Kentucky Revised Statutes
Statutes Last Updated July 23, 2012
Includes Enactments through the 2012 Extraordinary Session This page was produced on 7/24/2012 at 8:50:00 AM
Terms & Conditions | PDF Viewer KRS Chapter 304.17A
Terms & Conditions | PDF Viewer
.005 Definitions for subtitle.
.010 Repealed, 1998.
.020 Repealed, 1998.
.030 Repealed, 1998.
.040 Repealed, 1998.
.050 Repealed, 1998.
.060 Repealed, 1998.
.070 Repealed, 1998.
.071 Repealed, 2010.
Miscellaneous Provisions
.080 Health Insurance Advisory Council -- Powers -- Duties -- Members -- Expenses and supplies.
.090 Repealed, 1998
.095 Insurer issuing health benefit plan must file rates and charges -- Commissioner's approval -- Policy forms -- Administrative regulations -- Hearing.
.0952 Premium rate guidelines for individual, small group, and association plans.
.0954 Definitions for section -- Premium rate guidelines for employer-organized association plans.
.096 Basic health benefit plans permitted for individual, small group, and association markets -- Required coverage -- Exclusions from coverage.
.097 Disclosure of coverage levels in basic health benefit plan.
.098 Rewards or incentives to participate in voluntary wellness or health improvement program.
.100 Repealed, 1998.
.110 Repealed, 1998.
.120 Repealed, 1998.
.130 Repealed, 1998.
.131 Coverage for cochlear implants.
.132 Coverage for hearing aids.
.133 Coverage for mammograms.
.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.
.135 Coverage for treatment of breast cancer.
.136 Coverage for cancer clinical trials.
.137 Repealed, 2002.
.138 Prohibition against health benefit plan excluding coverage for telehealth -- Benefits subject to deductible, co-payment, or coinsurance -- Payment subject to provider network arrangements -- Administrative regulations.
.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.
.140 Coverage applicable to children to include legally-adopted children.
.141 Definitions for KRS 304.17A-141, 304.17A-142, and 304.17A-143.
.142 Coverage for autism spectrum disorders -- Limitations on coverage -- Utilization review -- Reimbursement not required.
.143 Coverage for treatment of autism in the individual and small group market -- Limitation -- Definitions.
.145 Maternity coverage to include specified amounts of inpatient care for mothers and newly-born children -- Exemption.
.146 Coverage for registered nurse first assistant.
.147 Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant.
.1473 Coverage for surgical first assisting or intraoperative surgical care to include services performed by certified surgical assistant or physician assistant.
.148 Coverage for diabetes.
.149 Coverage for anesthesia and services in connection with dental procedures for certain patients.
.150 Unfair trade practices -- Penalties.
.155 Prohibition against denial of coverage to victims of domestic violence.
.160 Repealed, 1998.
.163 Override of restrictions on medication sequence in step therapy or fail-first protocol.
.165 Prescription drug coverage to include exceptions or override policy for refills of covered drugs -- Limitations and exclusions.
.170 Definitions for KRS 304.17A-170 and 304.17A-171.
.171 Requirements for health benefit plans that include chiropractic benefits.
.173 Payment for coverage of services within scope of practice of optometrists.
.175 Limitation on amount of copayment or coinsurance charged for services rendered by chiropractor or optometrist.
.177 Limitation on amount of copayment or coinsurance charged for services rendered by occupational or physical therapist -- Insurer to clearly state coverage.
.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.
.210 Repealed, 2000.
.220 Pre-existing condition exclusion in group coverage -- Definitions for section.
.230 Pre-existing condition exclusion in individual market -- Prohibition against use of genetic information -- Administrative regulations.
.240 Renewal or continuation -- Ground for nonrenewal, cancellation, or discontinuance.
.243 Grace period for unpaid premiums.
.245 Required notice of cancellation -- Procedure -- Refund of unearned premium.
.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.
.252 Health benefit plan not required to include state-mandated benefits enacted after issuance.
.254 Duties of insurer offering health benefit plan.
.256 Options for dependent coverage under group health benefit plans -- Disclaimer.
.257 Coverage under health benefit plan for colorectal cancer examinations and laboratory tests.
.258 Coverage under health benefit plan for therapeutic food, formulas, supplements, and low-protein modified food products.
.260 Repealed, 2002.
.270 Nondiscrimination against provider in geographic coverage area.
