900 KAR 10:010. Exchange Participation Requirements and Certification of Qualified Health Plans and Qualified Dental Plans.

 

      RELATES TO: KRS 194A.050(1), 42 U.S.C. 18022, 18031, 18042, 18054, 45 C.F.R. Parts 155, 156

      STATUTORY AUTHORITY: KRS 194A.050(1)

      NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Office of the Kentucky Health Benefit Exchange, has responsibility to administer the state-based American Health Benefit Exchange. KRS 194A.050(1) requires the secretary of the cabinet to promulgate administrative regulations necessary to protect, develop, and maintain the health, personal dignity, integrity, and sufficiency of the individual citizens of the Commonwealth; to operate the programs and fulfill the responsibilities vested in the cabinet; and to implement programs mandated by federal law or to qualify for the receipt of federal funds. This administrative regulation establishes the policies and procedures relating to the certification of a qualified health plan to be offered on the Kentucky Health Benefit Exchange, pursuant to and in accordance with 42 U.S.C. 18031 and 45 C.F.R. Parts 155 and 156.

 

      Section 1. Definitions. (1) "Actuarial value" means the percentage of the total allowed costs of benefits paid by a health plan.

      (2) "Affordable Care Act" or "ACA" means the Patient Protection and Affordable Care Act, Public Law 111-148, enacted March 23, 2010, as amended by the Health Care and Education Reconciliation Act, Public Law 111-152, enacted March 30, 2010.

      (3) "Agent" is defined by KRS 304.9-020(1).

      (4) "Annual open enrollment period" is defined by 45 C.F.R. 155.410(e).

      (5) "Benefit year" means a calendar year for which a health plan provides coverage for health benefits.

      (6) "Catastrophic plan" means a health plan that is described in and meets the requirements of 45 C.F.R 156.155.

      (7) "Certificate of authority" is defined by KRS 304.1-110(1).

      (8) "Certification" means a determination by the Kentucky Health Benefit Exchange that a health plan or a stand-alone dental plan has met the requirements established in Sections 2 through 19 of this administrative regulation.

      (9) "Child-only plan" means an individual health policy that provides coverage to an individual under twenty-one (21) years of age and meets the requirements of 45 C.F.R 156.200(c)(2).

      (10) "Consumer Operated and Oriented Plan" or "CO-OP" means a private, non-profit health insurance issuer established in Section 1322 of the Affordable Care Act, 42 U.S.C. 18042, that has a certificate of authority.

      (11) "Dental Insurer" means an insurer defined by KRS 304.17C-010(4), which offers a limited health service benefit plan for dental services.

      (12) "Department of Health and Human Services" or "HHS" means the U.S. Department of Health and Human Services.

      (13) "Department of Insurance" or "DOI" is defined by KRS 304.1-050(2).

      (14) "Enrollee" means an eligible individual enrolled in a qualified health plan.

      (15) "Essential community provider" means either a:

      (a) Provider determined and approved by HHS as an essential community provider for the Commonwealth of Kentucky; or

      (b) Regional community services program for mental health or individuals with an intellectual disability established pursuant to KRS 210.370 through KRS 210.480, operating in Kentucky, and licensed pursuant to 902 KAR 20:091.

      (16) "Essential community provider category" means a provider as described in Chapter 7: Instructions for the Essential Community Providers Application Section, as incorporated by reference in this administrative regulation.

      (17) "Essential health benefits" means benefits as identified by 42 U.S.C. 18022 and approved by the Secretary of HHS for the Commonwealth of Kentucky.

      (18) "Health plan" is defined by 42 U.S.C. 18021(b)(1).

      (19) “Health plan form” or “form” means an application, policy, certificate, contract, rider, endorsement, provider agreement, or risk sharing arrangement filed in accordance with 806 KAR 14:007.

      (20) "Indian" is defined by 25 U.S.C. 450b(d).

      (21) “Individual exchange” means the Kentucky Health Benefit Exchange that serves the individual health insurance market.

