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Subtitle

Subtitle 17A. Health Benefit Plans

  • KRS 304.17A-005— Definitions for subtitle
  • KRS 304.17A-008— Application of subtitle
  • KRS 304.17A-010— Repealed, 1998
  • KRS 304.17A-020— Repealed, 1998
  • KRS 304.17A-030— Repealed, 1998
  • KRS 304.17A-040— Repealed, 1998
  • KRS 304.17A-050— Repealed, 1998
  • KRS 304.17A-060— Repealed, 1998
  • KRS 304.17A-070— Repealed, 1998
  • KRS 304.17A-071— Repealed, 2010
  • KRS 304.17A-080— Health Insurance Advisory Council -- Powers -- Duties -- Members -- Expenses and supplies
  • KRS 304.17A-090— Repealed, 1998
  • KRS 304.17A-095— Insurer issuing health benefit plan must file rates and charges -- Commissioner's approval -- Policy forms -- Administrative regulations -- Hearing
  • KRS 304.17A-096— Basic health benefit plans permitted for individual, small group, and association markets -- Required coverage -- Exclusions from coverage
  • KRS 304.17A-097— Disclosure of coverage levels in basic health benefit plan
  • KRS 304.17A-098— Rewards or incentives to participate in voluntary wellness or health improvement program
  • KRS 304.17A-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 regulations
  • KRS 304.17A-100— Repealed, 1998
  • KRS 304.17A-110— Repealed, 1998
  • KRS 304.17A-120— Repealed, 1998
  • KRS 304.17A-129— Coverage for stuttering
  • KRS 304.17A-130— Repealed, 1998
  • KRS 304.17A-131— Coverage for cochlear implants
  • KRS 304.17A-132— Coverage for hearing aids
  • KRS 304.17A-133— Coverage for mammograms -- Prohibition on cost-sharing requirements for covered diagnostic breast examinations or supplemental breast examinations
  • KRS 304.17A-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 plan
  • KRS 304.17A-135— Coverage for treatment of breast cancer
  • KRS 304.17A-136— Coverage for cancer clinical trials
  • KRS 304.17A-137— Repealed, 2002
  • KRS 304.17A-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 -- Administrative regulations
  • KRS 304.17A-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 enterocolitis
  • KRS 304.17A-140— Coverage applicable to children to include legally-adopted children
  • KRS 304.17A-141— Repealed, 2019
  • KRS 304.17A-142— Coverage for autism spectrum disorders -- Limitations on coverage -- Utilization review -- Reimbursement not required
  • KRS 304.17A-143— Repealed, 2019
  • KRS 304.17A-144— Liaison for autism spectrum disorders treatment benefits
  • KRS 304.17A-145— Maternity coverage to include specified services and amounts of inpatient care for mothers and newly born children -- Exemption
  • KRS 304.17A-146— Coverage for registered nurse first assistant
  • KRS 304.17A-147— Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant
  • KRS 304.17A-148— Coverage for diabetes -- Cap on cost-sharing requirements for insulin
  • KRS 304.17A-149— Coverage for anesthesia and services in connection with dental procedures for certain patients
  • KRS 304.17A-150— Unfair trade practices -- Penalties
  • KRS 304.17A-155— Prohibition against denial of coverage to victims of domestic violence
  • KRS 304.17A-160— Repealed, 1998
  • KRS 304.17A-161— Definitions for KRS 304.17A-161, 304.17A-162, 304.17A-163, and 304.17A-165
  • KRS 304.17A-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 manager
  • KRS 304.17A-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 protocol
  • KRS 304.17A-164— Limitations on insurers and pharmacy benefit managers regarding cost-sharing for prescription drugs -- Exceptions
  • KRS 304.17A-165— Prescription drug coverage to include exceptions or override policy for refills of covered drugs -- Limitations and exclusions -- Program for synchronization of medications
  • KRS 304.17A-166— Prescription eye drops coverage to include refills and additional bottle if conditions met
  • KRS 304.17A-167— Processes and standards for electronic prior authorizations -- Prior authorization of drugs for ongoing medication therapy -- Requirements -- Time span of authorization -- Exemptions
  • KRS 304.17A-168— Coverage for tobacco cessation medications and services
  • KRS 304.17A-170— Definitions for KRS 304.17A-170 and 304.17A-171
  • KRS 304.17A-171— Requirements for health benefit plans that include chiropractic benefits
  • KRS 304.17A-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 medications
  • KRS 304.17A-173— Reimbursement for services within scope of practice of optometrists -- Terms and conditions
  • KRS 304.17A-175— Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist
  • KRS 304.17A-177— Limitation on amount of copayment or coinsurance charged for services rendered by occupational or physical therapist -- Insurer to clearly state coverage
  • KRS 304.17A-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 -- Disclosure
  • KRS 304.17A-210— Repealed, 2000
  • KRS 304.17A-220— Pre-existing condition exclusion in group coverage -- Definitions for section
