Kentucky Access

KRS tit. XXV, ch. 304, subtit. 17B

in effect

KRS 304.17B-001 Definitions for subtitle

304.17B-001. Definitions for subtitle As used in this subtitle, unless the context requires otherwise: (1) "Administrator" is defined in KRS 304.9-051(1); (2) "Agent" is defined in KRS 304.9-020; (3) "Assessment process" means the process of assessing and allocating guaranteed acceptance program losses or Kentucky Access funding as provided for in KRS 304.17B-021; (4) "Authority" means the Kentucky Health Care Improvement Authority; (5) "Case management" means a process for identifying an enrollee with specific health care needs and interacting with the enrollee and their respective health care providers in order to facilitate the development and implementation of a plan that efficiently uses health care resources to achieve optimum health outcome; (6) "Commissioner" is defined in KRS 304.1-050(1); (7) "Department" is defined in KRS 304.1-050(2); (8) "Earned premium" means the portion of premium paid by an insured that has been allocated to the insurer's loss experience, expenses, and profit year to date; (9) "Enrollee" means a person who is enrolled in a health benefit plan offered under Kentucky Access; (10) "Eligible individual" is defined in KRS 304.17A-005(11); (11) "Guaranteed acceptance program" or "GAP" means the Kentucky Guaranteed Acceptance Program established and operated under KRS 304.17A-400 to 304.17A-480; (12) "Guaranteed acceptance program participating insurer" means an insurer that offered health benefit plans through December 31, 2000, in the individual market to guaranteed acceptance program qualified individuals; (13) "Health benefit plan" is defined in KRS 304.17A-005(22); (14) "High-cost condition" means acquired immune deficiency syndrome (AIDS), angina pectoris, ascites, chemical dependency, cirrhosis of the liver, coronary insufficiency, coronary occlusion, cystic fibrosis, Friedreich's ataxia, hemophilia, Hodgkin's disease, Huntington's chorea, juvenile diabetes, leukemia, metastatic cancer, motor or sensory aphasia, multiple sclerosis, muscular dystrophy, myasthenia gravis, myotonia, open-heart surgery, Parkinson's disease, polycystic kidney, psychotic disorders, quadriplegia, stroke, syringomyelia, Wilson's disease, chronic renal failure, malignant neoplasm of the trachea, malignant neoplasm of the bronchus, malignant neoplasm of the lung, malignant neoplasm of the colon, short gestation period for a newborn child, and low birth weight of a newborn child; (15) "Incurred losses" means for Kentucky Access the excess of claims paid over premiums received; (16) "Insurer" is defined in KRS 304.17A-005(29); (17) "Kentucky Access" means the program established in accordance with KRS 304.17B-001 to 304.17B-031; (18) "Kentucky Access Fund" means the fund established in KRS 304.17B-021; (19) "Kentucky Health Care Improvement Authority" means the board established to administer the program initiatives listed in KRS 304.17B-003(5); (20) "Kentucky Health Care Improvement Fund" means the fund established for receipt of the Kentucky tobacco master settlement moneys for program initiatives listed in KRS 304.17B-003(5); (21) "MARS" means the Management Administrative Reporting System administered by the Commonwealth; (22) "Medicaid" means coverage in accordance with Title XIX of the Social Security Act, 42 U.S.C. secs. 1396 et seq., as amended; (23) "Medicare" means coverage under both Parts A and B of Title XVIII of the Social Security Act, 42 U.S.C. secs. 1395 et seq., as amended; (24) "Office" means the Office of Health Data and Analytics in the Cabinet for Health and Family Services; (25) "Pre-existing condition exclusion" is defined in KRS 304.17A-220(6); (26) "Standard health benefit plan" means a health benefit plan that meets the requirements of KRS 304.17A-250; (27) "Stop-loss carrier" means any person providing stop-loss health insurance coverage; (28) "Supporting insurer" means all insurers, stop-loss carriers, and self-insured employer-controlled or bona fide associations; and (29) "Utilization management" is defined in KRS 304.17A-500(12). Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 11, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1273, effective July 15, 2010. -- Amended 2006 Ky. Acts ch. 253, sec. 6, effective July 12, 2006. -- Amended 2005 Ky. Acts ch. 144, sec. 10, effective June 20, 2005. -- Amended 2003 Ky. Acts ch. 150, sec. 4, effective June 24, 2003. -- Created 2000 Ky. Acts ch. 476, sec. 1, effective July 14, 2000. Legislative Research Commission Note (1/1/2020). Under the authority of KRS 7.136(1), a reference to "KRS 304.17A-005(27)" in subsection (16) of this statute has been changed to "KRS 304.17A-005(29)" by the Reviser of Statutes following the enactment of 2019 Ky. Acts ch. 190, sec. 5, which inserted new subsections into KRS 304.17A-005 and renumbered the subsequent subsections, but did not amend this statute to conform.

