of this statute. 2022 House Bill 350, which created this statute, included a definition of "provided-sponsored integrated health delivery network". However, it is clear from the context and from the reference to the definition of "provider-sponsored integrated health delivery network" found in KRS 304.17-005 that the defined term in subsection (1) of this statute was intended to read "provider-sponsored integrated health delivery network". Under the authority of KRS 7.136, the Reviser of Statutes has corrected this manifest typographical error.

KRS 304.38-050 Evidence of coverages and charges for health care service -- Exception

304.38-050. Evidence of coverages and charges for health care service -- Exception (1) No health maintenance organization shall deliver or issue for delivery in this state any contract describing health benefits available, or any endorsement, rider, or application which becomes a part thereof, or any amendments thereto or modifications thereof, or the schedule of fees or other periodic charges to be paid by enrollees, until a copy of the form has been filed with and approved by the commissioner. Each form shall contain a complete and clear statement of: (a) The health care services to which the enrollee is entitled; (b) Any limitations on the services, kind of services, or benefits to be provided, including any deductible or copayment feature; (c) Where and in what manner information is available as to how services may be obtained; and (d) Any other provisions pertaining to the delivery of health care services. Any schedule of fees or other periodic charges to be paid by enrollees submitted to and filed with the commissioner along with adequate supporting information to show that the charges or fees are not excessive, inadequate, or unfairly discriminatory. (2) At the expiration of sixty (60) days, the form so filed shall be deemed approved unless prior thereto it has been affirmatively approved or disapproved by order of the commissioner, or a hearing has been scheduled by order of the commissioner. In the event that a hearing is held, the sixty (60) day waiting period shall begin anew after the close of the hearing. Approval of the form by the commissioner shall constitute a waiver of any unexpired portion of the waiting period. The commissioner may extend by not more than an additional thirty (30) day period within which he or she may affirmatively approve or disapprove the form by giving notice to the insurer of the extension before expiration of the initial sixty (60) day period. At the expiration of the period as so extended, and in the absence of the prior affirmative approval or disapproval, the form shall be deemed approved. The commissioner may at any time withdraw the approval. (3) This section shall not apply to rate filings made under Subtitle 17A of this chapter. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1501, effective July 15, 2010. -- Amended 1998 Ky. Acts ch. 496, sec. 52, effective April 10, 1998. -- Amended 1994 Ky. Acts ch. 93, sec. 18, effective July 15, 1994. -- Amended 1982 Ky. Acts ch. 320, sec. 39, effective July 15, 1982. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 5, effective June 21, 1974.

KRS 304.38-060 Issuance of certificate of authority

304.38-060. Issuance of certificate of authority Upon receipt of an application for issuance of a certificate of authority, the commissioner shall issue or deny the same. Issuance of a certificate of authority shall be granted only if the commissioner finds that the applicant has complied with KRS 304.38-040 and has paid the application fee, and the commissioner is satisfied that the following conditions are met: (1) The persons responsible for the conduct of the affairs of the application are competent, trustworthy, and possess good reputations; (2) The health maintenance organization is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the commissioner may consider: (a) The financial soundness of the health maintenance organization's arrangements for health care services and the schedule of charges used in connection therewith; (b) The adequacy of working capital; (c) Any agreement with an insurer, a government, or any other organization for insuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage in the event of discontinuance of the health maintenance organization or its inability to meet its financial obligations; (d) Examples of any agreements with providers for the provision of health care services by provider type; and (e) Compliance with KRS 304.38-070 if the applicant is applying for a health maintenance organization certificate of authority as a guarantee that the obligations will be duly performed. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1502, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 105, sec. 24, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 427, sec. 4, effective July 14, 2000. -- Amended 1986 Ky. Acts ch. 437, sec. 27, effective July 15, 1986. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 6, effective June 21, 1974.

KRS 304.38-065 Repealed, 2002

304.38-065. Repealed, 2002 Catchline at repeal: Certificate of authority to designate type of services authorized. History: Repealed 2002 Ky. Acts ch. 105, sec. 34, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 427, sec. 7, effective July 14, 2000.

KRS 304.38-070 Requirements for protection against insolvency -- Risk-based capital requirements -- Requirements for health maintenance organizations

