Health Benefit Plans
KRS tit. XXV, ch. 304, subtit. 17A
in effectContents
section304.17A-005. Definitions for subtitlesection304.17A-008. Application of subtitlesection304.17A-010. Repealed, 1998section304.17A-020. Repealed, 1998section304.17A-030. Repealed, 1998section304.17A-040. Repealed, 1998section304.17A-050. Repealed, 1998section304.17A-060. Repealed, 1998section304.17A-070. Repealed, 1998section304.17A-071. Repealed, 2010section304.17A-080. Health Insurance Advisory Council -- Powers -- Duties -- Members -- Expenses and suppliessection304.17A-090. Repealed, 1998section304.17A-095. Insurer issuing health benefit plan must file rates and charges -- Commissioner's approval -- Policy forms -- Administrative regulations -- Hearingsection304.17A-096. Basic health benefit plans permitted for individual, small group, and association markets -- Required coverage -- Exclusions from coveragesection304.17A-097. Disclosure of coverage levels in basic health benefit plansection304.17A-098. Rewards or incentives to participate in voluntary wellness or health improvement programsection304.17A-099. Qualified health plans -- Effect of requirement that state make payments under federal law to defray the cost of application of provision of chapter -- Administrative regulationssection304.17A-100. Repealed, 1998section304.17A-110. Repealed, 1998section304.17A-120. Repealed, 1998section304.17A-128. Coverage for prostheses and orthoses -- Utilization review decision -- Denial letter -- Network adequacy -- Reports. (Effective January 1, 2027)section304.17A-129. Coverage for stutteringsection304.17A-130. Repealed, 1998section304.17A-131. Coverage for cochlear implantssection304.17A-132. Coverage for hearing aids. (Effective until January 1, 2027)section304.17A-133. Coverage for mammograms -- Prohibition on cost-sharing requirements for covered diagnostic breast examinations or supplemental breast examinationssection304.17A-134. Coverage for medical and surgical benefits with respect to mastectomy, diagnosis and treatment of endometrioses and endometritis, and bone density testing -- Requirements for health benefit plansection304.17A-135. Coverage for treatment of breast cancersection304.17A-136. Coverage for cancer clinical trialssection304.17A-137. Repealed, 2002section304.17A-138. Telehealth coverage and reimbursement -- Requirements for health benefit plan -- Reimbursement for rural health clinics, federally qualified health centers, and federally qualified health center look-alikes -- Benefits subject to deductible, copayment, or coinsurance -- Payment subject to provider network arrangements -- Audio-only encounters -- Administrativesection304.17A-139. Family or dependents coverage to apply to newly born child from moment of birth and to include inherited metabolic diseases -- Requirement for notification and payment of premium -- Coverage for milk fortifiers to prevent enterocolitissection304.17A-140. Coverage applicable to children to include legally-adopted childrensection304.17A-141. Repealed, 2019section304.17A-142. Coverage for autism spectrum disorders -- Limitations on coverage -- Utilization review -- Reimbursement not requiredsection304.17A-143. Repealed, 2019section304.17A-144. Liaison for autism spectrum disorders treatment benefitssection304.17A-145. Maternity coverage to include specified services and amounts of inpatient care for mothers and newly born children -- Exemptionsection304.17A-146. Coverage for registered nurse first assistantsection304.17A-147. Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistantsection304.17A-148. Coverage for diabetes -- Cap on cost-sharing requirements for insulinsection304.17A-149. Coverage for anesthesia and services in connection with dental procedures for certain patientssection304.17A-150. Unfair trade practices -- Penaltiessection304.17A-155. Prohibition against denial of coverage to victims of domestic violencesection304.17A-160. Repealed, 1998section304.17A-161. Definitions for KRS 304.17A-161, 304.17A-162, 304.17A-163, and 304.17A-165section304.17A-162. Identification of sources used to calculate drug product reimbursement -- Process to appeal disputes over maximum allowable cost pricing -- Adjustment of maximum allowable cost and drug product reimbursement -- Duties of pharmacy benefit managersection304.17A-163. Definitions for KRS 304.17A-163 and 304.17A-1631 -- Establishment of clinical review criteria -- Override of restrictions on medication sequence in step therapy or fail-first protocolsection304.17A-164. Limitations on insurers and pharmacy benefit managers regarding cost-sharing for prescription drugs -- Exceptionssection304.17A-165. Prescription drug coverage to include exceptions or override