KRS 304.17B-003 Establishment of Kentucky Health Care Improvement Authority -- Members and meetings -- Programs and expenditure of funds -- Public hearings -- Annual report to the Governor and the General Assembly -- Liabilities

304.17B-003. Establishment of Kentucky Health Care Improvement Authority -- Members and meetings -- Programs and expenditure of funds -- Public hearings -- Annual report to the Governor and the General Assembly -- Liabilities (1) There is hereby established the Kentucky Health Care Improvement Authority as an agency, instrumentality, and political subdivision of the Commonwealth and a public body corporate and politic with all the powers, duties, and responsibilities conferred upon it by statute and nec essary or convenient to carry out its functions. The authority shall be administered by a board of fifteen (15) members and is created to perform the public functions of administering programs financed by the funds appropriated to the authority in conforma nce with KRS 304.17B-001 to 304.17B-031 and any terms and conditions established by the General Assembly as a part of the act appropriating the funds. The members of the board shall consist of the following: (a) The secretary of the Cabinet for Health and Family Services, or the secretary's designated representative, who shall serve as chair; (b) The commissioner of the Department of Insurance, or the commissioner's designated representative, who shall serve as vice chair; (c) Two (2) nonvoting members serving ex officio from the House of Representatives, one (1) of whom shall be appointed by the Speaker of the House and one (1) appointed by the minority floor leader, and who shall serve a term of two (2) years; (d) Two (2) nonvoting members serving ex offic io from the Senate, one (1) of whom shall be appointed by the President of the Senate and one (1) appointed by the minority floor leader, and who shall serve a term of two (2) years; (e) The deans of the University of Louisville School of Medicine and the University of Kentucky College of Medicine, or their designated representatives; (f) The commissioner of the Department for Public Health, or the commissioner's designated representative; (g) Two (2) representatives of Kentucky health care providers, who s hall be appointed by the Governor; and (h) Four (4) citizens at large of the Commonwealth, who shall be appointed by the Governor. (2) The terms of office of the initial appointments of the citizen at -large members of the board shall expire one (1), two (2), three (3), and four (4) years respectively from the expiration date of the initial appointment. One (1) of the initial terms of the representatives of health care providers, at least one (1) of whom shall be male and at least one (1) of whom shall be female, shall be for two (2) years and one (1) shall be for four (4) years. All succeeding appointments shall be for four (4) years from the expiration date of the term of the initial appointment. Two (2) of the citizens at large shall be male and two (2) sh all be female. Board members shall serve until their successors are appointed. (3) In making private sector and citizen -at-large appointments to the board, the Governor shall assure broad geographical and ethnic representation as well as representation from consumers and the major sectors of Kentucky's health care and health insurance businesses. Private sector and citizen-at-large members shall serve without compensation but shall be reimbursed for reasonable and necessary expenses. (4) The authority shall establish procedures for accountability, including the review of expenditures, and develop mechanisms to measure the success of programs that receive allocated funds in accordance with any criteria or instructions provided by the General Assembly. The authority shall be attached to the Cabinet for Health and Family Services for administ rative purposes and shall establish advisory boards it deems appropriate, which shall consist of health insurance consumers, health care providers, and insurance company representatives, to assist with oversight of fund expenditures. (5) Grants and funds obtained under KRS 304.17B -001 to 304.17B-031 shall be used for expenditures as follows: (a) Seventy percent (70%) of all moneys in the fund shall be placed into the Kentucky Access fund for the purpose of funding Kentucky Access; (b) Twenty percent (20%) of all moneys in the fund shall be spent on a collaborative partnership between the University of Louisville and the University of Kentucky dedicated to lung cancer research; and (c) Ten percent (10%) of all moneys in the fund shall be used to discourage th e use of harmful substances by minors. (6) The authority shall ensure that a public hearing is held on the expenditure of funds allocated under this section, except for funds allocated to the Kentucky Access fund. Advertisement of the public hearing shall be published at least once but may be published two (2) more times, if one (1) publication occurs not less than seven (7) days nor more than twenty-one (21) days before the scheduled date of the public hearing. The authority shall submit an annual report to the Governor and the General Assembly indicating how the funds were used and an evaluation of the program's effectiveness in health care and access to health insurance for Kentucky residents. (7) Neither the authority nor its employees shall be liable for any obligations of any of the programs established under KRS 304.17B-001 to 304.17B-031. No member or employee of the authority shall be liable, and no cause of action of any nature may arise against them, for any act or omission related to the performance of their powers and duties under KRS 304.17B-001 to 304.17B-031, unless the act or omission constitutes willful or wanton misconduct. The authority may provide in its policies and procedures for indemnification of, and legal representation for, its members and employees. (8) The authority shall have all the powers necessary or convenient to carry out and effectuate the purposes and provisions of KRS 304.17B-001 to 304.17B-031, including, but not limited to, retaining the staff it deems necessary for the proper performance of its duties. (9) The authority shall meet at least quarterly and at other times upon call of the chair or a majority of the authority. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 12, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1274, effective July 15, 2010. -- Amended 2005 Ky. Acts ch. 37, sec. 1; and ch. 99, sec. 579, effective June 20, 2005. -- Created 2000 Ky. Acts ch. 476, sec. 2, effective July 14, 2000. 2026-2028 Budget Reference. See State/Executive Branch Budget, 2026 Ky. Acts ch. 168, Pt. X, (5) at 2169. 2026-2028 Budget Reference. See State/Executive Branch Budget, 2026 Ky. Acts ch. 168, Pt. X, E at 2172.