304.38-070. Requirements for protection against insolvency -- Risk-based capital requirements -- Requirements for health maintenance organizations (1) Except as provided in subsection (5) of this section, the following applies to a corporation or limited liability company applying for and holding a certificate of authority as a health maintenance organization: (a) Except as provided in paragraph (b) of this subsection, to qualify for authority to act as a health maintenance organization, a corporation or limited liability company shall possess and thereafter maintain unimpaired paid-in capital stock of one million dollars ($1,000,000), and, when first so authorized, shall possess initial free surplus of not less than two million dollars ($2,000,000); (b) A corporation holding a valid certificate of authority to transact business as a health maintenance organization in Kentucky immediately prior to July 15, 1986, may, if otherwise qualified therefor, continue to be so authorized while meeting the requirements for protection against insolvency required for that authority immediately prior to July 15, 1986. The exception provided in this paragraph shall cease to apply to any health maintenance organization from and after the date it has accumulated capital and surplus equal to or in excess of the capital and surplus required by paragraph (a) of this subsection; and (c) 1. Each corporation authorized as a health maintenance organization shall at all times: a. Maintain bona fide additional surplus in the amount of two hundred fifty thousand dollars ($250,000); and b. Comply with the risk-based capital requirements as established in administrative regulations promulgated by the commissioner. 2. A corporation holding a valid certificate of authority to transact business as a health maintenance organization in Kentucky immediately prior to July 15, 1986, may, if otherwise qualified therefor, continue to be so authorized while meeting the requirements for protection against insolvency as required for that authority immediately prior to July 15, 1986. The exception provided in this paragraph shall cease to apply to any health maintenance organization from and after the date upon which it has accumulated additional surplus equal to or in excess of the additional surplus required by this subsection. (2) The following applies to a partnership applying for or holding a certificate of authority as a health maintenance organization: (a) Except as provided in paragraph (b) of this subsection: 1. To qualify for authority to act as a health maintenance organization, a partnership shall possess, when first so authorized, a total of at least three million dollars ($3,000,000) in its capital accounts; and 2. Thereafter, a partnership authorized as a health maintenance organization shall: a. Possess and maintain a total of at least one million two hundred fifty thousand dollars ($1,250,000) in its capital accounts; and b. Comply at all times with the risk-based capital requirement established in administrative regulations promulgated by the commissioner; and (b) A partnership holding a valid certificate of authority to transact business as a health maintenance organization in Kentucky immediately prior to July 15, 1986, may, if otherwise qualified therefor, continue to be so authorized while meeting the requirements for protection against insolvency required for that authority immediately prior to July 15, 1986. The exception provided for in this paragraph shall cease to apply to any such health maintenance organization from and after the date upon which the total of the funds which it has accumulated in its capital accounts equal or exceed the total of the funds in its capital accounts required by this subsection. (3) A corporation, partnership, or limited liability company applying for and holding a certificate of authority as a health maintenance organization which by contract manages care and processes health care claims solely for Medicaid-eligible enrollees and the Kentucky Children's Health Insurance Program shall comply with risk-based capital (RBC) requirements as follows: (a) 1. For purposes of this subsection, risk-based capital shall be determined in accordance with the risk-based capital requirements for health maintenance organizations established under this subtitle and any administrative regulation promulgated pursuant to KRS Chapter 13A, except as otherwise provided in this subsection. 2. The corporation, partnership, or limited liability company shall comply with the same risk-based capital requirements as other health maintenance organizations, except that no additional phase-in or risk- based capital reports shall be required for 2000 or 2001, and the risk- based capital levels shall be established in accordance with paragraph (b) of this subsection; (b) For the risk-based capital reports required to be filed by health maintenance organizations which manage care and process health care claims solely for Medicaid-eligible enrollees and the Kentucky Children's Health Insurance Program, the risk-based capital levels shall be defined as follows: 1. "Company Action Level RBC" means the product of two (2.0) and its Authorized Control Level RBC; 2. "Regulatory Action Level RBC" means the product of one and five- tenths (1.5) and its Authorized Control Level RBC; 3. "Authorized Control Level RBC" means the product of four-tenths (.40) and the risk-based capital after covariance determined under the risk- based capital formula in accordance with the RBC instruction; and 4. "Mandatory Control Level RBC" means the product of seven-tenths (.70) and the Authorized Control Level RBC; and (c) A corporation, partnership, or limited liability company applying for and holding a certificate of authority as a health maintenance organization managing care, processing health care claims, or providing health benefits to groups or individuals in addition to Medicaid-eligible and Kentucky Children's Health Insurance Program enrollees shall comply with the risk- based capital requirements of subsection (1) of this section and this subtitle, and shall not be eligible to calculate its risk-based capital according to this subsection. (4) As used in subsection (5) of this section: (a) "MA organization" has the same meaning as in 42 C.F.R. sec. 422.2, as amended; (b) 1. "Net worth" means the excess of total admitted assets over total admitted liabilities, but the liabilities shall not include fully subordinated debt or surplus notes as approved by the commissioner. 2. In determining net worth: a. No debt shall be considered fully subordinated unless the debt is in a form approved by the commissioner; b. Any interest obligation relating to the repayment of any subordinated debt shall be similarly subordinated; and c. The interest expenses relating to the repayment of any fully subordinated debt shall be considered covered expenses. 3. For purposes of calculating a health maintenance organization's net worth, "admitted assets" includes the following, as may be subsequently modified by the commissioner: a. Receivables due from persons that are not more than ninety (90) days past due; b. Amounts due under reinsurance arrangements from insurance companies authorized to do business in this state; c. Undisputed tax refunds or other receivables due from the United States or this state; d. Amounts on deposit under KRS 304.38-073; and e. Investments determined as allowable by the commissioner under this chapter. 4. When determining liabilities for purposes of calculating a health maintenance organization's net worth, the health maintenance organization shall include an amount estimated in the aggregate to provide for: a. Any unearned premium; b. The payment of all claims for health care expenditures: i. That have been incurred, whether reported or unreported; ii. That are unpaid; and iii. For which the organization is or may be liable; and c. The expense of adjustment or settlement of claims; and (c) "Provider-sponsored integrated health delivery network" has the same meaning as in KRS 304.17A-005. (5) The following applies to a corporation or limited liability company applying for or holding, or a provider-sponsored integrated health delivery network that elects to convert to and hold, a certificate of authority as a health maintenance organization that solely operates as an MA organization that meets the requirements of 42 C.F.R. sec. 422.400, as amended: (a) The health maintenance organization shall possess, when first so authorized, an initial net worth of one million five hundred thousand dollars ($1,500,000); (b) Thereafter, the health maintenance organization shall possess and maintain a minimum net worth equal to the greater of: 1. One million five hundred thousand dollars ($1,500,000); or 2. As reported on the most recent annual statement filed with the commissioner, an amount totaling: a. Four percent (4%) of the first one hundred fifty million dollars ($150,000,000) of annual premium revenue; and b. One and one-half percent (1.5%) of the annual premium revenue in excess of one hundred fifty million dollars ($150,000,000); (c) To the extent permitted under federal law, the health maintenance organization shall: 1. Comply with the same risk-based capital requirements as other health maintenance organizations under subsection (1) of this section; and 2. Except as provided in paragraph (d) of this subsection, be subject to the provisions of this subtitle relating to licensing and solvency and to the following provisions of this chapter, to the extent applicable and not in conflict with the applicable provisions of this subtitle: a. Subtitle 1 -- Scope -- General Definitions and Provisions; b. Subtitle 2 -- Insurance Commissioner; c. Subtitle 3 -- Authorization of Insurers and General Requirements; d. Subtitle 4 -- Fees and Taxes; e. Subtitle 5 -- Kinds of Insurance -- Limits of Risk – Reinsurance; f. Subtitle 6 -- Assets and Liabilities; g. Subtitle 7 -- Investments; h. Subtitle 8 -- Administration of Deposits; i. Subtitle 9 -- Agents, Consultants, Solicitors, and Adjusters; j. Subtitle 12 -- Trade Practices and Frauds; k. Subtitle 25 -- Continuity of Management; l. Subtitle 33 -- Insurers Rehabilitation and Liquidation; m. Subtitle 37 -- Insurance Holding Company Systems; and n. Subtitle 99 -- Penalties; and (d) For purposes of determining compliance with KRS 304.38-073, the commissioner shall: 1. Take into account any and all deposits as may be held with other states; and 2. Coordinate with the other states to not require the health maintenance organization to have total deposits in all states that are greater than the amount required in the state with the highest deposit requirement. Effective: July 14, 2022 History: Amended 2022 Ky. Acts ch. 133, sec. 10, effective July 14, 2022. -- Amended 2010 Ky. Acts ch. 24, sec. 1503, effective July 15, 2010; and repealed and reenacted ch. 51, sec. 137, effective July 15, 2010. -- Amended 2007 Ky. Acts ch. 137, sec. 137, effective June 26, 2007. -- Amended 2003 Ky. Acts ch. 136, sec. 1, effective June 24, 2003. -- Amended 2000 Ky. Acts ch. 255, sec. 2, effective July 14, 2000. -- Amended 1986 Ky. Acts ch. 437, sec. 28, effective July 15, 1986. -- Amended 1982 Ky. Acts ch. 128, sec. 7, effective July 15, 1982. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 7, effective June 21, 1972. Legislative Research Commission Note (7/15/2010). This section was amended by 2010 Ky. Acts ch. 24 and repealed and reenacted by 2010 Ky. Acts ch. 51. These Acts do not appear to be in conflict and have been codified together pursuant to 2010 Ky. Acts ch. 51, sec. 184. Legislative Research Commission Note (7/15/2010). 2010 Ky. Acts ch. 51, sec. 183, provides, "The specific textual provisions of Sections 1 to 178 of this Act which reflect amendments made to those sections by 2007 Ky. Acts ch. 137 shall be deemed effective as of June 26, 2007, and those provisions are hereby made expressly retroactive to that date, with the remainder of the text of those sections being unaffected by the provisions of this section."