      (22) “Individual market” is defined by KRS 304.17A-005(26).

      (23) “Initial open enrollment period” means the period beginning October 1, 2013, and extending through March 31, 2014, during which a qualified individual or qualified employee may enroll in health coverage through an exchange for the 2014 benefit year.

      (24) "Issuer" is defined by 45 C.F.R. 144.103.

      (25) "Kentucky Health Benefit Exchange" or "KHBE" means the Kentucky state-based exchange conditionally approved by HHS pursuant to 45 C.F.R. 155.105 to offer a QHP beginning January 1, 2014, that includes an:

      (a) Individual exchange; and

      (b) Small Business Health Options Program.

      (26) "Metal level of coverage" means health care coverage provided within plus or minus two (2) percentage points of the full actuarial value as follows:

      (a) Bronze level with an actuarial value of 60 percent;

      (b) Silver level with an actuarial value of 70 percent;

      (c) Gold level with an actuarial value of 80 percent; and

      (d) Platinum level with an actuarial value of 90 percent.

      (27) "Multi-state plan" means a health plan that is offered under a contract with the U.S. Office of Personnel Management in accordance with Section 1334 of the Affordable Care Act, 42 U.S.C. 18054.

      (28) "Office of the Kentucky Health Benefit Exchange" or "Office" means the office created to administer the Kentucky Health Benefit Exchange.

      (29) "Participating agent" means an agent who has been certified by the office to participate on the KHBE.

      (30) "Participation agreement" means an agreement between the office and the issuer to offer a QHP or qualified dental plan on the KHBE.

      (31) "Pediatric dental essential health benefit" means a dental service to prevent disease and promote oral health, restore an oral structure to health and function, and treat an emergency condition provided to an individual under the age of twenty-one (21) years that meets the requirements of 45 C.F.R. 156.110(a)(10).

      (32) "Plan management data template" means the data collection templates used to facilitate data submission for certification of qualified health plan issuers and qualified health plans as established in CMS Form Number CMS-10433, as amended.

      (33) "Plan year" means a consecutive twelve (12) month period during which a health plan provides coverage for health benefits.

      (34) "Premium" is defined by KRS 304.14-030.

      (35) "Provider network" is defined by KRS 304.17A-005(35).

      (36) "Qualified dental plan" means a dental plan certified by the office that provides a limited scope of dental benefits as defined in 26 U.S.C. 9832(c)(2)(A), limited to a pediatric dental essential health benefit which complies with the requirements of 45 C.F.R. 156.110(a)(10).

      (37) "Qualified employee" means an individual employed by a qualified employer who has been offered health insurance coverage by the qualified employer through the SHOP.

      (38) "Qualified employer" means an employer that elects to make, at a minimum, all full-time employees of the employer eligible for one (1) or more QHPs in the small group market offered through the SHOP.

      (39) "Qualified health plan" or "QHP" means a health plan that meets the standards described in 45 C.F.R. 156 Subpart C and that has in effect a certification issued by the office.

      (40) "Qualified individual" means an individual who has been determined eligible to enroll through the KHBE in a QHP in the individual market.

      (41) "Service area" means a geographical area in which an issuer may offer a QHP.

      (42) "SHOP" means a Small Business Health Options Program operated by the KHBE through which a qualified employer can provide a qualified employee and their dependents with access to one (1) or more QHPs.

      (43) "Small group" is defined by KRS 304.17A-005(42).

      (44) "Stand-alone dental plan" means a dental plan as described by 45 C.F.R. 155.1065.

      (45) "Summary of Benefits and Coverage" or "SBC" means a standard format, created in accordance with 42 U.S.C. 300gg-15, for providing information to consumers about a health plan’s coverage and benefits.

      (46) "System for Electronic Rate and Form Filing" or "SERFF" means an online system established and maintained by the National Association of Insurance Commissioners (NAIC) that enables an issuer to send and a state to receive, comment on, and approve or reject rate and form filings.