KRS 304.17B-005 Creation of Kentucky Access -- Appointment of division director -- Purpose -- Liabilities

304.17B-005. Creation of Kentucky Access -- Appointment of division director -- Purpose -- Liabilities (1) There is hereby created Kentucky Access, which shall ensure that health coverage is made available to each Kentucky individual resident applying and qualifying for coverage. Any health coverage provided under this section shall begin no sooner than January 1, 2001. Kentucky Access is designed for the purpose of implementing an acceptable alternative mechanism within the meaning of 42 U.S.C. sec. 300gg- 44(a)(1) so that Kentucky may preserve the flexibility over the regulation of health coverage allowed by federal law. (2) Kentucky Access shall operate under the Division of Health Benefit Exchange in the Office of Health Data and Analytics, Cabinet for Health and Family Services. The division shall be headed by a division director appointed by the secretary of the Cabinet for Health and Family Services in accordance with KRS 12.050. (3) Neither the office nor its employees shall be liable for any obligations of Kentucky Access. No member or employee of the office shall be liable, and no cause of action of any nature may arise against them, for any act or omission related to the performance of their powers and duties under KRS 304.17B-001 to 304.17B-031, unless such act or omission constitutes willful or wanton misconduct. The office may provide in its policies and procedures for indemnification of, and legal representation for, its members and employees. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 13, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1275, effective July 15, 2010. -- Amended 2001 Ky. Acts ch. 33, sec. 1, effective June 21, 2001. -- Created 2000 Ky. Acts ch. 476, sec. 3, effective July 14, 2000.

KRS 304.17B-007 Duties of the Office of Health Data and Analytics in operation and administration of Kentucky Access

304.17B-007. Duties of the Office of Health Data and Analytics in operation and administration of Kentucky Access In its duties to operate and administer Kentucky Access, the Office of Health Data and Analytics shall, through itself or designated agents: (1) Establish administrative and accounting procedures for the operation of Kentucky Access; (2) Enter into contracts as necessary; (3) Take legal action necessary: (a) To avoid the payment of improper claims against Kentucky Access or the coverage provided by or through Kentucky Access; (b) To recover any amounts erroneously or improperly paid by Kentucky Access; (c) To recover any amounts paid by the Kentucky Access as a result of mistake of fact or law; (d) To recover other amounts due Kentucky Access; or (e) To operate and administer its obligations under the provisions of KRS 304.17B-001 to 304.17B-031; (4) Establish, and modify as appropriate, rates, rate schedules, rate adjustments, premium rates, expense allowances, claim reserve formulas, and any other actuarial function appropriate to the administration and operation of Kentucky Access. Premium rates and rate schedules may be adjusted for appropriate factors, including, but not limited to, age and sex, and shall take into consideration appropriate factors in accordance with established actuarial and underwriting practices; (5) Establish procedures under which applicants and participants in Kentucky Access shall have an internal grievance process and a mechanism for external review through an independent review organization in accordance with this chapter; (6) Select a third-party administrator in accordance with KRS 304.17B-011; (7) Require that all health benefit plans, riders, endorsements, or other forms and documents used to administer Kentucky Access meet the requirements of Subtitles 12, 14, 17, 17A, and 38 of this chapter; (8) Adopt nationally recognized uniform claim forms in accordance with this chapter; (9) Develop and implement a marketing strategy to publicize the existence of Kentucky Access, including, but not limited to, eligibility requirements, procedures for enrollment, premium rates, and a toll–free telephone number to call for questions; (10) Establish and review annually provider reimbursement rates that ensure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under Kentucky Access at least to the extent that such care and services are available to the general population. The office shall only authorize contracts with health care providers that prohibit the provider from collecting from the enrollee any amounts in excess of copayment amounts, coinsurance amounts, deductible amounts, and amounts for noncovered services; (11) Conduct periodic audits to assure the general accuracy of the financial and claims data submitted to the office and be subject to an annual audit of its operations; (12) Issue health benefit plans in accordance with the requirements of KRS 304.17B-001 to 304.17B-031; (13) Require a referral fee of fifty dollars ($50) to be paid to agents who refer applicants who are subsequently enrolled in Kentucky Access. The referral fee shall be paid only on the initial enrollment of an applicant. Referral fees shall not be paid on any enrollments of enrollees who have been previously enrolled in Kentucky Access, or for renewals for enrollees; (14) Bill and collect premiums from enrollees in the amount determined by the office; (15) Assess insurers and stop-loss carriers in accordance with KRS 304.17B-021; (16) Reimburse GAP participating insurers for GAP losses pursuant to KRS 304.17B- 021; (17) Establish a provider network for Kentucky Access by developing a statewide provider network or by contracting with an insurer for a statewide provider network. In the event the office contracts with an insurer, the office may take into consideration factors including, but not limited to, the size of the provider network, the composition of the provider network, and the current market rate of the provider network. The provider network shall be made available to the third-party administrator specified in KRS 304.17B-011 and shall be limited to Kentucky Access enrollees. (18) Be audited by the Auditor of Public Accounts; (19) By administrative regulation, amend the definition of high-cost conditions provided in KRS 304.17B-001 by adding other high-cost conditions; and (20) Any other actions as may be necessary and proper for the execution of the office's powers, duties, and obligations under KRS 304.17B-001 to 304.17B-031. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 14, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1276, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 4, effective July 14, 2000.