  • KRS 304.17A-230— Pre-existing condition exclusion in individual market -- Prohibition against use of genetic information -- Administrative regulations
  • KRS 304.17A-235— Notice of proposed material change in health benefit plan's agreement with participating provider
  • KRS 304.17A-240— Renewal or continuation -- Ground for nonrenewal, cancellation, or discontinuance
  • KRS 304.17A-243— Grace period for unpaid premiums
  • KRS 304.17A-245— Required notice of cancellation -- Procedure -- Refund of unearned premium
  • KRS 304.17A-250— Standard health benefit plan -- Individual or small group markets -- Writing requirement for provider participation -- Time limit for rate quote -- Notice of denial of coverage
  • KRS 304.17A-252— Health benefit plan not required to include state-mandated benefits enacted after issuance
  • KRS 304.17A-254— Duties of insurer offering health benefit plan
  • KRS 304.17A-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 payments
  • KRS 304.17A-256— Options for dependent coverage under group health benefit plans -- Disclaimer
  • KRS 304.17A-257— Coverage under health benefit plan for colorectal cancer examinations and laboratory tests
  • KRS 304.17A-258— Coverage under health benefit plan for therapeutic food, formulas, supplements, low-protein modified food products, and amino acid-based elemental formula
  • KRS 304.17A-259— Coverage under health benefit plan for genetic test for cancer risk
  • KRS 304.17A-260— Repealed, 2002
  • KRS 304.17A-261— Coverage under health benefit plan for oocyte and sperm preservation services
  • KRS 304.17A-262— Coverage for orchiectomy or orchidectomy as treatment for urological cancers
  • KRS 304.17A-263— Coverage under health benefit plan for biomarker testing
  • KRS 304.17A-264— Coverage under health benefit plan for cancer screening, test, or procedure
  • KRS 304.17A-265— Insurer may not restrict assignment of benefits to substance abuse or mental health facility -- Exceptions -- Requirements for assignment -- Construction
  • KRS 304.17A-270— Nondiscrimination against provider in geographic coverage area
  • KRS 304.17A-275— Health benefit plan not to discriminate against physician on basis of degree in medicine or osteopathy
  • KRS 304.17A-280— Repealed, 2000
  • KRS 304.17A-290— Prohibition against renewal of nonstate employees and small groups under KRS 18A.2251 or 18A.2281
  • KRS 304.17A-300— Provider-sponsored integrated health delivery network -- Qualifications -- Fees -- Network subject to provisions of other subtitles
  • KRS 304.17A-310— Financial solvency requirements for network
  • KRS 304.17A-320— Certificate of filing for employer-organized association -- Effect -- Revocation
  • KRS 304.17A-330— Health insurance reporting requirements -- Exemption
  • KRS 304.17A-340— Restrictions on use of Kentucky Children's Health Insurance Program allocated funds
  • KRS 304.17A-350— Repealed, 2002
  • KRS 304.17A-400— Repealed, 2000
  • KRS 304.17A-410— Definitions for KRS 304.17A-400 to 304.17A-480
  • KRS 304.17A-420— Repealed, 2000
  • KRS 304.17A-430— Criteria for program plan -- Alternative underwriting
  • KRS 304.17A-440— Repealed, 2000
  • KRS 304.17A-450— Cost-containment feature requirement for program plans
  • KRS 304.17A-460— Repealed, 2000
  • KRS 304.17A-470— Repealed, 2000
  • KRS 304.17A-480— Repealed, 2000
  • KRS 304.17A-500— Definitions for KRS 304.17A-500 to 304.17A-590
  • KRS 304.17A-505— Disclosure of terms and conditions of health benefit plan -- Filing with department
  • KRS 304.17A-510— Notification by insurer offering managed care plans of availability of printed document
  • KRS 304.17A-515— Requirements for managed care plan
  • KRS 304.17A-520— Enrollee choice of primary care providers
  • KRS 304.17A-525— Standards for provider participation -- Mechanisms for consideration of provider applications -- Policy for removal or withdrawal
  • KRS 304.17A-527— Filing of provider agreements, risk-sharing arrangements, and subcontract agreements with commissioner -- Contents -- Disclosure of financial information not required
  • KRS 304.17A-530— Prohibition against contract limiting disclosure to patient of patient medical condition or treatment options
  • KRS 304.17A-532— Prohibition against contract requiring mandatory use of hospitalist
  • KRS 304.17A-533— Repealed, 2004
  • KRS 304.17A-535— Drug utilization waiver program -- Limitations on generic substitution -- Application to drug formulary
  • KRS 304.17A-540— Disclosure of limitations on coverage -- Denial letter
  • KRS 304.17A-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 evaluations
  • KRS 304.17A-550— Out-of-network benefits
  • KRS 304.17A-555— Patient's right of privacy regarding mental health or chemical dependency -- Authorized disclosure
  • KRS 304.17A-560— Most-favored-nation provision