policy for refills of covered drugs -- Limitations and exclusions -- Program for synchronization of medicationssection304.17A-166. Prescription eye drops coverage to include refills and additional bottle if conditions metsection304.17A-167. Processes and standards for electronic prior authorizations -- Prior authorization of drugs for ongoing medication therapy -- Requirements -- Time span of authorization -- Exemptionssection304.17A-168. Coverage for tobacco cessation medications and servicessection304.17A-170. Definitions for KRS 304.17A-170 and 304.17A-171section304.17A-171. Requirements for health benefit plans that include chiropractic benefitssection304.17A-172. Requirements for health benefit plans that include anticancer medications that are injected or intravenously administered by a health care provider and patient-administered anticancer medicationssection304.17A-173. Reimbursement for services within scope of practice of optometrists -- Terms and conditionssection304.17A-175. Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometristsection304.17A-177. Limitation on amount of copayment or coinsurance charged for services rendered by occupational or physical therapist -- Insurer to clearly state coveragesection304.17A-200. Prohibition against establishing certain rules of eligibility in small group, large group, or association markets -- Limitation on premium -- Participation rules -- Effect of denial of coverage -- Disclosuresection304.17A-210. Repealed, 2000section304.17A-220. Pre-existing condition exclusion in group coverage -- Definitions for sectionsection304.17A-230. Pre-existing condition exclusion in individual market -- Prohibition against use of genetic information -- Administrative regulationssection304.17A-235. Notice of proposed material change in health benefit plan's agreement with participating providersection304.17A-240. Renewal or continuation -- Ground for nonrenewal, cancellation, or discontinuancesection304.17A-243. Grace period for unpaid premiumssection304.17A-245. Required notice of cancellation -- Procedure -- Refund of unearned premiumsection304.17A-250. Standard health benefit plan -- Individual or small group markets -- Writing requirement for provider participation -- Time limit for rate quote -- Notice of denial of coveragesection304.17A-252. Health benefit plan not required to include state-mandated benefits enacted after issuancesection304.17A-254. Duties of insurer offering health benefit plansection304.17A-255. Definition of "cost sharing" and "plan year" -- Payments from specified federal programs on behalf of an insured count toward insured's premium and cost-sharing requirement -- Payments made by any person on behalf of insured permissible -- Exceptions -- Insured's responsibility towards premium paymentssection304.17A-256. Options for dependent coverage under group health benefit plans -- Disclaimersection304.17A-257. Coverage under health benefit plan for colorectal cancer examinations and laboratory testssection304.17A-258. Coverage under health benefit plan for therapeutic food, formulas, supplements, low-protein modified food products, and amino acid-based elemental formulasection304.17A-259. Coverage under health benefit plan for genetic test for cancer risksection304.17A-260. Repealed, 2002section304.17A-261. Coverage under health benefit plan for oocyte and sperm preservation servicessection304.17A-262. Coverage for orchiectomy or orchidectomy as treatment for urological cancerssection304.17A-263. Coverage under health benefit plan for biomarker testingsection304.17A-264. Coverage under health benefit plan for cancer screening, test, or proceduresection304.17A-265. Insurer may not restrict assignment of benefits to substance abuse or mental health facility -- Exceptions -- Requirements for assignment -- Constructionsection304.17A-270. Nondiscrimination against provider in geographic coverage areasection304.17A-275. Health benefit plan not to discriminate against physician on basis of degree in medicine or osteopathysection304.17A-280. Repealed, 2000section304.17A-290. Prohibition against renewal of nonstate employees and small groups under KRS 18A.2251 or 18A.2281section304.17A-300. Provider-sponsored integrated health delivery network -- Qualifications -- Fees -- Network subject to provisions of other subtitlessection304.17A-310. Financial solvency requirements for networksection304.17A-320. Certificate of filing for employer-organized association -- Effect -- Revocationsection304.17A-330. Self-insurance reporting requirements -- Exemptionsection304.17A-340. Restrictions on use of Kentucky Children's Health Insurance Program allocated fundssection304.17A-350. Repealed, 2002section304.17A-400. Repealed, 