KRS 304.17B-009 Powers of the Office of Health Data and Analytics in operation and administration of Kentucky Access

304.17B-009. Powers of the Office of Health Data and Analytics in operation and administration of Kentucky Access In its duties to operate and administer Kentucky Access, the Office of Health Data and Analytics may, through itself or third parties: (1) Exercise any and all powers granted to insurers under this chapter; and (2) Sue or be sued. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 15, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1277, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 5, effective July 14, 2000.

KRS 304.17B-011 Third-party administrator to administer Kentucky Access -- Selection and duties -- Reimbursement for expenses

304.17B-011. Third-party administrator to administer Kentucky Access -- Selection and duties -- Reimbursement for expenses (1) The Office of Health Data and Analytics shall select a third-party administrator, through the state competitive bidding process, to administer Kentucky Access. The third-party administrator shall be an administrator licensed by the department. The office shall consider criteria in selecting a third-party administrator that shall include, but not be limited to, the following: (a) A third-party administrator's proven ability to demonstrate performance of the operations of an insurer to include the following: enrollee enrollment, eligibility determination, provider enrollment and credentialing, utilization management, quality improvement, drug utilization review, premium billing and collection, claims payment, and data reporting; (b) The total cost to administer Kentucky Access; (c) A third-party administrator's proven ability to demonstrate that Kentucky Access shall be administered in a cost-efficient manner; (d) A third-party administrator's proven ability to demonstrate experience in two (2) or more states administering a risk pool for a minimum of a three (3) year period; and (e) A third-party administrator's financial condition and stability. (2) The office may contract with the third-party administrator for a period of four (4) years with an option for a two (2) year extension as approved by the office on a year-by-year contract basis. At least one (1) year prior to the expiration of the third- party administrator's contract, the office may solicit third-party administrators, including the current third-party administrator, to submit bids to serve as the third- party administrator for the succeeding four (4) year period. (3) In addition to any duties and obligations set forth in the contract with the third-party administrator, the third-party administrator shall: (a) Develop and establish policies and procedures for enrollee enrollment, eligibility determination, provider enrollment and credentialing, utilization management, case management, disease management, quality improvement, drug utilization review, premium billing and collection, data reporting, and other responsibilities determined by the office; (b) Develop and establish policies and procedures for paying the agent referral fee under KRS 304.17B-001 to 304.17B-031; (c) Develop and establish policies and procedures to ensure timely and efficient payment of claims to include, but not limited to, the following: 1. Develop and provide a claims billing manual to health care providers enrolled in Kentucky Access that includes information relating to the proper billing of a claim and the types of claim forms to use; 2. Payment of all claims in accordance with the provisions of this chapter, KRS 304.12-237, and the administrative regulations promulgated thereunder; and 3. Notification to an enrollee through an explanation of benefits if a claim is denied or if there is enrollee financial responsibility of a paid claim for deductible or coinsurance amounts; (d) Issue denial letters under KRS 304.17A-540 for denial of preauthorization and precertification requests for medical necessity and medical appropriateness determinations; (e) Submit information to the office and the department under KRS 304.17A-330; (f) Submit reports to the office regarding the operation and financial condition of Kentucky Access. The frequency, content, and form of the reports shall be determined by the office; (g) Submit an annual report to the office three (3) months after the end of each calendar year. The annual report shall include: 1. Earned premium; 2. Administrative expenses; 3. Incurred losses for the year; 4. Paid losses for the year; 5. Number of enrollees enrolled in Kentucky Access by category of eligibility; and 6. Any other information requested by the office; and (h) Be subject to examination by the office under Subtitles 2 and 3 of this chapter. (4) The third-party administrator shall be paid for necessary and reasonable expenses, as provided in the contract between the office and the third-party administrator. Effective: June 29, 2021 History: Amended 2021 Ky. Acts ch. 30, sec. 4, effective June 29, 2021. -- Amended 2019 Ky. Acts ch. 90, sec. 16, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1278, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 6, effective July 14, 2000.

KRS 304.17B-013 Premium rates for health benefit plans under Kentucky Access

304.17B-013. Premium rates for health benefit plans under Kentucky Access (1) The schedule of rates, premium rates charged to enrollees, deductible amounts, copayment amounts, coinsurance amounts, and other cost-sharing amounts shall be established by the Office of Health Data and Analytics. Premium rates charged to enrollees are not intended to fully cover the cost of providing health care coverage to Kentucky Access enrollees, and any claims in excess of premium rates shall be covered by the Kentucky Access fund. (2) Premium rates for health benefit plans provided under Kentucky Access shall bear a reasonable relationship to each other. Premium rates shall be varied based on age and gender. The initial premium rates for plan coverage shall not exceed one hundred fifty percent (150%) of the applicable individual standard risk rates, as established by the department. In no event shall premium rates exceed one hundred seventy-five percent (175%) of the rates applicable to individual standard risks. (3) Premium rates for coverage issued by Kentucky Access shall be established annually by the office, using reasonable actuarial principles, and shall reflect anticipated experience and expenses for risks under Kentucky Access. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 17, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1279, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 7, effective July 14, 2000.