KRS 304.38-073 Deposit of cash or securities for performance of obligations to enrollees

304.38-073. Deposit of cash or securities for performance of obligations to enrollees Each health maintenance organization shall furnish to the commissioner a deposit of cash or securities approved by the commissioner in an amount not less than five hundred thousand dollars ($500,000) so that the obligations to the enrollees shall be performed. A health maintenance organization may be required to furnish an additional deposit if the commissioner determines, after a hearing, that an additional deposit is necessary for the protection of the health maintenance organization's enrollees. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1504, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 105, sec. 25, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 427, sec. 14, effective July 14, 2000. -- Created 1996 Ky. Acts ch. 286, sec. 2, effective July 15, 1996.

KRS 304.38-075 Requirements for transfer of risk to provider -- Additional reserves may be required

304.38-075. Requirements for transfer of risk to provider -- Additional reserves may be required (1) Any health maintenance organization that contracts with a provider or provider organization for the transfer of risk to the provider shall take reasonable steps to ensure the transferee is able to accept and manage the risk to be transferred. The health maintenance organization shall submit a plan for evaluating a provider's or provider organization's ability to accept and manage risk to the department for approval at least forty-five (45) days prior to the proposed date of the transfer of any risk. (2) If a health maintenance organization transfers risk to a provider: (a) Not in compliance with the standards listed in its approved plan; or (b) Prior to filing or receiving approval of its plan; the commissioner may require the health maintenance organization to retain additional reserves to cover the risk transferred. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1505, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 255, sec. 3, effective July 14, 2000.

KRS 304.38-077 Repealed, 2002

304.38-077. Repealed, 2002 Catchline at repeal: Single service organization -- Net worth and risk-based capital requirements. History: Repealed 2002 Ky. Acts ch. 105, sec. 34, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 427, sec. 13, effective July 14, 2000.

KRS 304.38-080 Information to enrollees

304.38-080. Information to enrollees (1) Each enrollee residing in this state shall be entitled to evidence of health care services provided and the same shall be issued and delivered to him by the health maintenance organization, be it in the form of a contract, certificate, or other comparable document. Such evidence shall state clearly the total amount of payment for health care services and any indemnity or service benefits which the enrollee is obligated to pay with respect to such health care services. (2) Each health maintenance organization shall annually make available to its enrollees at its principal office and place of business: (a) Its most recent annual statement of financial condition including a balance sheet and summary of receipts and disbursement; and (b) A current description of its organizational structure and operation. Effective: April 10, 1998 History: Amended 1998 Ky. Acts ch. 496, sec. 56, effective April 10, 1998. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 8, effective June 21, 1974.

KRS 304.38-090 Annual report

304.38-090. Annual report Organizations subject to the provisions of this subtitle shall make and file with the commissioner and the Kentucky Certificate of Need and Licensure Board annually before March 1 of each year, a statement under oath upon a form to be prescribed by the commissioner covering the preceding year, and shall include (a) a financial statement of the organization, including a balance sheet, receipts, and disbursements for the preceding year; (b) the number of persons enrolled during the year, the number of enrollees as of the end of the year, the number of enrollments terminated during the year, and any other information relating to the operation of the health maintenance organization as may be prescribed by the commissioner in order to enable the commissioner to evaluate the performance of the health maintenance organization. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1506, effective July 15, 2010. -- Amended 1998 Ky. Acts ch. 483, sec. 28, effective July 15, 1998. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 9, effective June 21, 1974.

KRS 304.38-095 Application of KRS 304.2-205

304.38-095. Application of KRS 304.2-205 In his or her discretion, the commissioner may require organizations subject to the provisions of this subtitle to comply with KRS 304.2-205. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1507, effective July 15, 2010. -- Created 1986 Ky. Acts ch. 263, sec. 4, effective July 15, 1986.

KRS 304.38-098 Compliance with KRS 304.18-124 to 304.18-127

304.38-098. Compliance with KRS 304.18-124 to 304.18-127 Health maintenance organizations shall comply with KRS 304.18-124 to 304.18-127. Effective: July 13, 1990 History: Created 1990 Ky. Acts ch. 119, sec. 6, effective July 13, 1990.

KRS 304.38-100 Investments

304.38-100. Investments The funds of a health maintenance organization shall be invested only in securities or other investments permitted by Subtitle 7 of Chapter 304 of the Kentucky Revised Statutes, or such other securities or investments as the commissioner may permit. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1508, effective July 15, 2010. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 10, effective June 21, 1974.

KRS 304.38-110 Agent of health maintenance organization -- Licensing -- Continuing education -- Appointment

304.38-110. Agent of health maintenance organization -- Licensing -- Continuing education -- Appointment (1) An agent of a health maintenance organization shall be licensed as an agent with a health line of authority in accordance with the provisions of Subtitle 9 of this chapter regulating all aspects of agent licenses. (2) Subsection (1) of this section includes the requirement that the agent shall satisfactorily complete the continuing education requirements in accordance with KRS 304.9-295. (3) An agent of a health maintenance organization shall be appointed by the health maintenance organization in accordance with the provisions of Subtitle 9 of this chapter regulating all aspects of agent appointments. Effective: July 15, 2002 History: Repealed and reenacted 2002 Ky. Acts ch. 273, sec. 50, effective July 15, 2002. -- Amended 1998 Ky. Acts ch. 378, sec. 4, effective July 15, 1998. -- Amended 1986 Ky. Acts ch. 437, sec. 29, effective July 15, 1986. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 11, effective June 21, 1974.