2000section304.17A-410. Definitions for KRS 304.17A-400 to 304.17A-480section304.17A-420. Repealed, 2000section304.17A-430. Criteria for program plan -- Alternative underwritingsection304.17A-440. Repealed, 2000section304.17A-450. Cost-containment feature requirement for program planssection304.17A-460. Repealed, 2000section304.17A-470. Repealed, 2000section304.17A-480. Repealed, 2000section304.17A-500. Definitions for KRS 304.17A-500 to 304.17A-590section304.17A-505. Disclosure of terms and conditions of health benefit plan -- Filing with departmentsection304.17A-510. Notification by insurer offering managed care plans of availability of printed documentsection304.17A-515. Requirements for managed care plansection304.17A-520. Enrollee choice of primary care providerssection304.17A-525. Standards for provider participation -- Mechanisms for consideration of provider applications -- Policy for removal or withdrawalsection304.17A-527. Filing of provider agreements, risk-sharing arrangements, and subcontract agreements with commissioner -- Contents -- Disclosure of financial information not requiredsection304.17A-530. Prohibition against contract limiting disclosure to patient of patient medical condition or treatment optionssection304.17A-532. Prohibition against contract requiring mandatory use of hospitalistsection304.17A-533. Repealed, 2004section304.17A-535. Drug utilization waiver program -- Limitations on generic substitution -- Application to drug formularysection304.17A-540. Disclosure of limitations on coverage -- Denial lettersection304.17A-545. Medical director for managed care plan -- Duties -- Quality assurance or improvement standards -- Process to select health care providers -- Uniform application form and guidelines for health care provider evaluationssection304.17A-550. Out-of-network benefitssection304.17A-555. Patient's right of privacy regarding mental health or chemical dependency -- Authorized disclosuresection304.17A-560. Most-favored-nation provisionsection304.17A-565. Commissioner to enforce KRS 304.17A-500 to 304.17A-570 -- Administrative regulationssection304.17A-570. Applicability of KRS 304.17A-500 to 304.17A-570 for health insurance contracts or certificatessection304.17A-575. Definitions for KRS 304.17A-575 to 304.17A-577section304.17A-576. Notice by managed care plan insurer of health care provider's application for credentialing -- Payments to applicantsection304.17A-577. Disclosure of payment or fee schedule to managed care plan health care provider -- Disclosure of schedule change -- Confidentiality of payment informationsection304.17A-578. Renumbered as KRS 304.17A-235section304.17A-580. Education of insured about appropriate use of emergency and medical services -- Coverage of emergency medical conditions and emergency department services -- Emergency personnel to contact primary care provider or insurer -- Exclusion of limited-benefit health insurance policiessection304.17A-590. Participating provider directoriessection304.17A-591. Definitions for KRS 304.17A-591 to 304.17A-599section304.17A-593. Requirement to provide reasonably adequate and accessible pharmacy networks -- Annual report to commissioner -- Confidential information not subject to disclosuresection304.17A-595. Definitions for section -- Requirements for contract for provision of pharmacy services -- Minimum reimbursements -- Administrative regulationssection304.17A-597. Prohibition against certain actions of administrator of pharmacy benefits against pharmacy -- Right of pharmacist to provide information about lower cost alternatives to insuredsection304.17A-599. Commissioner review of alleged violations of KRS 304.17A-593, 304.17A-595, or 304.17A-597section304.17A-600. Definitions for KRS 304.17A-600 to 304.17A-633section304.17A-603. Application of KRS 304.17A-600 to 304.17A-633 -- Written procedures for coverage and utilization review determinations to be accessible on insurers' Web sites -- Preauthorization review requirements for insurerssection304.17A-605. Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal governmentsection304.17A-606. Definitions for section -- Prior authorization exemption program -- Program requirements and options. (Effective January 1, 2028)section304.17A-607. Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the department -- Requirement that private review agent provide timely notice of entities for whom it is providingsection304.17A-609. Emergency administrative regulations governing utilization review and internal appeal to be promulgated by the departmentsection304.17A-611. Prohibition against retrospective denial of coverage for health care services under certain circumstances -- Prohibition against prospective or concurrent review of prescription drug for alcohol or opioid use disordersection304.17A-613. Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaintssection304.17A-615. Prohibition against denying or reducing payments under certain circumstancessection304.17A-617. Internal appeals process -- Procedures -- Review of coverage denialssection304.17A-619. Duty of covered person, authorized person, or provider to provide insurer with new information regarding internal appeal -- Time frame for insurer to render a decision based on new information -- Insurer's failure to make timely determination or provide written noticesection304.17A-621. Independent External Review Programsection304.17A-623. External review of adverse benefit determination -- Who may request -- Criteria for review -- Fee -- Conditions under which covered person not entitled to review -- Resolution of disputes -- Confidentiality -- Expedited external reviewsection304.17A-625. Factors to be considered by independent review entity conducting external review -- Basis for decision -- Insurer's responsibilities -- Contents, admissibility, and effect of decision -- Consequence of insurer's failure to provide coverage -- Liability -- Written complaintssection304.17A-627. Certification as independent review entity -- Requirements and restrictionssection304.17A-629. Administrative regulations to implement provisions of KRS 304.17A- 621, 304.17A-623, 304.17A-625, 304.17A-627, 304.17A-629, and 304.17A-631section304.17A-631. Time for insurers to comply with administrative regulationssection304.17A-633. Commissioner to report to Interim Joint Committee on Banking and Insurance and to Governor -- Contents of reportsection304.17A-640. Definitions for KRS 304.17A-640 et seqsection304.17A-641. Treatment of a stabilized covered person with an emergency medical condition in a nonparticipating hospital's emergency roomsection304.17A-643. Treatment of covered person under special circumstancessection304.17A-645. Covered person's access to participating nonprimary care physician specialistsection304.17A-647. Covered person's access to participating obstetrician or gynecologist - - Authorization for annual pap smear without referralsection304.17A-649. Administrative regulations for the implementation of KRS 304.17A- 640 et seqsection304.17A-655. Definitions for KRS 304.17A-655 to 304.17A-659. (Effective January 1, 2027)section304.17A-657. Coverage for feeding or eating disorders. (Effective January 1, 2027)section304.17A-659. Prohibited standards and permitted factors for coverage of feeding or eating disorder treatments. (Effective January 1, 2027)section304.17A-660. Definitions for KRS 304.17A-660 to 304.17A-669section304.17A-661. Treatment of mental health conditions to be covered under terms or conditions that are no more restrictive than terms or conditions for treatment of physical health conditions -- Parity coverage for nonquantitative treatment limitations and medical necessity criteriasection304.17A-662. Reimbursement for health benefits delivered through psychiatric collaborative care model -- Exceptionsection304.17A-665. Commissioner to report to Legislative Research Commission on impact of health insurance costs under KRS 304.17A-660 to 304.17A-669section304.17A-669. KRS 304.17A-660 to 304.17A-669 not to be construed as mandating coverage for mental health conditions -- Exemption from KRS 304.17A-660 to 304.17A-669section304.17A-700. Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123section304.17A-702. Claims payment time frames -- Duties of insurersection304.17A-704. Insurer's acknowledgment of receipt of claim -- Inaccurate or insufficient claim information -- Claim status informationsection304.17A-705. Electronic claims submissionsection304.17A-706. Contested claims -- Delay of payment -- Conditions -- Proceduresection304.17A-708. Resolution of payment errors -- Retroactive denial of claims -- Conditionssection304.17A-710. Disclosure of claims payment information to providersection304.17A-712. Claim refunds and overpaymentssection304.17A-714. Collection of claim overpayments -- Dispute resolutionsection304.17A-716. Prohibition against denial or reduction of payment for covered health benefit -- Conditionssection304.17A-718. Disclosure of claims payment information to covered personsection304.17A-720. Administrative regulations for standardized health claim attachments -- Conformity with federal standardssection304.17A-722. Administrative regulations on claims payment practicessection304.17A-724. Applicability of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123section304.17A-726. Exclusive application of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123 to claims