KRS 304.17B-015 Eligibility for coverage under Kentucky Access

304.17B-015. Eligibility for coverage under Kentucky Access (1) Any individual who is an eligible individual and a resident of Kentucky is eligible for coverage under Kentucky Access, except as specified in paragraphs (a), (b), (d), and (e) of subsection (4) of this section. (2) Any individual who is not an eligible individual who has been a resident of the Commonwealth for at least twelve (12) months immediately preceding the application for Kentucky Access coverage is eligible for coverage under Kentucky Access if one (1) of the following conditions is met: (a) The individual has been rejected by at least one (1) insurer for coverage of a health benefit plan that is substantially similar to Kentucky Access coverage; (b) The individual has been offered coverage substantially similar to Kentucky Access coverage at a premium rate greater than the Kentucky Access premium rate at the time of enrollment or upon renewal; or (c) The individual has a high-cost condition listed in KRS 304.17B-001. (3) A Kentucky Access enrollee whose premium rates exceed claims for a three (3) year period shall be issued a notice of insurability. The notice shall indicate that the Kentucky Access enrollee has not had claims exceed premium rates for a three (3) year period and may be used by the enrollee to obtain insurance in the regular individual market. (4) An individual shall not be eligible for coverage under Kentucky Access if: (a) 1. The individual has, or is eligible for, on the effective date of coverage under Kentucky Access, substantially similar coverage under another contract or policy, unless the individual was issued coverage from a GAP participating insurer as a GAP qualified individual prior to January 1, 2001. A GAP qualified individual shall be automatically eligible for coverage under Kentucky Access without regard to the requirements of subsection (2) of this section; or 2. For individuals meeting the requirements of KRS 304.17A-005(11), the individual has, or is eligible for, on the effective date of coverage under Kentucky Access, coverage under a group health plan. An individual who is ineligible for coverage pursuant to this paragraph shall not preclude the individual's spouse or dependents from being eligible for Kentucky Access coverage. As used in this paragraph, "eligible for" includes any individual and an individual's spouse or dependent who was eligible for coverage but waived that coverage. That individual and the individual's spouse or dependent shall be ineligible for Kentucky Access coverage through the period of waived coverage; (b) The individual is eligible for coverage under Medicaid or Medicare; (c) The individual previously terminated Kentucky Access coverage and twelve (12) months have not elapsed since the coverage was terminated, unless the individual demonstrates a good faith reason for the termination; (d) Except for covered benefits paid under the standard health benefit plan as specified in KRS 304.17B-019, Kentucky Access has paid two million dollars ($2,000,000) in covered benefits per individual. The maximum limit under this paragraph may be increased by the office; (e) The individual is confined to a public institution or incarcerated in a federal, state, or local penal institution or in the custody of federal, state, or local law enforcement authorities, including work release programs; or (f) The individual's premium, deductible, coinsurance, or copayment is partially or entirely paid or reimbursed by an individual or entity other than the individual or the individual's parent, grandparent, spouse, child, stepchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, sibling, brother-in- law, sister-in-law, grandchild, guardian, or court-appointed payor. (5) The coverage of any person who ceases to meet the requirements of this section or the requirements of any administrative regulation promulgated under this subtitle may be terminated. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 18, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1280, effective July 15, 2010; and ch. 126, sec. 1, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 351, sec. 8, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 476, sec. 8, effective July 14, 2000.

KRS 304.17B-017 Responsibility of the Office of Health Data and Analytics for evaluation and revision of rates and plans offered to Kentucky Access enrollees

304.17B-017. Responsibility of the Office of Health Data and Analytics for evaluation and revision of rates and plans offered to Kentucky Access enrollees (1) At least annually, the Office of Health Data and Analytics shall evaluate and revise as necessary rates to be charged to Kentucky Access enrollees. (2) Except as provided in KRS 304.17B-019, the office may revise its health benefit plans, cost-sharing arrangements, plan delivery rules, schedule of benefits, rates, and cost-containment features provided under Kentucky Access at the time of the health benefit plan renewal as necessary to ensure that Kentucky Access maintains adequate resources for continued operation. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 19, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1281, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 9, effective July 14, 2000.