.275 Health benefit plan not to discriminate against physician on basis of degree in medicine or osteopathy.
.280 Repealed, 2000.
.290 Prohibition against renewal of nonstate employees and small groups under KRS 18A.2251 or 18A.2281.
.300 Provider-sponsored integrated health delivery network -- Qualifications -- Fees -- Network subject to provisions of other subtitles.
.310 Financial solvency requirements for network.
.320 Certificate of filing for employer-organized association -- Effect -- Revocation.
.330 Self-insurance reporting requirements -- Exemption.
.340 Restrictions on use of Kentucky Children's Health Insurance Program allocated funds.
.350 Repealed, 2002.
Kentucky Guaranteed Acceptance Program
.400 Repealed, 2000.
.410 Definitions for KRS 304.17A-400 to 304.17A-480.
.420 Repealed, 2000.
.430 Criteria for program plan -- Alternative underwriting.
.440 Repealed, 2000.
.450 Cost-containment feature requirement for program plans.
.460 Repealed, 2000.
.470 Repealed, 2000.
.480 Repealed, 2000.
Managed Care Plans
.500 Definitions for KRS 304.17A-500 to 304.17A-590.
.505 Disclosure of terms and conditions of health benefit plan -- Filing with department.
.510 Notification by insurer offering managed care plans of availability of printed document.
.515 Requirements for managed care plan.
.520 Enrollee choice of primary care providers.
.525 Standards for provider participation -- Mechanisms for consideration of provider applications -- Policy for removal or withdrawal.
.527 Filing of provider agreements, risk-sharing arrangements, and subcontract agreements with commissioner -- Contents -- Disclosure of financial information not required.
.530 Prohibition against contract limiting disclosure to patient of patient medical condition or treatment options.
.532 Prohibition against contract requiring mandatory use of hospitalist.
.533 Repealed, 2004.
.535 Drug utilization waiver program -- Limitations on generic substitution -- Application to drug formulary.
.540 Disclosure of limitations on coverage -- Denial letter.
.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.
.550 Out-of-network benefits.
.555 Patient's right of privacy regarding mental health or chemical dependency -- Authorized disclosure.
.560 Most-favored-nation provision.
.565 Commissioner to enforce KRS 304.17A-500 to 304.17A-570 -- Administrative regulations.
.570 Applicability of KRS 304.17A-500 to 304.17A-570 for health insurance contracts or certificates.
.575 Definitions for KRS 304.17A-575 to 304.17A-578.
.576 Notice by managed care plan insurer of health care provider's application for credentialing -- Payments to applicant.
.577 Disclosure of payment or fee schedule to managed care plan health care provider -- Disclosure of schedule change -- Confidentiality of payment information.
.578 Notice to health care provider of material change to managed care plan.
.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.
.590 Participating provider directories.
Utilization Reviews
.600 Definitions for KRS 304.17A-600 to 304.17A-633.
.603 Application of KRS 304.17A-600 to 304.17A-633.
.605 Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal government.
.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.
.609 Emergency administrative regulations governing utilization review and internal appeal to be promulgated by the department.
.611 Prohibition against retrospective denial of coverage for health care services under certain circumstances.
.613 Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaints.
.615 Prohibition against denying or reducing payments under certain circumstances.
.617 Internal appeals process -- Procedures -- Review of coverage denials.
.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.
.621 Independent External Review Program established.
.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.
.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.
.627 Certification as independent review entity -- Requirements and restrictions.
.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.
.631 Time for insurers to comply with administrative regulations.
.633 Commissioner to report to Interim Joint Committee on Banking and Insurance and to Governor -- Contents of report.
Emergency Medical Conditions
.640 Definitions for KRS 304.17A-640 et seq.
.641 Treatment of a stabilized covered person with an emergency medical condition in a nonparticipating hospital's emergency room.
.643 Treatment of covered person under special circumstances.
.645 Covered person's access to participating nonprimary care physician specialist.
.647 Covered person's access to participating obstetrician or gynecologist -- Authorization for annual pap smear without referral.
.649 Administrative regulations for the implementation of KRS 304.17A-640 et seq.
Mental Health Conditions
.660 Definitions for KRS 304.17A-660 to 304.17A-669.
.661 Treatment of mental health conditions to be covered under same terms and conditions as treatment of physical health conditions.
