CABINET FOR HEALTH AND FAMILY SERVICES

Kentucky Office of Health Benefit and Health Information

Exchange

(Amendment)

 

      900 KAR 10:010. Exchange participation requirements and certification of qualified health plans and qualified stand-alone 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 Office of Health Benefit and Health Information 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 or a qualified stand-alone dental 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) "Accreditation" means an accrediting entity recognized by HHS has reviewed the local performance of the health insurer’s health insurance plans and assigned a level of accreditation.

      (2) "Actuarial value" is defined by 45 C.F.R. 156.20[means the percentage of the total allowed costs of benefits paid by a health plan].

      (3)[(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.

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

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

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

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

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

      (9)[(8)] "Certification" means a determination by the Kentucky Office of Health Benefit and Health Information Exchange (KOHBHIE) that a health plan or a stand-alone dental plan has met the requirements established in Sections 2 through 21[19] of this administrative regulation.

      (10)[(9)] "Child-only plan" means an individual health policy that meets the requirements of 45 C.F.R. 156.200(c)(2) and provides coverage:

      (a) To an individual under twenty-one (21) years of age; or

      (b) That does not restrict the age of the primary subscriber to an individual over age twenty-one (21)[and meets the requirements of 45 C.F.R 156.200(c)(2)].

      (11)[(10)] "Consumer Operated and Oriented Plan" or "CO-OP" is defined by 45 C.F.R. 156.505[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].

      (12) "Cost-sharing reduction" or "CSR" means a reduction in cost sharing for an eligible individual enrolled in a silver level plan in an individual exchange or for an individual who is an Indian enrolled in a qualified health plan in an individual exchange.

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

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

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

      (16)[(14)] "Enrollee" means an eligible individual enrolled in a qualified health plan or qualified stand-alone dental plan.

      (17)[(15)] "Essential community provider" means either a:

      (a) Provider defined by 45 C.F.R. 156.235(c) that is 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.

      (18)[(16)] "Essential community provider category" means a provider as described in 45 C.F.R. 156.235(a)(2)(ii)(B)[Chapter 7: Instructions for the Essential Community Providers Application Section, as incorporated by reference in this administrative regulation].

      (19)[(17)] "Essential health benefits" or "EHB" means the essential health benefits package referenced in 45 C.F.R. 156.20[benefits as identified by 42 U.S.C. 18022] and approved by the Secretary of HHS for the Commonwealth of Kentucky.

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

      (21)[(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.

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

      (23)[(21)] "Individual exchange" means the Kentucky Health Benefit Exchange that serves the individual health insurance market.

      (24)[(22)] "Individual market" is defined by KRS 304.17A-005(26).

      (25)[(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.

      (26)[(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 or SADP[beginning January 1, 2014], that includes an:

      (a) Individual exchange; and

      (b) SHOP[Small Business Health Options Program].

      (27) "Kentucky Office of Health Benefit and Health Information Exchange", "KOHBHIE", or "office" means the office created to administer the Kentucky Health Benefit Exchange.

      (28) "Market segment" means either small group or individual market.

      (29)[(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 sixty (60) percent;

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

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

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

      (30)[(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.

      (31)[(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.

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

      (33)[(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) and includes the benefits specified in 907 KAR 1:026.

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

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

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

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

      (38)[(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.

      (39)[(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.

      (40)[(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.

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

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

      (43)[(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.

      (44)[(43)] "Small group" is defined by KRS 304.17A-005(42) until superseded by 45 C.F.R. 155.20.

      (45) "Spending account fact sheet" means a document that provides details about a health spending account, flexible spending account, or a health reimbursement account arrangement offered by the issuer as part of the benefits in a QHP.

      (46)[(44)] "Stand-alone dental plan" or "SADP" means a dental plan as described by 45 C.F.R. 155.1065 that has been certified by the office to provide a limited scope of dental benefits as defined in 26 U.S.C. 9832(c)(2)(A), including a pediatric dental essential health benefit.

      (47) "Statement of dental coverage" means a written statement for providing information to consumers about an SADP’s coverage, benefits, and cost-sharing.

      (48)[(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.

      (49)[(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) For the first year of participation in a new market segment, 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 each county within Kentucky in accordance with 45 C.F.R 155.1065, essential health benefits excluding pediatric dental essential health benefits;

      (8)(a) Submit to the office[Implement and report on] a quality improvement strategy plan in compliance with 45 C.F.R. 156.200(b)(5) and 45 C.F.R. 156.1130[or strategies consistent with the standards of 42 U.S.C. 18031(g)];

      (b) In the initial QHP certification process, submit an attestation to the office that the issuer shall comply with the quality requirements identified in 45 C.F.R. 156.200(b)(5) including:

      1. Collection, disclosure, and report of information related to health care quality and outcomes in year two (2) of offering QHPs on the KHBE and annually thereafter; and

      2. Implementation of an enrollee satisfaction survey in year two (2) of offering QHPs on the KHBE and annually thereafter;

      (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 eight (8)[four (4)] QHPs within a specified metal level of coverage within a market segment. 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 and in accordance with 900 KAR 10:020;

      (16) Allow a registered participating agent to enroll qualified individuals, qualified employers, and qualified employees on KHBE in accordance with the requirements of 900 KAR 10:050[:

      (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; and

      (19) Submit form KHBE-C2, Kentucky Health Benefit Exchange Attestations.