 

      Section 2. QHP Issuer General Requirements. In order for an issuer to participate in the KHBE beginning January 1, 2014, the issuer shall:

      (1) Hold a certificate of authority and be in good standing with the Kentucky Department of Insurance;

      (2) Be authorized by the office to participate on the KHBE;

      (3) By April 1 of each year, submit Form KHBE-C1, Issuer Participation Intent Form, a nonbinding notice of intent to participate in the exchange during the next calendar year;

      (4) Enter into a participation agreement with the office;

      (5) Offer KHBE certified QHPs in the individual exchange or the SHOP exchange;

      (6) Comply with benefit design standards as established in 45 C.F.R. 156.20;

      (7) Provide coverage of the:

      (a) Essential health benefits; or

      (b) If the stand-alone pediatric dental essential health benefit is offered in the KHBE in accordance with 45 C.F.R 155.1065, essential health benefits excluding pediatric dental essential health benefits;

      (8) Implement and report on a quality improvement strategy or strategies consistent with the standards of 42 U.S.C. 18031(g);

      (9) Comply with applicable standards described in 45 C.F.R. Part 153;

      (10) For the individual exchange, offer at least a:

      (a) QHP with a silver metal level of coverage;

      (b) QHP with a gold metal level of coverage;

      (c) Child-only plan; and

      (d) Catastrophic plan;

      (11) For the SHOP exchange, offer at least a:

      (a) QHP with a silver metal level of coverage; and

      (b) QHP with a gold metal level of coverage;

      (12) For the individual and SHOP exchange, offer no more than four (4) QHPs within a specified metal level of coverage. For the purposes of establishing the number of QHPs offered in a metal level, the office shall consider the same plan offered with dental benefits and offered without dental benefits as one (1) QHP;

      (13) Not discriminate, with respect to a QHP, on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation;

      (14) Assure that the non-discrimination requirements in 42 U.S.C. 300gg-5 are met;

      (15) If participating in the small group market, comply with KHBE processes, procedures, and requirements established in accordance with 42 C.F.R. 155.705 for the small group market;

      (16) Allow a participating agent to:

      (a) Enroll individuals, employers, and employees in QHPs offered on the exchange;

      (b) Enroll qualified individuals in a QHP in a manner that constitutes enrollment through the KHBE; and

      (c) Assist individuals in applying for advance payments of premium tax credit and cost sharing reductions;

      (17)(a) Offer a QHP in a statewide service area, except as allowed under paragraph (b) of this subsection; or

      (b) Offer a QHP in a service area less than statewide if:

      1. A QHP is available statewide;

      2. The issuer’s service area includes one (1) or more counties;

      3. The issuer’s service area is approved by the DOI; and

      4. The issuer’s service area is established in a nondiscriminatory manner without regard to:

      a. Race;

      b. Ethnicity;

      c. Language;

      d. Health status of an individual in a service area; or

      e. A factor that excludes a high utilizing, high cost, or medically-underserved population; and

      (18) Comply with the requirements of KRS Chapter 304.

 

      Section 3. QHP Rate and Benefit Information. (1) A QHP issuer shall:

      (a) Comply with the provisions of 45 C.F.R. 156.210 and KRS 304.17A-095(4);

      (b) Submit to DOI through the SERFF system:

      1. Form filings in compliance with KRS 304.14-120 and applicable administrative regulations promulgated thereunder;

      2. Rate filings in compliance with KRS 304.17A-095 and applicable administrative regulations promulgated thereunder; and

      3. Plan management data templates;

      (c) Receive approval from DOI for a rate filing prior to implementation of the approved rate; and

      (d) For a rate increase, post the justification prominently on the QHP issuer’s Web site.

      (2) A CO-OP, multi-state plan, and qualified dental plan shall comply with the requirements established in subsection (1) of this section.

 

      Section 4. QHP Certification and Recertification Timeframes. (1) The office shall take final action on the request for:

      (a) Certification no later than September 30 for the following plan year; or

      (b) Recertification of QHPs no later than September 15 for the following plan year.