KRS 304.38-120 Financial condition, market conduct, and business practices subject to examination

304.38-120. Financial condition, market conduct, and business practices subject to examination Health maintenance organizations shall be subject to the provisions of KRS 304.2-210, 304.2-220, 304.2-230, 304.2-240, 304.2-250, 304.2-260, 304.2-270, 304.2-280, 304.2- 290, 304.2-300, and Subtitle 2 of this chapter for determining financial condition, market conduct, and business practices. Effective: July 13, 2004 History: Amended 2004 Ky. Acts ch. 24, sec. 42, effective July 13, 2004. -- Amended 1982 Ky. Acts ch. 320, sec. 40, effective July 15, 1982. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 12, effective June 21, 1974.

KRS 304.38-130 Revocation or suspension of certificate of authority

304.38-130. Revocation or suspension of certificate of authority (1) The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this subtitle if the commissioner finds that any of the conditions exist for which the commissioner could suspend or revoke a certificate of authority as provided in Subtitles 2 and 3 of this chapter or if the commissioner finds that any of the following conditions exist: (a) The health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in and reasonably inferred from any other information submitted under KRS 304.38-040, unless amendments to such submissions have been filed with and approved by the commissioner; (b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of KRS 304.38-050 or Subtitle 17A of this chapter; (c) The health maintenance organization does not provide or arrange for health care services as approved by the commissioner in KRS 304.38-050(1)(a); (d) The certificate of need and licensure board certifies to the commissioner that the health maintenance organization fails to meet the requirements of the board or that the health maintenance organization is unable to fulfill its obligations to furnish health care services; (e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees; (f) The health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner; (g) The continued operation of the health maintenance organization would be hazardous to its enrollees; (h) The health maintenance organization has otherwise failed to substantially comply with this subtitle; or (i) The health maintenance organization has contracted with the Department for Medicaid Services to act as a managed care organization providing Medicaid benefits pursuant to KRS Chapter 205 and has exhibited willful or frequent and repeated failure to comply with KRS 304.17A-700 to 304.17A-730, 205.593, and 304.14-135 and KRS 205.522, 205.532 to 205.536, and 304.17A-515. (2) If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of the suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever. (3) If the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The commissioner may, by written order, permit the further operation of the organization as the commissioner may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage. If the commissioner permits such further operation the health maintenance organization will continue to collect the periodic prepayments required of enrollees. Effective: July 14, 2018 History: Amended 2018 Ky. Acts ch. 106, sec. 12, effective July 14, 2018. -- Amended 2010 Ky. Acts ch. 24, sec. 1509, effective July 15, 2010. -- Amended 2004 Ky. Acts ch. 24, sec. 43, effective July 13, 2004. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 13, effective June 21, 1974.

KRS 304.38-140 Rehabilitation, liquidation, or conservation of health maintenance organization

304.38-140. Rehabilitation, liquidation, or conservation of health maintenance organization Any rehabilitation or liquidation of a health maintenance organization shall be conducted under the supervision of the commissioner pursuant to and in accordance with Subtitle 33 of Chapter 304 of the Kentucky Revised Statutes. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1510, effective July 15, 2010. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 14, effective June 21, 1974.

KRS 304.38-150 Rules and regulations

304.38-150. Rules and regulations The commissioner may promulgate reasonable rules and regulations not inconsistent with the provisions of this subtitle that he or she deems necessary for the proper administration of this subtitle. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1511, effective July 15, 2010. -- Amended 1986 Ky. Acts ch. 437, sec. 30, effective July 15, 1986. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 15, effective June 21, 1974.

KRS 304.38-160 Repealed, 1982

304.38-160. Repealed, 1982 Catchline at repeal: Fees. History: Repealed 1982 Ky. Acts ch. 320, sec. 52, effective July 15, 1982. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 16, effective June 21, 1974.

KRS 304.38-170 Public documents -- Statutory construction

304.38-170. Public documents -- Statutory construction (1) All applications, filings, and reports required under this subtitle shall be treated as public documents, except as otherwise provided for herein. (2) The nonprofit hospital, medical-surgical, dental, and health service corporation law of this state shall not be applicable to any health maintenance organization granted a certificate of authority under this subtitle. This provision does not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance laws or the hospital or medical service corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to this subtitle. Effective: July 13, 2004 History: Amended 2004 Ky. Acts ch. 24, sec. 44, effective July 13, 2004. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 17, effective June 21, 1974.

KRS 304.38-180 Prohibited practices

304.38-180. Prohibited practices (1) No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising or solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. (2) No health maintenance organization shall cancel an enrollee's coverage, except for the failure to pay the charge for such coverage, or for such other reasons as may be promulgated in regulations issued by the commissioner. (3) Subtitle 12 of this chapter shall be construed to apply to health maintenance organizations and evidences of coverage, except to the extent that the commissioner determines that the nature of health maintenance organizations and evidence of coverage under such sections is clearly inappropriate. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1512, effective July 15, 2010. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 18, effective June 21, 1974.

KRS 304.38-185 Coordination of benefits

304.38-185. Coordination of benefits In his or her discretion, the commissioner may include health maintenance organizations or designated types of health maintenance organizations doing business pursuant to this subtitle in coordination of benefits guidelines prescribed pursuant to KRS 304.18-085. Effective: July 15, 2010 History: Amended 2010 Ky. Acts ch. 24, sec. 1513, effective July 15, 2010. -- Amended 2000 Ky. Acts ch. 427, sec. 11, effective July 14, 2000. -- Created 1986 Ky. Acts ch. 433, sec. 3, effective July 15, 1986.

KRS 304.38-190 Powers of insurers

304.38-190. Powers of insurers (1) Any domestic stock and mutual insurance company licensed in this state, or any nonprofit hospital, medical-surgical, dental, and health service corporation authorized to do business in this state, may either directly or indirectly through a subsidiary, organize and operate a health maintenance organization under the provisions of this subtitle. (2) Notwithstanding any provision of KRS Chapter 304, Subtitles 24 and 32 to the contrary, any domestic or stock insurance company licensed in this state or any nonprofit hospital, medical-surgical, dental, and health service corporation authorized to do business in this state, may contract with a health maintenance organization organized under this subtitle to provide protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. Effective: June 21, 1974 History: Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 19, effective June 21, 1974.

KRS 304.38-191 Conversion and continuation rights upon termination of group coverage

304.38-191. Conversion and continuation rights upon termination of group coverage Any group policy, group plan, or group contract issued, delivered, or renewed by a health maintenance organization shall include continuation rights for certificate holders, pursuant to KRS 304.18-110, and conversion rights for certificate holders equal to that provided in KRS 304.18-114 subject to the minimum benefits specified in KRS 304.18- 120. Effective: July 13, 2004 History: Amended 2004 Ky. Acts ch. 157, sec. 4, effective July 13, 2004. -- Amended 2002 Ky. Acts ch. 105, sec. 26, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 427, sec. 12, effective July 14, 2000. -- Amended 1986 Ky. Acts ch. 163, sec. 4, effective July 15, 1986. -- Created 1980 Ky. Acts ch. 258, sec. 3, effective July 15, 1980.