incurred and contracts made after July 14, 2000section304.17A-728. Contract disclosures of discounted fees -- Violation is unfair claims settlement practicesection304.17A-730. Payment of interest for failing to pay, denying, or settling a clean claim as requiredsection304.17A-732. Annual reports on providers prescribing medication for addiction treatmentsection304.17A-740. Definitions for KRS 304.17A-740 to 304.17A-743section304.17A-741. Audit of pharmacy records -- Conditionssection304.17A-743. Pharmacy audit appeals processsection304.17A-745. KRS 304.17A-740 to 304.17A-743 not applicable to audits conducted by state agency pursuant to KRS Chapter 205section304.17A-747. KRS 304.17A-740 to 304.17A-743 not applicable when fraud, willful misrepresentation, or abuse allegedsection304.17A-750. Definitions for KRS 304.17A-750 to 304.17A-770 and 304.47-020section304.17A-752. Registration of insurance purchasing outlets -- Licensed agents -- Administrative regulationssection304.17A-754. Application -- Approval and issuance of certificate -- Information to be filed -- Administrative regulationssection304.17A-756. Denial, suspension, and revocation of application or license -- Civil penaltysection304.17A-758. Activities allowed under administrator license -- Financial statements -- Books and records -- Renewal of certificate -- Nontransferability -- Feessection304.17A-760. Duties and powers of insurance purchasing outletsection304.17A-762. Outlet to act as policyholder for member -- Certificate of coverage for each member -- Disclosure to memberssection304.17A-764. Determination of premiums -- Restrictions in calculationsection304.17A-766. Coverage deemed group health insurance -- Requirements for health benefit plans -- Member who no longer meets participation requirementssection304.17A-768. Voucher -- Redemption -- Payment of premium amount -- Fee to process voucher -- Administrative regulationssection304.17A-770. Provisions applicable to insurance purchasing outletssection304.17A-800. Purpose of KRS 304.17A-800 to 304.17A-844section304.17A-802. Definitions for KRS 304.17A-800 to 304.17A-844section304.17A-804. Applicability of KRS 304.17A-800 to 304.17A-844 -- Self-insured employer-organized association groupssection304.17A-806. Certificate of filing requiredsection304.17A-808. Application for certificate of filing -- Feesection304.17A-810. Conditions for issuance of certificate of filingsection304.17A-812. Initial and continuing financial solvency requirementssection304.17A-814. Notification of change in informationsection304.17A-816. Investment of fundssection304.17A-818. Agent of self-insured employer-organized association group -- Licensing -- Continuing educationsection304.17A-820. Examination of financial condition, affairs, and management by commissionersection304.17A-822. Appointment of Secretary of State as attorney to receive legal processsection304.17A-824. Continuing effectiveness of certificate -- Termination of certificate at request of group -- Merger with another groupsection304.17A-826. Operation of group by board of trustees -- Powers and duties -- Prohibited actssection304.17A-828. Membership -- Liability on termination of membership, insolvency, or bankruptcysection304.17A-830. Trustees, officers, directors, or employees not to have interest in administrator or groupsection304.17A-832. Statement of financial condition -- Authority for administrative regulationssection304.17A-834. Filing of rates, underwriting guidelines, evidence of coverage, and changes -- Filing feesection304.17A-836. Contribution plans to be establishedsection304.17A-838. Members to receive evidences of coverage -- Contentssection304.17A-840. Suspension or revocation of certificate of filingsection304.17A-842. Authority for administrative regulationssection304.17A-844. Prohibited activities -- Penaltiessection304.17A-846. Providing of requested information on insureds by group health benefit plan insurers -- Confidentiality -- Additional information to be provided to large groupssection304.17A-0952. Premium rate guidelines for individual, small group, and association planssection304.17A-0954. Premium rate guidelines for employer-organized association planssection304.17A-1473. Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant or physician assistantsection304.17A-1631. Administrative regulations -- Requirement of annual report to commissionersection304.17A-6061. Commissioner to report to the Legislative Research Commission on prior authorization exemption program -- Contents of report. (Effective January 1, 2028)
Source: Kentucky Legislative Research Commission (legislature.ky.gov)URL: https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715Fetched: 10/20/2026