      (2) A QHP not certified by September 30 or recertified by September 15 shall not be offered on the exchange at any time during the following calendar year.

 

      Section 5. Transparency in Coverage. (1) A QHP issuer shall provide the following information to the office in accordance with the standards established by subsection (2) of this section:

      (a) Claims payment policies and practices;

      (b) Periodic financial disclosures;

      (c) Data on enrollment;

      (d) Data on disenrollment;

      (e) Data on the number of denied claims;

      (f) Data on rating practices;

      (g) SBC;

      (h) Information on cost-sharing and payments for out-of-network coverage; and

      (i) Information on enrollee rights under Title I of the Affordable Care Act.

      (2) A QHP issuer shall:

      (a) Submit, in an accurate and timely manner, to be determined by HHS, the information described in subsection (1) of this section to the KHBE, HHS, and DOI; and

      (b) Provide public access to the information described in subsection (1) of this section.

      (3) A QHP issuer shall ensure that the information submitted under subsection (1) of this section is provided in plain language as the term is defined by 45 C.F.R. 155.20.

      (4)(a) A QHP issuer shall make available, in a timely manner, information about the amount of enrollee cost-sharing under the enrollee’s plan or coverage relating to provision of a specific item or service by a participating provider upon the request of the enrollee.

      (b) The information shall be made available to an enrollee through:

      1. An Internet Web site; and

      2. Other means if the enrollee does not have access to the Internet.

 

      Section 6. Marketing and Benefit Design of QHPs. A QHP issuer and its officials, employees, agents, and representatives shall:

      (1) Comply with issuer marketing practices provided under KRS Chapter 304.17A and 806 KAR 12:010; and

      (2) Not employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with complex health care needs in QHPs.

 

      Section 7. Network Adequacy Standards. (1) A QHP issuer shall ensure that the provider network of a QHP:

      (a) Is available to all enrollees within the QHP service area;

      (b) Includes essential community providers in the QHP provider network in accordance with 45 C.F.R. 156.235 and meets the network adequacy standards for essential community providers as established in Section 8 of this administrative regulation;

      (c) Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be provided in a timely manner; and

      (d) Meets the reasonable network adequacy provisions of 45 C.F.R. 156.230 and KRS 304.17A-515.

      (2) A QHP issuer shall make its provider directory for a QHP available:

      (a) To the KHBE for online publication;

      (b) To potential enrollees in hard copy upon request; and

      (c) In accordance with KRS 304.17A-590.

      (3) A QHP issuer shall identify in the QHP provider directory a provider that is not accepting new patients.

 

      Section 8. Network Adequacy Standards for Essential Community Providers. A QHP issuer shall:

      (1)(a) Demonstrate a provider network, which includes at least twenty (20) percent of available essential community providers in the QHP service area participate in the issuers provider network; and

      (b) Offer a contract to:

      1. At least one (1) essential community provider in each essential community provider category in each county in the service area where an essential community provider in that category is available; and

      2. Available Indian providers in the service area, using the Model Indian Addendum as developed by The Centers for Medicare and Medicaid Services and identified in Supplementary Response: Inclusion of Essential Community Providers, incorporated by reference in this administrative regulation; or

      (2) If unable to comply with the requirements in subsection (1) of this section:

      (a) Demonstrate a provider network which includes at least ten (10) percent of available essential community providers in the QHP service area; and

      (b) Submit a supplementary response as identified in Supplementary Response: Inclusion of Essential Community Providers as incorporated by reference in this administrative regulation.

 

      Section 9. Health Plan Applications and Notices. A QHP issuer shall provide an application, including the streamlined application designated by the office, and notices to enrollees pursuant to standards described in 45 C.F.R. 155.230.

 

      Section 10. Consistency of Premium Rates Inside and Outside the KHBE for the Same QHP. A QHP issuer shall charge the same premium rate without regard to whether the plan is offered:

      (1) Through the KHBE;

      (2) By an issuer outside the KHBE; or

      (3) Through a participating agent.