KRS 304.38-192 Repealed, 1986

304.38-192. Repealed, 1986 Catchline at repeal: Continuation of group coverage. History: Repealed 1986 Ky. Acts ch. 163, sec. 5, effective July 15, 1986; amended 1986 Ky. Acts ch. 153, sec. 3, effective July 15, 1986. -- Amended 1982 Ky. Acts ch. 406, sec. 13, effective July 15, 1982. -- Created 1980 Ky. Acts ch. 130, sec. 3, effective July 15, 1980. Legislative Research Commission Note. KRS 304.38-192 was amended by Acts 1986, ch. 153, § 3 and repealed by Acts 1986, ch. 163, § 5. Pursuant to KRS 446.260, the repeal prevails.

KRS 304.38-193 Coverage for treatment for mental illness

304.38-193. Coverage for treatment for mental illness (1) For purposes of this section, "mental illness" means psychosis, neurosis or an emotional disorder. (2) Any offer to sell a policy of general health insurance or health maintenance organization coverage issued, delivered, issued for delivery, amended or renewed by a health maintenance organization in this state after January 1, 1987, shall include an offer of coverage for the inpatient and outpatient treatment of mental illness, at least to the same extent and degree as coverage provided by the policy or contract for the treatment of physical illnesses. (3) Nothing in this section shall be construed to prohibit a health maintenance organization from issuing or continuing to issue a health insurance policy or contract which provides benefits greater than the minimum benefits required by this section or from issuing such policies or contracts providing benefits which are generally more favorable to the insured than those required by this section. Effective: July 15, 1986 History: Created 1986 Ky. Acts ch. 482, sec. 4, effective July 15, 1986.

KRS 304.38-194 Pooling of claims experience required

304.38-194. Pooling of claims experience required Pooling of claims experience for groups with fewer than fifty (50) insureds shall be required. No more than twenty-five percent (25%) of the premium for these groups shall be based on their own claims experience. This provision shall not permit competing health insurers or health maintenance organizations to jointly pool health insurance claims experience, health maintenance organization claims experience, or both, or to jointly develop rates. Effective: July 15, 1988 History: Created 1988 Ky. Acts ch. 354, sec. 6, effective July 15, 1988.

KRS 304.38-195 Policy covering services performed by dentist deemed to cover such services performed by physician

304.38-195. Policy covering services performed by dentist deemed to cover such services performed by physician Any certificate, agreement or contract issued in this state by a health maintenance organization which provides coverage for services which can be lawfully performed within the scope of the license of a duly licensed dentist, shall be deemed to provide benefits for such services whether performed by a duly licensed physician or a duly licensed dentist. Effective: June 19, 1976 History: Created 1976 Ky. Acts ch. 112, sec. 5, effective June 19, 1976.

KRS 304.38-196 Indemnity payable for services performed by chiropractors, physicians, osteopaths, or podiatrists

304.38-196. Indemnity payable for services performed by chiropractors, physicians, osteopaths, or podiatrists (1) Any certificate, agreement or contract issued in this state by a health maintenance organization which provides coverage for any service which is within the lawful scope of practice of a chiropractor duly licensed under KRS Chapter 312, shall be deemed to provide benefits for such services whether performed by a duly licensed physician, osteopath, or chiropractor, notwithstanding any provision contained in the certificate, agreement or contract. An enrollee requesting chiropractic treatment for otherwise covered conditions shall not unreasonably be denied chiropractic treatment if treatment of the conditions is within the lawful scope of chiropractic practice. (2) Any certificate, agreement, or contract issued in this state by a health maintenance organization which provides coverage for any service which is within the lawful scope of practice of a podiatrist duly licensed under KRS Chapter 311, shall be deemed to provide benefits for those services whether performed by a duly licensed physician, osteopath, chiropractor, or podiatrist, notwithstanding any provision contained in the certificate, agreement, or contract. Effective: July 15, 1994 History: Amended 1994 Ky. Acts ch. 466, sec. 3, effective July 15, 1994. -- Amended 1990 Ky. Acts ch. 185, sec. 1, effective July 13, 1990. -- Created 1986 Ky. Acts ch. 399, sec. 4, effective July 15, 1986.

KRS 304.38-197 Coverage for treatment of alcoholism

304.38-197. Coverage for treatment of alcoholism Any group policy, group plan, or group contract issued in this state by a health maintenance organization shall offer the master policyholder the option to purchase in new contracts the minimum benefits for treatment of alcoholism as specified in KRS 304.18-130 to 304.18-170. Effective: January 1, 1979 History: Created 1978 Ky. Acts ch. 131, sec. 8, effective January 1, 1979.

KRS 304.38-198 Optional nursery care coverage for a well newly born child

304.38-198. Optional nursery care coverage for a well newly born child (1) Any group policy, group plan, or group contract issued in this state by a health maintenance organization which provides maternity benefits shall offer the master policyholder the option to purchase coverage to pay for routine nursery care for a well newly born child for up to five (5) full days in a hospital nursery. (2) The coverage for the well newly born child shall pay the hospital charges for each day in the hospital nursery. (3) The requirements of this section shall apply to all policies, plans, or contracts issued by a health maintenance organization in effect on October 1, 1980, and those policies, plans or contracts issued thereafter. Effective: July 15, 1980 History: 1980 Ky. Acts ch. 9, sec. 4, effective July 15, 1980.

KRS 304.38-199 Coverage for newly-born child

304.38-199. Coverage for newly-born child (1) All health maintenance organization contracts issued by health maintenance organizations, regardless of whether the contracts are for nonfamily or family coverage, shall provide that health insurance benefits shall be payable with respect to a newly-born child of the subscribed from the moment of birth. (2) The coverage for newly-born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically-diagnosed congenital defects and birth abnormalities. (3) If payment of a specific premium or fee is required to provide coverage for a child, the policy or contract may require that the notification of birth of a newly-born child and payment of the required premium or fees must be furnished to the health maintenance organization within thirty-one (31) days after the date of birth in order to have the coverage continued beyond such thirty-one (31) days. (4) The requirements of this section shall apply to all contracts delivered or issued for delivery in this state on and after July 15, 1994. Effective: July 15, 1994 History: Amended 1994 Ky. Acts ch. 93, sec. 14, effective July 15, 1994. -- Created 1982 Ky. Acts ch. 123, sec. 18, effective July 15, 1982.