KRS 304.17B-019 Types of health benefit plans to be issued under Kentucky Access

304.17B-019. Types of health benefit plans to be issued under Kentucky Access (1) Kentucky Access shall offer at least three (3) health benefit plans to enrollees, which shall be similar to the health benefit plans currently being marketed to individuals in the individual market. (2) At least one (1) plan shall be offered in a traditional fee-for-service form. At least one (1) plan may be offered in a managed-care form at such time as the Office of Health Data and Analytics can establish an appropriate provider network in available service areas. (3) The office shall provide for utilization review and case management for all health benefit plans issued under Kentucky Access. (4) The office shall review and compare health benefit plans provided under Kentucky Access to health benefit plans provided in the individual market. Based on the review, the office may amend or replace the health benefit plans issued under Kentucky Access. (5) Individuals who apply and are determined eligible for health benefit plans issued under Kentucky Access shall have coverage effective the first day of the month after the application month. (6) For eligible individuals, health benefit plans issued under Kentucky Access shall not impose any pre-existing condition exclusions. In all other cases, a pre-existing condition exclusion may be imposed in accordance with KRS 304.17A-230. (7) Health benefit plans issued under Kentucky Access shall be guaranteed renewable except as otherwise specified in KRS 304.17B-015 and KRS 304.17A-240. (8) All health benefit plans issued under Kentucky Access shall provide that, upon the death or divorce of the individual in whose name the contract was issued, every other person covered in the contract may elect within sixty-three (63) days to continue under the same or a different contract. (9) Health benefit plans issued under Kentucky Access shall coordinate benefits with other health benefit plans and be the payor of last resort. (10) Health benefit plans issued under Kentucky Access shall pay covered benefits up to a lifetime limit of two million dollars ($2,000,000) per covered individual. The maximum limit under this subsection may be increased by the office. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 20, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1282, effective July 15, 2010; and ch. 126, sec. 2, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 10, effective July 14, 2000.

KRS 304.17B-021 Assessment of insurers -- Kentucky Access fund -- Reimbursement of GAP losses -- Examination of insurers and stop -loss carriers to determine accuracy of information provided

304.17B-021. Assessment of insurers -- Kentucky Access fund -- Reimbursement of GAP losses -- Examination of insurers and stop -loss carriers to determine accuracy of information provided (1) In addition to the other powers enumerated in KRS 304.17B -001 to 304.17B-031, the Office of Health Data and Analytics shall assess insurers in the amounts specified in this section. The assessment shall be used for the purpose of funding GAP losses and Kentucky Access. (a) The amount of the assessment for each calen dar year shall be as follows: 1. From each stop-loss carrier, an amount that is equal to two dollars ($2) upon each one hundred dollars ($100) of health insurance stop -loss premiums; 2. From all insurers, an amount based on the total amount of all health benefit plan premiums earned during the prior assessment period and paid by all insurers who received any of the health benefit plan premiums on which the annual assessment is based. The percentage rate used for the annual assessment shall be the same perce ntage rate as calculated in the GAP risk adjustment process for the six (6) month period of July 1, 1998, through December 31, 1998; 3. If determined necessary by the office, a second assessment may be assessed in the same manner as the annual assessment i n subparagraph 2. of this paragraph; and 4. In no event shall the sum of the first assessment provided for in subparagraph 2. of this paragraph and the second assessment provided for in subparagraph 3. of this paragraph be greater than one percent (1%) of the total amount of all assessable health benefit plan premiums earned during the prior assessment period. (b) The first assessment shall be for the period from January 1, 2000, through December 31, 2000, and shall be paid on or before March 31, 2001. Subsequent annual assessments shall be paid on or before March 31 of the year following the assessment period. (2) Every supporting insurer shall report to the office, in a form and at the time as the office may specify, the following information for the speci fied period: (a) The insurer's total stop-loss premiums and health benefit plan premiums in the individual, small group, large group, and association markets; and (b) Other information as the office may require. (3) As part of the assessment process, the office shall establish and maintain the Kentucky Access fund. All funds shall be held at interest, in a single depository designated in accordance with KRS 304.8-090(1) under a written trust agreement in accordance with KRS 304.8-095. All expense and revenue transactions of the fund shall be posted to the Management Administrative Reporting System (MARS) and its successors. (4) The Kentucky Access fund shall be funded from the following sources: (a) Premiums paid by Kentucky Access enrollees; (b) The funds designated for Kentucky Access in the Kentucky Health Care Improvement fund; (c) Appropriations from the General Assembly; (d) Annual assessments from supporting insurers; (e) A second assessment from supporting insurers; (f) Gifts, grants, or other voluntary contributions; (g) Interest or other earnings on the investment of the moneys held in the account; and (h) Any funds remaining on January 1, 2001, in the guaranteed acceptance program account may be transferred to the Kentucky Access fund. (5) The office shall determine on behalf of Kentucky Access the premiums, the expenses for administration, the incurred losses, taking into account investment income and other amounts needed to satisfy reserves, estimated claim l iabilities, and other obligations for each calendar year. The office shall also determine the amount of the actual guaranteed acceptance program plan losses for each calendar year. The office shall assess insurers as follows: (a) On or before March 31 of each year, the amount set forth in subsection (1)(a)1. and (1)(a)2. of this section. (b) If the amount of actual guaranteed acceptance program plan losses exceeds the assessment provided for in paragraph (a) of this subsection, a second assessment shall be authorized under subsection (1)(a)3. of this section. If the amount of GAP losses exceeds the assessments provided under subsection (1)(a)1., subsection (1)(a)2., and subsection (1)(a)3. of this section, moneys received and available from the Kentucky Health Care Improvement Fund after the office determines available funding for Kentucky Access for the current calendar year pursuant to subsection (6) of this section, shall be used to reimburse GAP participating insurers for any actual guaranteed acceptance program losses. If the amount of GAP losses exceeds the amount in the Kentucky Health Care Improvement Fund after reserving sufficient funds for Kentucky Access for the current year, each GAP participating insurer shall be reimbursed up to the amount of its proportional share of actual guaranteed acceptance program plan losses from the fund. Effective for any assessment on or after January 1, 2001, in calculating GAP losses, total premiums and total claims of the GAP participating insurer shall be used. Act ual guaranteed acceptance program losses shall be calculated as the difference between the total GAP claims and the total GAP premiums on an aggregate basis. (c) If GAP losses are fully covered by the assessment process provided for in subsection (1)(a)1. and (1)(a)2. of this section and the second assessment provided for in subsection (1)(a)3. of this section is not necessary to cover GAP losses, and as determined by the office using reasonable actuarial principles Kentucky Access funding is needed, a seco nd assessment provided for in subsection (1)(a)3. of this section shall be completed. (6) After the end of each calendar year, GAP losses shall be reimbursed only after the office determines that appropriate funding is available for Kentucky Access for the current calendar year. GAP losses shall be reimbursed after reserving sufficient funds for Kentucky Access. (7) With respect to a GAP participating insurer who reasonably will be expected both to pay assessments and to receive payments from the assessment fund, the office shall calculate the net amount owed to or to be received from the fund, and the office shall only collect assessments for or make payments from the fund based upon net amounts. (8) Insurers paying an assessment may include in any health insurance rate filing the amount of these assessments as provided for in Subtitle 17A of this chapter. (9) Insurers shall pay any assessment amounts authorized in KRS 304.17B-001 to 304.17B-031 within thirty (30) days of receiving notice from the office of the assessment amount. (10) Any surpluses remaining in the Kentucky Access fund after completion of the assessment process for a calendar year shall be maintained for use in the assessment process for future calendar years and such funds shall not lapse. The general fund appropriations to the Kentucky Access fund shall not lapse. (11) Assessments on health benefit plan premiums that are required under KRS 304.17B-001 to 304.17B-031 shall not be applied to premiums received by an insurer for state employees, Medicaid recipients, Medicare beneficiaries, and CHAMPUS insureds. (12) The office shall direct that receipts of Kentucky Access be held at interest, and may be used to offset future losses or to reduce plan premiums in accordance with the terms of KRS 304.17B-001 to 304.17B-031. As used in this subsection, "future losses" may include reserves for incurred but not reported claims. (13) The office shall conduct examinations of insurers and stop-loss carriers reasonably necessary to determine if the information provided by the insurers or stop-loss carriers is accurate. (14) The insurer, as a condition of conducting health insurance business in Kentucky, shall pay the assessments specified in KRS 304.17B-001 to 304.17B-031. (15) The stop-loss carrier, as a condition of doing health insurance business in Kentucky, shall pay the assessments specified in KRS 304.17B-001 to 304.17B-031. Effective: April 14, 2026 History: Amended 2026 Ky. Acts ch. 161, sec. 68, effective April 14, 2026. -- Amended 2019 Ky. Acts ch. 90, sec. 21, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1283, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 11, effective July 14, 2000. 2026-2028 Budget Reference. See State/Executive Branch Budget, 2026 Ky. Acts ch. 168, Pt. I, G, 2, b, (9) at 2087.