 

      Section 11. Enrollment Periods for Qualified Individuals. (1) A QHP issuer participating in the individual market shall:

      (a) Enroll a qualified individual during the initial and annual open enrollment periods described in 45 C.F.R 155.410(b) and (e) and comply with the effective dates of coverage established by the office in accordance with 45 C.F.R. 155.410(c)(1) and (f); and

      (b) Make available, at a minimum, special enrollment periods described in 45 C.F.R. 155.420(d), for QHPs and comply with the effective dates of coverage established by the KHBE in accordance with 45 C.F.R 155.420(b).

      (2) A QHP issuer shall notify a qualified individual of the effective date of coverage.

      (3) Notwithstanding the requirements of this section, coverage shall not be effective until premium payment is submitted by the individual.

 

      Section 12. Enrollment Process for Qualified Individuals. (1) A QHP issuer shall process enrollment of an individual in accordance with this section.

      (2) A QHP issuer participating in the individual market shall enroll a qualified individual if the KHBE:

      (a) Notifies the QHP issuer that the individual is a qualified individual; and

      (b) Transmits information to the QHP issuer in accordance with 45 C.F.R. 155.400(a).

      (3) If an applicant initiates enrollment directly with the QHP issuer for enrollment in a plan offered through the KHBE, the QHP issuer shall either:

      (a) Direct the individual to file an application with the KHBE in accordance with 45 C.F.R. 155.310; or

      (b) Ensure the applicant received an eligibility determination for coverage through the KHBE through the KHBE Internet Web site.

      (4) A QHP issuer shall accept enrollment information in accordance with the privacy and security requirements established by the office pursuant to 45 C.F.R. 155.260 and in an electronic format pursuant to with 45 C.F.R. 155.270.

      (5) A QHP issuer shall follow the premium payment process established by the KHBE in accordance with 45 C.F.R. 155.240.

      (6) A QHP issuer shall provide new enrollees with an enrollment information package that complies with the accessibility and readability requirements established by 45 C.F.R. 155.230(b).

      (7) A QHP issuer shall reconcile enrollment files with the KHBE no less than once a month in accordance with 45 C.F.R. 155.400(d).

      (8) A QHP issuer shall acknowledge receipt of enrollment information transmitted from the KHBE in accordance with KHBE requirements established by 45 C.F.R. 155.400(b)(2).

 

      Section 13. Termination of Coverage for Qualified Individuals. (1) A QHP issuer may terminate coverage of an enrollee in accordance with 45 C.F.R. 155.430(b)(2).

      (2) If an enrollee’s coverage in a QHP is terminated for any reason, the QHP issuer shall:

      (a) Provide the enrollee with a notice of termination of coverage that includes the reason for termination at least thirty (30) days prior to the final day of coverage, in accordance with the effective date established pursuant to 45 C.F.R. 155.430(d);

      (b) Notify the KHBE of the termination effective date and reason for termination; and

      (c) Comply with the requirements of KRS 304.17A-240 to 304.17A-245.

      (3) Termination of coverage of enrollees due to non-payment of premium in accordance with 45 C.F.R. 155.430(b)(2)(ii) shall:

      (a) Include the grace period for enrollees receiving advance payments of the premium tax credits as described in 45 C.F.R. 156.270(d); and

      (b) Be applied uniformly to enrollees in similar circumstances.

      (4) A QHP issuer shall provide a grace period of three (3) consecutive months if an enrollee receiving advance payments of the premium tax credit has previously paid at least one (1) full month’s premium during the benefit year. During the grace period, the QHP issuer:

      (a) 1. Shall pay claims for services provided to the enrollee in the first month of the grace period; and

      2. May suspend payment of claims for services provided to the enrollee in the second and third months of the grace period;

      (b) Shall notify HHS of the non-payment of the premium due; and

      (c) Shall notify providers of the possibility for denied claims for services provided to an enrollee in the second and third months of the grace period.