  • KRS 304.17A-565— Commissioner to enforce KRS 304.17A-500 to 304.17A-570 -- Administrative regulations
  • KRS 304.17A-570— Applicability of KRS 304.17A-500 to 304.17A-570 for health insurance contracts or certificates
  • KRS 304.17A-575— Definitions for KRS 304.17A-575 to 304.17A-577
  • KRS 304.17A-576— Notice by managed care plan insurer of health care provider's application for credentialing -- Payments to applicant
  • KRS 304.17A-577— Disclosure of payment or fee schedule to managed care plan health care provider -- Disclosure of schedule change -- Confidentiality of payment information
  • KRS 304.17A-578— Renumbered as KRS 304.17A-235
  • KRS 304.17A-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 policies
  • KRS 304.17A-590— Participating provider directories
  • KRS 304.17A-591— Definitions for KRS 304.17A-591 to 304.17A-599
  • KRS 304.17A-593— Requirement to provide reasonably adequate and accessible pharmacy networks -- Annual report to commissioner -- Confidential information not subject to disclosure
  • KRS 304.17A-595— Definitions for section -- Requirements for contract for provision of pharmacy services -- Minimum reimbursements -- Administrative regulations
  • KRS 304.17A-597— Prohibition against certain actions of administrator of pharmacy benefits against pharmacy -- Right of pharmacist to provide information about lower cost alternatives to insured
  • KRS 304.17A-599— Commissioner review of alleged violations of KRS 304.17A-593, 304.17A-595, or 304.17A-597
  • KRS 304.17A-600— Definitions for KRS 304.17A-600 to 304.17A-633
  • KRS 304.17A-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 insurers
  • KRS 304.17A-605— Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal government
  • KRS 304.17A-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 providing review
  • KRS 304.17A-609— Emergency administrative regulations governing utilization review and internal appeal to be promulgated by the department
  • KRS 304.17A-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 disorder
  • KRS 304.17A-613— Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaints
  • KRS 304.17A-615— Prohibition against denying or reducing payments under certain circumstances
  • KRS 304.17A-617— Internal appeals process -- Procedures -- Review of coverage denials
  • KRS 304.17A-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 notice
  • KRS 304.17A-621— Independent External Review Program established
  • KRS 304.17A-623— External review of adverse determination -- Who may request -- Criteria for review -- Fee -- Conditions under which covered person not entitled to review -- Resolution of disputes -- Confidentiality -- Expedited external review
  • KRS 304.17A-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 complaints
  • KRS 304.17A-627— Certification as independent review entity -- Requirements and restrictions
  • KRS 304.17A-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-631
  • KRS 304.17A-631— Time for insurers to comply with administrative regulations
  • KRS 304.17A-633— Commissioner to report to Interim Joint Committee on Banking and Insurance and to Governor -- Contents of report
  • KRS 304.17A-640— Definitions for KRS 304.17A-640 et seq
  • KRS 304.17A-641— Treatment of a stabilized covered person with an emergency medical condition in a nonparticipating hospital's emergency room
  • KRS 304.17A-643— Treatment of covered person under special circumstances
  • KRS 304.17A-645— Covered person's access to participating nonprimary care physician specialist
  • KRS 304.17A-647— Covered person's access to participating obstetrician or gynecologist -- Authorization for annual pap smear without referral
  • KRS 304.17A-649— Administrative regulations
  • KRS 304.17A-660— Definitions for KRS 304.17A-660 to 304.17A-669
  • KRS 304.17A-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 criteria
  • KRS 304.17A-665— Commissioner to report to Legislative Research Commission on impact of health insurance costs under KRS 304.17A-660 to 304.17A-669
  • KRS 304.17A-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-669
  • KRS 304.17A-700— Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123
  • KRS 304.17A-702— Claims payment time frames -- Duties of insurer
  • KRS 304.17A-704— Insurer's acknowledgment of receipt of claim -- Inaccurate or insufficient claim information -- Claim status information
  • KRS 304.17A-705— Electronic claims submission
  • KRS 304.17A-706— Contested claims -- Delay of payment -- Conditions -- Procedure
  • KRS 304.17A-708— Resolution of payment errors -- Retroactive denial of claims -- Conditions
  • KRS 304.17A-710— Disclosure of claims payment information to provider
  • KRS 304.17A-712— Claim refunds and overpayments
  • KRS 304.17A-714— Collection of claim overpayments -- Dispute resolution
  • KRS 304.17A-716— Prohibition against denial or reduction of payment for covered health benefit -- Conditions