.665 Commissioner to report to Legislative Research Commission on impact of health insurance costs under KRS 304.17A-660 to 304.17A-669.
.669 KRS 304.17A-660 to 304.17A-669 not to be construed as mandating coverage for mental health conditions -- Exemptions from KRS 304.17A-660 to 304.17A-669.
KRS 304.17A-700 to 304.17A-730
.700 Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
.702 Claims payment time frames -- Duties of insurer.
.704 Insurer's acknowledgment of receipt of claim -- Inaccurate or insufficient claim information -- Claim status information.
.705 Electronic claims submission.
.706 Contested claims -- Delay of payment -- Conditions -- Procedure.
.708 Resolution of payment errors -- Retroactive denial of claims -- Conditions.
.710 Disclosure of claims payment information to provider.
.712 Claim refunds and overpayments.
.714 Collection of claim overpayments -- Dispute resolution.
.716 Prohibition against denial or reduction of payment for covered health benefit -- Conditions.
.718 Disclosure of claims payment information to covered person.
.720 Administrative regulations for standardized health claim attachments -- Conformity with federal standards.
.722 Administrative regulations on claims payment practices.
.724 Applicability of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
.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.
.728 Contract disclosures of discounted fees -- Violation is unfair claims settlement practice.
.730 Payment of interest for failing to pay, denying, or settling a clean claim as required.
Audits of Pharmacy Records
.740 Definitions for KRS 304.17A-740 to 304.17A-743.
.741 Audit of pharmacy records -- Conditions.
.743 Pharmacy audit appeals process.
.745 KRS 304.17A-740 to 304.17A-743 not applicable to audits conducted by state agency pursuant to KRS Chapter 205.
.747 KRS 304.17A-740 to 304.17A-743 not applicable when fraud, willful misrepresentation, or abuse alleged.
Insurance Purchasing Outlets
.750 Definitions for KRS 304.17A-750 to 304.17A-770 and 304.47-020.
.752 Registration of insurance purchasing outlets -- Licensed agents -- Administrative regulations.
.754 Application -- Approval and issuance of certificate -- Information to be filed -- Administrative regulations.
.756 Denial, suspension, and revocation of application or license -- Civil penalty.
.758 Activities allowed under administrator license -- Financial statements -- Books and records -- Renewal of certificate -- Nontransferability -- Fees.
.760 Duties and powers of insurance purchasing outlet.
.762 Outlet to act as policyholder for member -- Certificate of coverage for each member -- Disclosure to members.
.764 Determination of premiums -- Restrictions in calculation.
.766 Coverage deemed group health insurance -- Requirements for health benefit plans -- Member who no longer meets participation requirements.
.768 Voucher -- Redemption -- Payment of premium amount -- Fee to process voucher -- Administrative regulations.
.770 Provisions applicable to insurance purchasing outlets.
Self-Insured Employer-Organized Association Groups
.800 Purpose of KRS 304.17A-800 to 304.17A-844.
.802 Definitions for KRS 304.17A-800 to 304.17A-844.
.804 Applicability of KRS 304.17A-800 to 304.17A-844 -- Self-insured employer-organized association groups.
.806 Certificate of filing required.
.808 Application for certificate of filing - Fee.
.810 Conditions for issuance of certificate of filing.
.812 Initial and continuing financial solvency requirements.
.814 Notification of change in information.
.816 Investment of funds.
.818 Agent of self-insured employer-organized association group -- Licensing -- Continuing education.
.820 Examination of financial condition, affairs, and management by commissioner.
.822 Appointment of Secretary of State as attorney to receive legal process.
.824 Continuing effectiveness of certificate -- Termination of certificate at request of group -- Merger with another group.
.826 Operation of group by board of trustees -- Powers and duties -- Prohibited acts.
.828 Membership -- Liability on termination of membership, insolvency, or bankruptcy.
.830 Trustees, officers, directors, or employees not to have interest in administrator or group.
.832 Statement of financial condition -- Authority for administrative regulations.
.834 Filing of rates, underwriting guidelines, evidence of coverage, and changes -- Filing fee.
.836 Contribution plans to be established.
.838 Members to receive evidences of coverage -- Contents.
.840 Suspension or revocation of certificate of filing.
.842 Authority for administrative regulations.
.844 Prohibited activities -- Penalties.
.846 Providing of requested information on insureds by group health benefit plan insurers -- Confidentiality -- Additional information to be provided to large groups.