KRS 304.38-200 Application of other subtitles

304.38-200. Application of other subtitles Except as provided in KRS 304.38-070(5), health maintenance organizations shall be subject to the provisions of this subtitle, and to the following provisions of this chapter, to the extent applicable and not in conflict with the expressed provisions of this subtitle: (1) Subtitle 1 -- Scope -- General Definitions and Provisions; (2) Subtitle 2 -- Insurance Commissioner; (3) Subtitle 3 -- Authorization of Insurers and General Requirements; (4) Subtitle 4 -- Fees and Taxes; (5) Subtitle 5 -- Kinds of Insurance -- Limits of Risk -- Reinsurance; (6) Subtitle 6 -- Assets and Liabilities; (7) Subtitle 7 -- Investments; (8) Subtitle 8 -- Administration of Deposits; (9) Subtitle 9 -- Agents, Consultants, Solicitors, and Adjusters; (10) Subtitle 12 -- Trade Practices and Frauds; (11) Subtitle 14 -- The Insurance Contract; (12) Subtitle 17 -- Health Insurance Contracts; (13) Subtitle 17A -- Health Benefit Plans; (14) Subtitle 17B -- Kentucky Access; (15) Subtitle 17C -- Limited Health Service Benefit Plans; (16) Subtitle 18 -- Group and Blanket Health Insurance; (17) Subtitle 24 -- Domestic Stock and Mutual Insurers; (18) Subtitle 25 -- Continuity of Management; (19) Subtitle 26 -- Insider Trading of Equity Securities; (20) Subtitle 33 -- Insurers Rehabilitation and Liquidation; (21) Subtitle 37 -- Insurance Holding Company Systems; (22) Subtitle 47 -- Insurance Fraud; and (23) Subtitle 99 -- Penalties. Effective: July 14, 2022 History: Amended 2022 Ky. Acts ch. 133, sec. 12, effective July 14, 2022. -- Amended 2010 Ky. Acts ch. 24, sec. 1514, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 105, sec. 27, effective July 15, 2002. -- Amended 2000 Ky. Acts ch. 427, sec. 5, effective July 14, 2000; and ch. 476, sec. 29, effective July 14, 2000. -- Amended 1998 Ky. Acts ch. 405, sec. 3, effective July 15, 1998; and ch. 496, sec. 48, effective April 10, 1998. -- Amended 1996 Ky. Acts ch. 286, sec. 1, effective July 15, 1996; and ch. 371, sec. 14, effective July 15, 1996. -- Amended 1994 Ky. Acts ch. 512, sec. 67, effective July 15, 1994. -- Amended 1990 Ky. Acts ch. 178, sec. 3, effective July 13, 1990. -- Amended 1982 Ky. Acts ch. 37, sec. 7, effective February 26, 1982; and ch. 320, sec. 41, effective July 15, 1982. -- Created 1974 Ky. Acts ch. 357, subtit. 38, sec. 20, effective June 21, 1974.

KRS 304.38-205 Medicare supplement coverage for persons not eligible for Medicare by reason of age

304.38-205. Medicare supplement coverage for persons not eligible for Medicare by reason of age Health maintenance organizations delivering or issuing for delivery in Kentucky Medicare supplement contracts as defined in KRS 304.14-500 to 304.14-550, or renewing such contracts, shall make available upon request Medicare supplement coverage for persons not eligible for Medicare by reason of age. In the case of group contracts, the request shall be made by the group contract holder. Effective: July 15, 1988 History: Created 1988 Ky. Acts ch. 354, sec. 4, effective July 15, 1988.

KRS 304.38-210 Health maintenance organizations as insurers to offer home health care coverage -- Conditions

304.38-210. Health maintenance organizations as insurers to offer home health care coverage -- Conditions (1) Health maintenance organizations issuing policies in the Commonwealth which provide hospital, medical, or surgical expense benefits shall make available and offer to include benefits for home health care. On group benefits the option for home health care benefits shall be made available and offered to the master policyholder. The coverage may contain a limitation on the number of home health care visits for which benefits are payable, but the number of such visits shall not be less than sixty (60) in any calendar year or in any continuous period of twelve (12) months for each person covered under the policy. Each visit by an authorized representative of a home health agency shall be considered as one (1) home health care visit except that at least four (4) hours of home health service shall be considered as one (1) home health visit. (2) Home health care coverage shall be subject to the same deductible and coinsurance provisions as are other services covered by health maintenance organizations which issue policies in the Commonwealth that provide hospital, medical, or surgical expense benefits. (3) Home health care shall not be reimbursed unless an attending physician, an advanced practice registered nurse, or a physician assistant certifies that hospitalization or confinement in a skilled nursing facility as defined by the Kentucky Health Facilities and Health Services Certificate of Need and Licensure Board would otherwise be required if home health care was not provided. (4) Medicare beneficiaries shall be deemed eligible to receive home health care benefits under a policy, contract or plan entered into, issued, delivered, or amended in this state by a health maintenance organization which provides hospital, medical, or surgical expense benefits provided that the policy, contract or plan shall only pay for those home health care services which are not paid for by Medicare and do not exceed the maximum liability of the policy, contract or plan. (5) Pursuant to the provisions of this section, all health maintenance organizations issuing policies in the Commonwealth which provide hospital, medical, or surgical expense benefits or coverage for home health care shall inform the beneficiaries of such policies, in writing, of the specific home health care benefits which are covered. Such written notification shall take place at the time of issuance or reissuance of the policy. Effective:March 22, 2021 History: Amended 2021 Ky. Acts ch. 59, sec. 5, effective March 22, 2021. -- Created 1980 Ky. Acts ch. 61, sec. 5, effective January 1, 1981.

KRS 304.38-220 Long-term health care benefits

304.38-220. Long-term health care benefits Health maintenance organizations issuing long-term care coverage shall comply with KRS 304.14-600 to 304.14-625. Effective: July 14, 1992 History: Amended 1992 Ky. Acts ch. 423, sec. 9, effective July 14, 1992. -- Created 1986 Ky. Acts ch. 409, sec. 4, effective July 1, 1987.