  • KRS 304.17A-718— Disclosure of claims payment information to covered person
  • KRS 304.17A-720— Administrative regulations for standardized health claim attachments -- Conformity with federal standards
  • KRS 304.17A-722— Administrative regulations on claims payment practices
  • KRS 304.17A-724— Applicability of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123
  • KRS 304.17A-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, 2000
  • KRS 304.17A-728— Contract disclosures of discounted fees -- Violation is unfair claims settlement practice
  • KRS 304.17A-730— Payment of interest for failing to pay, denying, or settling a clean claim as required
  • KRS 304.17A-732— Annual reports on providers prescribing medication for addiction treatment
  • KRS 304.17A-740— Definitions for KRS 304.17A-740 to 304.17A-743
  • KRS 304.17A-741— Audit of pharmacy records -- Conditions
  • KRS 304.17A-743— Pharmacy audit appeals process
  • KRS 304.17A-745— KRS 304.17A-740 to 304.17A-743 not applicable to audits conducted by state agency pursuant to KRS Chapter 205
  • KRS 304.17A-747— KRS 304.17A-740 to 304.17A-743 not applicable when fraud, willful misrepresentation, or abuse alleged
  • KRS 304.17A-750— Definitions for KRS 304.17A-750 to 304.17A-770 and 304.47-020
  • KRS 304.17A-752— Registration of insurance purchasing outlets -- Licensed agents -- Administrative regulations
  • KRS 304.17A-754— Application -- Approval and issuance of certificate -- Information to be filed -- Administrative regulations
  • KRS 304.17A-756— Denial, suspension, and revocation of application or license -- Civil penalty
  • KRS 304.17A-758— Activities allowed under administrator license -- Financial statements -- Books and records -- Renewal of certificate -- Nontransferability -- Fees
  • KRS 304.17A-760— Duties and powers of insurance purchasing outlet
  • KRS 304.17A-762— Outlet to act as policyholder for member -- Certificate of coverage for each member -- Disclosure to members
  • KRS 304.17A-764— Determination of premiums -- Restrictions in calculation
  • KRS 304.17A-766— Coverage deemed group health insurance -- Requirements for health benefit plans -- Member who no longer meets participation requirements
  • KRS 304.17A-768— Voucher -- Redemption -- Payment of premium amount -- Fee to process voucher -- Administrative regulations
  • KRS 304.17A-770— Provisions applicable to insurance purchasing outlets
  • KRS 304.17A-800— Purpose of KRS 304.17A-800 to 304.17A-844
  • KRS 304.17A-802— Definitions for KRS 304.17A-800 to 304.17A-844
  • KRS 304.17A-804— Applicability of KRS 304.17A-800 to 304.17A-844 -- Self-insured employer-organized association groups
  • KRS 304.17A-806— Certificate of filing required
  • KRS 304.17A-808— Application for certificate of filing -- Fee
  • KRS 304.17A-810— Conditions for issuance of certificate of filing
  • KRS 304.17A-812— Initial and continuing financial solvency requirements
  • KRS 304.17A-814— Notification of change in information
  • KRS 304.17A-816— Investment of funds
  • KRS 304.17A-818— Agent of self-insured employer-organized association group -- Licensing -- Continuing education
  • KRS 304.17A-820— Examination of financial condition, affairs, and management by commissioner
  • KRS 304.17A-822— Appointment of Secretary of State as attorney to receive legal process
  • KRS 304.17A-824— Continuing effectiveness of certificate -- Termination of certificate at request of group -- Merger with another group
  • KRS 304.17A-826— Operation of group by board of trustees -- Powers and duties -- Prohibited acts
  • KRS 304.17A-828— Membership -- Liability on termination of membership, insolvency, or bankruptcy
  • KRS 304.17A-830— Trustees, officers, directors, or employees not to have interest in administrator or group
  • KRS 304.17A-832— Statement of financial condition -- Authority for administrative regulations
  • KRS 304.17A-834— Filing of rates, underwriting guidelines, evidence of coverage, and changes -- Filing fee
  • KRS 304.17A-836— Contribution plans to be established
  • KRS 304.17A-838— Members to receive evidences of coverage -- Contents
  • KRS 304.17A-840— Suspension or revocation of certificate of filing
  • KRS 304.17A-842— Authority for administrative regulations
  • KRS 304.17A-844— Prohibited activities -- Penalties
  • KRS 304.17A-846— Providing of requested information on insureds by group health benefit plan insurers -- Confidentiality -- Additional information to be provided to large groups
  • KRS 304.17A-0952— Premium rate guidelines for individual, small group, and association plans
  • KRS 304.17A-0954— Premium rate guidelines for employer-organized association plans
  • KRS 304.17A-1473— Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant or physician assistant
  • KRS 304.17A-1631— Administrative regulations -- Requirement of annual report to commissioner