KRS 304.17B-023 Duties of GAP participating insurer and department to report and to provide information -- Payment of GAP losses -- Examination of insurers to determine accuracy of information provided

304.17B-023. Duties of GAP participating insurer and department to report and to provide information -- Payment of GAP losses -- Examination of insurers to determine accuracy of information provided (1) After the end of each calendar year, a GAP participating insurer shall report the following information for the previous calendar year: (a) The total earned premium in the individual, small group, large group, and association markets; (b) The number of GAP policies in force as of December 31; (c) The amount of the insurer's GAP premiums received during the calendar year covered by the report; (d) The amount of the insurer's GAP claims paid during the calendar year covered by the report; (e) The amount of the insurer's GAP losses; and (f) Other information as the office may require to be reported. (2) After the end of each calendar year, and based upon the reports filed under subsection (1) of this section, the office shall calculate and provide to each insurer who filed a report the following information relating to the calendar year: (a) The amount of each reporting insurer's market share; (b) The total amount of GAP premiums for all reporting insurers; (c) The total amount of GAP claims paid by all reporting insurers; (d) The amount of total actual GAP losses; (e) The amount of the insurer's assessment or refund; and (f) Other information as the office may elect to calculate and report. The office shall complete its calculation and provide each insurer the results of its calculation within sixty (60) days after receiving all required information. (3) The office shall pay GAP losses to GAP participating insurers in accordance with this section and KRS 304.17B-021(5). (4) The office shall conduct examinations of insurers participating in Kentucky Access as are reasonably necessary to determine if the information provided by the insurers is accurate. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 22, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1284, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 12, effective July 14, 2000.

KRS 304.17B-025 Enrollee's option to renew health benefit plan -- Guaranteed Acceptance Program to remain in effect with certain exceptions

304.17B-025. Enrollee's option to renew health benefit plan -- Guaranteed Acceptance Program to remain in effect with certain exceptions (1) Any health benefit plan issued to a GAP qualified individual under the GAP program shall be renewed at the option of the enrollee, except for the reasons set out in KRS 304.17A-240. (2) The Guaranteed Acceptance Program shall remain in effect except for KRS 304.17A-400, 304.17A-420, 304.17A-440, 304.17A-460, 304.17A-470, and 304.17A-480. Effective: July 14, 2000 History: Created 2000 Ky. Acts ch. 476, sec. 13, effective July 14, 2000.