KRS 304.38-225 Requirements for health maintenance organization that provides hospital benefits coverage and requires utilization review of benefits

304.38-225. Requirements for health maintenance organization that provides hospital benefits coverage and requires utilization review of benefits (1) Every health maintenance organization in this state which provides coverage of hospital benefits and requires the utilization review of such benefits or administers a health benefit program which provides for the coverage of hospital benefits and requires the utilization review of such benefits by a private review agent shall: (a) Be a registered private review agent in accordance with KRS 304.17A-607 and administrative regulations promulgated under the authority of KRS 304.17A-613; or (b) Contract with a private review agent that has been registered in accordance with KRS 304.17A-607 and administrative regulations promulgated under the authority of KRS 304.17A-613. (2) Notwithstanding any other provision of KRS 304.17A-603, 304.17A-605, 304.17A- 607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615, a health maintenance organization shall not deny or reduce payment of health benefits to any person, licensed practitioner, or health facility for covered services which have been rendered to an insured unless: (a) Notice of denial has been issued. The notice shall inform patients, authorized persons, and health-care providers of their right to appeal adverse determinations of a utilization review by the insurer, its designee, or private review agent to the insurer for the internal review process established by the insurer in accordance with KRS 304.17A-617 and 304.17A-619. The notice shall also include instructions on filing an internal appeal; and (b) The health maintenance organization is in compliance with subsection (1) of this section. Effective: July 14, 2000 History: Amended 2000 Ky. Acts ch. 262, sec. 31, effective July 14, 2000. -- Amended 1998 Ky. Acts ch. 426, sec. 528, effective July 15, 1998. -- Amended 1996 Ky. Acts ch. 353, sec. 4, effective July 15, 1996. -- Created 1990 Ky. Acts ch. 451, sec. 11, effective July 13, 1990.

KRS 304.38-230 Funding of benefits by employer or group contract holder

304.38-230. Funding of benefits by employer or group contract holder Notwithstanding the definition of health maintenance organization in KRS 304.38-030, an authorized health maintenance organization may issue contracts under which benefits are funded, in whole or in part, by an employer or other group contract holder. Effective: July 13, 1990 History: Created 1990 Ky. Acts ch. 289, sec. 1, effective July 13, 1990.

KRS 304.38-240 Solicitation of proposals designating medical necessity criteria for Medicaid managed care organizations -- Administrative regulation

304.38-240. Solicitation of proposals designating medical necessity criteria for Medicaid managed care organizations -- Administrative regulation (1) (a) The commissioner shall promulgate an administrative regulation to establish procedures for conducting a competitive process to solicit proposals from publishers of medical necessity criteria to designate for each category of services which medical necessity criteria Medicaid managed care organizations, as defined in KRS 205.532, shall use to determine the medical necessity and clinical appropriateness of proposed services pursuant to the utilization review plan required by KRS 205.536. (b) The procedures shall require: 1. The department to provide adequate public notice of the deadline for publishers of medical necessity criteria to submit proposals; and 2. a. The commissioner to issue a final order at the conclusion of the competitive process. b. The order shall designate, for each category of services, one (1) set of medical necessity criteria determined by the commissioner to be the most advantageous to the Commonwealth. c. Nothing in this section shall preclude the commissioner from designating the same set of medical necessity criteria for two (2) or more categories of service if the commissioner determines, in accordance with the procedures required by this subsection, that the designation would be the most advantageous to the Commonwealth. (c) The procedures shall permit any person who is aggrieved in connection with the solicitation of proposals or the commissioner's final order to request a hearing pursuant to KRS 304.2-310. (2) (a) For purposes of this subsection, "objective and evidence-based" includes: 1. Methods or systems where: a. The publisher evaluates and grades the sufficiency of medical evidence incorporated into the criteria; b. The publisher reviews and updates the criteria periodically as appropriate, but no less frequently than annually; and c. The criteria are evaluated annually by a panel of one (1) or more physicians not directly employed by the publisher of the criteria; and 2. Sufficient unique citations to published medical research and other peer- reviewed literature to substantiate the criteria's evidentiary basis. (b) In conducting the competitive process required by subsection (1) of this section, the commissioner shall only accept proposals from publishers of medical necessity criteria if the criteria: 1. Are nationally recognized; 2. Are objective and evidence-based; and 3. Are not proprietary property of a Medicaid managed care organization or a subsidiary of a Medicaid managed care organization, or a corporation which a Medicaid managed care organization controls or owns more than five percent (5%) of the stock. (3) The categories of service shall be limited to: (a) Physical health services; (b) Behavioral health services; and (c) Any other categories of service required under federal law for Medicaid managed care. (4) (a) Notwithstanding KRS 13A.3102, any administrative regulation promulgated under this section shall expire two (2) years from the last effective date, as defined in KRS 13A.010, unless the department follows the certification or amendment process established in KRS 13A.3104. (b) If the department files a certification letter pursuant to KRS 13A.3104, and does not intend to amend an administrative regulation promulgated under this section, it shall allow for a public comment period and public hearing on the certification letter meeting the requirements of KRS 13A.270. (5) In promulgating any administrative regulation under this section, the commissioner shall: (a) Collaborate with the Department for Medicaid Services to ensure that the regulation is consistent with: 1. Federal requirements relating to Medicaid managed care medical necessity review criteria; and 2. Any administrative regulation promulgated by the Department for Medicaid Services that is not inconsistent with this section, relating to the processes Medicaid managed care organizations are required to follow when using the medical necessity criteria designated pursuant to this section; (b) Set forth in any federal mandate analysis comparison for an administrative regulation promulgated under this section: 1. A description of any federal requirements relating to Medicaid managed care medical necessity review criteria; and 2. A summary of all input provided by the Department for Medicaid Services to the commissioner relating to the form and content of the regulation; and (c) Receive from the Department for Medicaid Services the input of healthcare professionals, which shall include members of the Advisory Council for Medical Assistance established pursuant to KRS 205.540, in each category of care in accordance with subsection (3) of this section. Effective: July 14, 2018 History: Created 2018 Ky. Acts ch. 106, sec. 10, effective July 14, 2018.

KRS 304.38-500 Repealed, 2002

304.38-500. Repealed, 2002 Catchline at repeal: Certificate of filing required for health discount plan -- Application and evidence of coverage requirements. History: Repealed 2002 Ky. Acts ch. 105, sec. 34, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 427, sec. 8, effective July 14, 2000.

KRS 304.38-505 Repealed, 2002

304.38-505. Repealed, 2002 Catchline at repeal: Plan disclosure requirements. History: Repealed 2002 Ky. Acts ch. 105, sec. 34, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 427, sec. 9, effective July 14, 2000.

KRS 304.38-510 Repealed, 2002

304.38-510. Repealed, 2002 Catchline at repeal: Suspension or revocation of certificate of filing -- Conditions -- Effect. History: Repealed 2002 Ky. Acts ch. 105, sec. 34, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 427, sec. 10, effective July 14, 2000.