      (5) For the three (3) months grace period described in subsection (4) of this section, a QHP issuer shall:

      (a) Continue to collect advance payments of the premium tax credit on behalf of the enrollee from the U.S. Department of the Treasury; and

      (b) Return advance payments of the premium tax credit paid on behalf of the enrollee for the second and third months of the grace period if the enrollee exhausts the grace period as described in subsection (7) of this section.

      (6) If an enrollee is delinquent on premium payment, the QHP issuer shall provide the enrollee with a notice of the payment delinquency.

      (7) If an enrollee receiving advance payments of the premium tax credit exhausts the three (3) months grace period in subsection (4) of this section without paying the outstanding premiums, the QHP issuer shall terminate the enrollee’s coverage on the effective date of termination described in 45 C.F.R. 155.430(d)(4) if the QHP issuer meets the notice requirement specified in subsection (2) of this section.

      (8) A QHP issuer shall maintain records in accordance with KHBE requirements established pursuant to 45 C.F.R. 155.430(c).

      (9) A QHP issuer shall comply with the termination of coverage effective dates as described in 45 C.F.R. 155.430(d).

 

      Section 14. Accreditation of QHP Issuers. (1) A QHP issuer shall:

      (a) Be accredited on the basis of local performance of a QHP by an accrediting entity recognized by HHS in categories identified by 45 C.F.R. 156.275(a)(1); and

      (b) Pursuant to 45 C.F.R. 156.275(a)(2) authorize the accrediting entity that accredits the QHP issuer to release to the KHBE and HHS:

      1. A copy of the most recent accreditation survey; and

      2. Accreditation survey-related information that HHS may require, including corrective action plans and summaries of findings.

      (2)(a) A QHP issuer shall be accredited prior to the fourth year of QHP certification and in every subsequent year of certification in accordance with requirements identified by 45 C.F.R. 155.1045.

      (b) A QHP issuer seeking certification of a QHP that has not received accreditation for the QHP shall submit evidence to support that the issuer has a plan for obtaining accreditation of the QHP within the timeline identified in paragraph (a) of this subsection.

      (3) The QHP issuer shall maintain accreditation so long as the QHP issuer offers QHPs.

 

      Section 15. Recertification, Non-renewal, and Decertification of QHPs. (1) A QHP shall be recertified in accordance with the requirements of this administrative regulation every two (2) years no later than September 15 for the following two (2) plan years.

      (2) An issuer shall submit to the exchange a request for recertification of a QHP at least 120 days prior to an expiration of a certification.

      (3) If a QHP issuer elects not to seek recertification with the office, the QHP issuer, at a minimum, shall:

      (a) Notify the office of its decision prior to the beginning of the recertification process and follow the procedures adopted by the KHBE in accordance with 45 C.F.R. 155.1075;

      (b) Provide benefits for enrollees through the final day of the plan or benefit year;

      (c) Submit reports as required by the office for the final plan or benefit year of the certification;

      (d) Provide notices to enrollees in accordance with Section 13 of this administrative regulation;

      (e) Terminate coverage of enrollees in the QHP in accordance with 45 C.F.R. 156.270, as applicable; and

      (f) Comply with requirements of KRS 304.17A-240 and 304.17A-245, as applicable.

      (4) If a QHP is decertified by the office pursuant to 45 C.F.R. 155.1080, the QHP issuer shall terminate coverage of enrollees only after:

      (a) The KHBE has provided notification as required by 45 C.F.R 155.1080(e);

      (b) Enrollees have an opportunity to enroll in other coverage; and

      (c) The QHP issuer has complied with the requirements of KRS 304.17A-240 and 304.17A-245, as applicable.