KRS 304.17B-027 Exemption of Kentucky Access and the Office of Health Data and Analytics from state and local taxes

304.17B-027. Exemption of Kentucky Access and the Office of Health Data and Analytics from state and local taxes Kentucky Access and the Office of Health Data and Analytics shall be exempt from all taxes levied by the state or any of its subdivisions. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 23, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1285, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 14, effective July 14, 2000.

KRS 304.17B-029 Duties of the Office of Health Data and Analytics to report to General Assembly -- State Auditor to audit Kentucky Access and report to the Legislative Research Commission and the Office of Health Data and Analytics

304.17B-029. Duties of the Office of Health Data and Analytics to report to General Assembly -- State Auditor to audit Kentucky Access and report to the Legislative Research Commission and the Office of Health Data and Analytics (1) Sixty (60) days prior to the regular session of the General Assembly in the year 2002, and sixty (60) days prior to each subsequent regular session of the General Assembly thereafter, the office shall submit a written report to the Legislative Research Commission and provide a detailed briefing. The report shall contain an evaluation of Kentucky Access, an evaluation of issues concerning high-risk individuals, and other information as the office deems necessary. (2) The Auditor of Public Accounts shall audit Kentucky Access and within sixty (60) days of completion of the audit shall submit a copy of the audit to the Legislative Research Commission, the Office of Health Data and Analytics, and the Department of Insurance. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 24, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1286, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 15, effective July 14, 2000.

KRS 304.17B-031 Administrative regulations to carry out KRS 304.17B-001 to 304.17B- 031 -- Kentucky Access subject to other laws

304.17B-031. Administrative regulations to carry out KRS 304.17B-001 to 304.17B- 031 -- Kentucky Access subject to other laws (1) The Office of Health Data and Analytics shall promulgate administrative regulations necessary to carry out the provisions of KRS 304.17B-001 to 304.17B- 031. (2) Kentucky Access 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: (a) Subtitle 1; (b) Subtitle 2; (c) Subtitle 3; (d) Subtitle 5; (e) Subtitle 8; (f) Subtitle 9; (g) Subtitle 12; (h) Subtitle 14; (i) Subtitle 17; (j) Subtitle 17A; (k) Subtitle 25; (l) Subtitle 38; and (m) Subtitle 47. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 25, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1287, effective July 15, 2010. -- Created 2000 Ky. Acts ch. 476, sec. 16, effective July 14, 2000.

KRS 304.17B-033 List of high-cost conditions -- Recommendations and changes -- Administrative regulations

304.17B-033. List of high-cost conditions -- Recommendations and changes -- Administrative regulations (1) No less than annually, the Health Insurance Advisory Council shall review the list of high-cost conditions established under KRS 304.17B-001(14) and recommend changes to the director of the Division of Health Benefit Exchange. The director may accept or reject any or all of the recommendations and may make whatever changes by administrative regulation the director deems appropriate. The council, in making recommendations, and the director, in making changes, shall consider, among other things, actual claims and losses on each diagnosis and advances in treatment of high-cost conditions. (2) The director may by administrative regulation add to or delete from the list of high- cost conditions for Kentucky Access. Effective: June 27, 2019 History: Amended 2019 Ky. Acts ch. 90, sec. 26, effective June 27, 2019. -- Amended 2010 Ky. Acts ch. 24, sec. 1288, effective July 15, 2010. -- Created 2002 Ky. Acts ch. 351, sec. 7, effective July 15, 2002.

KRS 304.17B-035 Payment for coverage of services within scope of practice of optometrists

304.17B-035. Payment for coverage of services within scope of practice of optometrists Any health benefit plan issued or renewed on or after July 12, 2006, by Kentucky Access which provides coverage for services rendered by a physician or osteopath duly licensed under KRS Chapter 311 that are within the scope of practice of an optometrist duly licensed under the provisions of KRS Chapter 320 shall provide the same payment for coverage to optometrists as allowed for those services rendered by physicians or osteopaths. Effective: July 12, 2006 History: Created 2006 Ky. Acts ch. 164, sec. 7, effective July 12, 2006.

KRS 304.17B-037 Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist

304.17B-037. Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist Health benefit plans provided under Kentucky Access shall not impose a copayment or coinsurance amount charged to the insured for services rendered by a chiropractor licensed under KRS Chapter 312 or an optometrist licensed under KRS Chapter 320 that is greater than the copayment or coinsurance amount charged to the insured for the services of a physician or an osteopath licensed under KRS Chapter 311 for the same or similar diagnosed condition, even if different nomenclature is used to describe the condition or complaint. Effective: July 12, 2006 History: Created 2006 Ky. Acts ch. 253, sec. 11, effective July 12, 2006.

Source: Kentucky Legislative Research Commission (legislature.ky.gov)URL: https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38725Fetched: 10/20/2026