KRS 304.38-1933 Coverage for services of licensed psychologist or licensed clinical social worker

304.38-1933. Coverage for services of licensed psychologist or licensed clinical social worker Every policy, contract, agreement, or certificate entered into, issued or delivered by a health maintenance organization which provides coverage for services performed by a licensed psychologist pursuant to KRS Chapter 319, or a licensed clinical social worker pursuant to KRS Chapter 335, shall be deemed to provide benefits for those services regardless of provider profession. If the policy, contract, or agreement permits, payment may be made directly to the provider of the services. If the policy, contract, or agreement does not permit, the person entitled to these benefits shall be entitled to reimbursement for the cost of services received. Nothing in this section shall require a policy issued by a health maintenance organization which places the insured within a preferred or exclusive provider arrangement to cover services by a provider with whom the insurer does not have a contract, or to make payment of or reimbursement for the cost of any service which exceeds the limits of the policy. Effective: July 15, 1994 History: Created 1994 Ky. Acts ch. 218, sec. 4, effective July 15, 1994.

KRS 304.38-1934 Coverage for medical and surgical benefits with respect to mastectomy, diagnosis and treatment of endometrioses and endometritis, and bone density testing -- Duties of health maintenance organization

304.38-1934. Coverage for medical and surgical benefits with respect to mastectomy, diagnosis and treatment of endometrioses and endometritis, and bone density testing -- Duties of health maintenance organization (1) Health maintenance organizations issuing contracts in this Commonwealth that provide hospital, medical, or surgical expense benefits shall make available and offer to the purchaser coverage for: (a) The following, if a health maintenance organization provides medical and surgical benefits with respect to a mastectomy, in a manner determined in consultation with the attending physician and the covered person, and subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the coverage: 1. All stages of breast reconstruction surgery of the breast on which the mastectomy has been performed; 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and physical complications of all stages of mastectomy, including lymphedemas; (b) Diagnosis and treatment of endometriosis if the health maintenance organization also covers hysterectomies; and (c) Bone density testing for women age thirty-five (35) years and older, as indicated by the health-care provider, in accordance with standard medical practice, to obtain baseline data for the purpose of early detection of osteoporosis. (2) No health maintenance organization under this section shall offer medical and surgical benefits with respect to mastectomy that requires the procedure be performed on an outpatient basis. (3) A health maintenance organization shall provide written notice to a covered person of the availability of medical and surgical benefits with respect to a mastectomy upon enrollment and annually thereafter. (4) A health maintenance organization shall not: (a) Deny eligibility, or continued eligibility, to an individual to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of 42 U.S.C. secs. 300gg-6 and 300gg-52; and (b) Penalize or otherwise reduce or limit the reimbursement of an attending provider or provide incentives to an attending provider, to induce the provider to provide care to an individual in a manner inconsistent with 42 U.S.C. secs. 300gg-6 and 300gg-52. Effective: July 15, 2002 History: Amended 2002 Ky. Acts ch. 181, sec. 21, effective July 15, 2002. -- Created 1998 Ky. Acts ch. 427, sec. 5, effective July 15, 1998.

KRS 304.38-1935 Coverage for mammograms -- Prohibition on cost-sharing requirements for covered diagnostic breast examinations or supplemental breast examinations

304.38-1935. Coverage for mammograms -- Prohibition on cost-sharing requirements for covered diagnostic breast examinations or supplemental breast examinations Health maintenance organization contracts in this Commonwealth shall comply with KRS 304.17-316. Effective: January 1, 2025 History: Amended 2024 Ky. Acts ch. 97, sec. 6, effective January 1, 2025. -- Amended 2000 Ky. Acts ch. 18, sec. 5, effective July 14, 2000. -- Created 1990 Ky. Acts ch. 46, sec. 4, effective July 13, 1990. Legislative Research Commission Note (1/1/2025). 2024 Ky. Acts ch. 97, sec. 9, provides that the amendments to this statute in that Act shall apply to policies, plans, certificates, and contracts issued or renewed on or after January 1, 2025.

KRS 304.38-1936 Coverage for treatment of breast cancer

304.38-1936. Coverage for treatment of breast cancer (1) Health maintenance organizations issuing contracts in this Commonwealth which provide hospital, medical, or surgical expense benefits for treatment of breast cancer by chemotherapy shall also provide coverage for treatment of breast cancer by high- dose chemotherapy with autologous bone marrow transplantation or stem cell transplantation. (2) The administration of high-dose chemotherapy with autologous bone marrow transplantation or stem cell transplantation shall only be covered when performed in institutions that comply with the guidelines of the American Society for Blood and Marrow Transplantation or the International Society of Hematotherapy and Graft Engineering, whichever has the higher standard. (3) Treatment of breast cancer by high-dose chemotherapy with autologous bone marrow transplantation or stem cell transplantation shall not be considered experimental or investigational. Coverage for transplantation under this section shall not be subject to any greater coinsurance or copayment than that applicable to any other coverage provided by the health plan. Effective: March 28, 1996 History: Created 1996 Ky. Acts ch. 114, sec. 4, effective March 28, 1996.

KRS 304.38-1937 Coverage for treatment of temporomandibular joint disorders and craniomandibular jaw disorders

304.38-1937. Coverage for treatment of temporomandibular joint disorders and craniomandibular jaw disorders (1) All contracts, agreements, certificates, or other comparable documents of health care services provided which provide coverage for surgical or nonsurgical treatment of skeletal disorders shall provide coverage for medically necessary procedures relating to temporomandibular joint disorders and craniomandibular jaw disorders. (2) The requirements of this section shall apply to all policies issued, delivered, or renewed in this state on or after January 1, 1991. (3) Nothing in this section shall require a health insurance policy to provide dental services if dental services are not otherwise scheduled or provided as a part of policy benefits. Effective: July 13, 1990 History: Created 1990 Ky. Acts ch. 438, sec. 4, effective July 13, 1990.

KRS 304.38-1955 Construction of provisions for services by licensed optometrist or licensed ophthalmic dispenser to include same services from licensed physician

304.38-1955. Construction of provisions for services by licensed optometrist or licensed ophthalmic dispenser to include same services from licensed physician Any certificate, agreement, or contract issued in this state by a health maintenance organization which provides coverage for services which can be lawfully performed within the statutory scope of practice of a duly-licensed optometrist or duly-licensed ophthalmic dispenser shall be deemed to provide benefits for such services whether performed by a duly-licensed physician or a duly-licensed optometrist or duly-licensed ophthalmic dispenser, notwithstanding any provision contained in the certificate, agreement, or contract. Effective: July 15, 1996 History: Created 1996 Ky. Acts ch. 187, sec. 3, effective July 15, 1996.

Source: Kentucky Legislative Research Commission (legislature.ky.gov)URL: https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38754Fetched: 10/20/2026