 

      Section 16. General Requirements for a Stand-alone Dental Plan. (1) In order for a dental insurer to participate in the KHBE beginning January 1, 2014 and offer a stand-alone dental plan, the dental insurer shall:

      (a) Hold a certificate of authority to offer dental plans and be in good standing with the Kentucky Department of Insurance;

      (b) Be authorized by the office to participate on the KHBE;

      (c) By April 1 of each year, submit Form KHBE-C1, Issuer Participation Intent Form, a nonbinding notice of intent to participate in the exchange during the next calendar year;

      (d) Enter into a participation agreement with the office;

      (e) Offer a pediatric dental plan certified by the office in accordance with this administrative regulation in the individual exchange or SHOP exchange that shall:

      1. Comply with the requirements of KRS Chapter 304 Subtitle17C;

      2. Submit to DOI through the SERFF system:

      a. Form filings in compliance with KRS Chapter 304;

      b. Rate filings in compliance with KRS 304.17-380; and

      c. Dental plan management data templates;

      (f) Offer a stand-alone dental plan that shall:

      1. Be limited to a pediatric dental essential health benefit required by 42 U.S.C. 18022(b)(1)(J) for individuals up to twenty-one (21) years of age;

      2. Pursuant to 45 C.F.R. 156.150, provide within a variation of plus or minus two (2) percentage points:

      a. A low level of coverage with an actuarial value of seventy (70) percent; and

      b. A high level of coverage with an actuarial value of eighty five (85) percent; and

      3. Have an annual limitation on cost-sharing at or below:

      a. $1,000 for a plan with one (1) child enrollee; or

      b. $2,000 for a plan with two (2) or more child enrollees;

      (g) Comply with the:

      1. Provider network adequacy requirements identified by KRS 304.17C-040 and maintain a network that is sufficient in number and types of dental providers to assure that all dental services will be accessible without unreasonable delay in accordance with 45 C.F.R. 156.230;

      2. Requirements for stand-alone dental plans referenced in 45 C.F.R. 156 Subpart E; and

      3. Essential community provider requirement in 45 C.F.R. 156.235;

      (h) Not discriminate, with respect to a pediatric dental plan, on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation; and

      (i) Make its provider directory for a QHP available:

      1. To the KHBE for online publication;

      2. To potential enrollees in hard copy upon request; and

      3. In accordance with KRS 304.17A-590.

      (2) A dental insurer offering a stand-alone dental plan participating in the KHBE beginning January 1, 2014:

      (a) May offer a stand-alone dental plan which includes coverage for individuals regardless of age which includes at a minimum a pediatric dental essential health benefit required by 42 U.S.C. 18022(b)(1)(J) coverage for individuals up to twenty-one (21) years of age; and

      (b) If electing to offer the plan specified in paragraph (a) of this subsection, shall comply with the requirements of subsection (1) of this section.

 

      Section 17. Essential health benefits for individuals up to twenty-one (21) years of age. The KHBE shall ensure that an individual up to age twenty-one (21) years of age eligible to enroll in a QHP shall obtain coverage for pediatric dental coverage.

 

      Section 18. Enforcement. The DOI shall be responsible for enforcing the requirements of KRS Chapter 304 and any administrative regulations promulgated thereunder against any issuer.

 

      Section 19. Issuer Appeals. (1) An issuer may appeal the office’s decision to:

      (a) Deny certification of a QHP;

      (b) Deny recertification of a QHP; or

      (c) Decertify a QHP.

      (2) An issuer appeal identified in subsection (1) of this section shall be made to the office in accordance with KRS Chapter 13B.

 

      Section 20. Incorporation by Reference. (1) The following material is incorporated by reference:

      (a) "Chapter 7: Instructions for the Essential Community Providers Application Section", April 2013 version;

      (b) "Form KHBE-C1, Issuer Participation Intent Form", revised October, 2013; and

      (c) "Supplementary Response: Inclusion of Essential Community Providers", April 2013 version.

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Office of the Kentucky Health Benefit Exchange, 12 Mill Creek Park, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m., or from its Web site at www.healthbenefitexchange.ky.gov. (39 Ky.R. 2443; 40 Ky.R. 597; 1075; eff. 12-10-2013.)