 

      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 stand-alone 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 twenty-five (25) calendar days prior to the start of the annual open enrollment period[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 twenty-five (25) calendar days prior to the start of the annual open enrollment period[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) Data as identified in 45 C.F.R. 155.1050(a) and 156.220[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 written in English for each cost sharing reduction level in a QHP with the exception of zero cost sharing level for an Indian;

      (c) SBC written in Spanish for each cost sharing reduction level in a QHP with the exception of zero cost sharing level for an Indian, with verification that the Spanish language version is a certified translation of the English version;

      (d) If the plan includes a health reimbursement account, flexible spending account, or health savings account, a spending account fact sheet written in English for each cost sharing reduction level in a QHP consistent with the requirements in KRS 304.12-020 and 806 KAR 12:010;

      (e) If the plan includes a health reimbursement account, flexible spending account, or health savings account, a spending account fact sheet written in Spanish for each cost sharing reduction level in a QHP with verification that the Spanish language version is a certified translation of the English version;

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

      (g)[(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)(a), (f), and (g) of this section to the KHBE, HHS, and DOI;[and]

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

      (c) Provide the items described in subsection (1)(b) and (d) of this section to KHBE within five (5) calendar days of the date DOI has approved rate and form filings in SERFF; and

      (d) Provide the items described in subsection (1)(c) and (e) of this section to KHBE within fourteen (14) calendar days of the date KHBE has approved the items described in paragraph (c) of this subsection.

      (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.

      (5) A QHP issuer may provide the following information to KHBE in accordance with the standards established by subsection (2) of this section:

      (a) SBC written in English for each zero cost sharing level for an Indian in a QHP; and

      (b) SBC written in Spanish for each zero cost sharing level for an Indian in a QHP, with verification that the Spanish language version is a certified translation of the English version.

 

      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; and

      (e) If not a managed care plan, 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 the minimum[twenty (20)] percent of available essential community providers in the QHP service area participate in the issuer’s[issuers] provider network as required by 45 C.F.R. 156.235(a)(2)(i); 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 accept an enrollment during the open enrollment period or special enrollment period for a qualified individual participating in the individual market with effective dates of coverage established by the office in accordance with 45 C.F.R. 155.410(c)(1) and (f) and 45 C.F.R 155.420(b)[:

      (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) Premium invoices shall be generated to a qualified individual within five (5) business days from receipt of KHBE enrollment transactions.

      (4) A QHP issuer shall allow a qualified individual a minimum of thirty (30) days from the date of the initial invoice to submit premium payment before coverage can be cancelled.

      (5) A QHP issuer shall allow a qualified individual a minimum of thirty (30) days from the date of a corrected invoice to submit premium payment before coverage can be terminated.

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

      (7) The issuer shall mail proof of coverage, including insurance identification cards, to enrollees within ten (10) calendar days of receipt of initial premium payment for ninety-nine (99) percent of enrollments.

 

      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 that meets the requirements established by the office 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 or Cancellation 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 by the issuer 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) Prior to termination of coverage, 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 the KHBE[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) month[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).

      (10) A QHP issuer may cancel coverage of an enrollee in accordance with 45 C.F.R. 155.430(b)(2) and (e).

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

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

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

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

      (12) Cancellation of coverage of enrollees due to non-payment of premium in accordance with 45 C.F.R. 155.430(b)(2)(ii) shall be applied uniformly to enrollees in similar circumstances.

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

      (14) If coverage of an enrollee is terminated or cancelled by the KHBE for any reason, the QHP issuer shall provide the enrollee a notice of the termination or cancellation within fifteen (15) days of receipt of the transaction from the KHBE.

 

      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 thereafter in accordance with requirements and timeline identified under[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 an attestation to the office that the issuer shall obtain[evidence to support that the issuer has a plan for obtaining] accreditation in accordance with[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 or withdrawn by the issuer after certification, 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.

      (2) If a QHP issuer fails to meet ongoing compliance requirements of Section 20 of this administrative regulation, the office may require the issuer to:

      (a) Submit a corrective action plan to address deficiencies to ongoing compliance requirements within thirty (30) days of notification of the deficiency; and

      (b) Submit evidence of compliance with the corrective action plan within the timeframes established in the office approved corrective plan.

      (3) If the office finds that the QHP issuer failed to meet the requirements of subsection (2) of this section, the office may implement a prohibition against new enrollments on KHBE for the QHP issuer and market segment out of compliance or may decertify all plans offered by the QHP issuer within the market segment.

 

      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 that would permit the issuer 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) For the first year of participation in a new market segment, 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. Provide the[Be limited to a] pediatric dental essential health benefits[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 for a stand-alone dental plan covering the pediatric dental EHB under 45 C.F.R. 155.1065 at or below:

      a. $350[$1,000] for a plan with one (1) child enrollee; or

      b. $700[$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 shall provide the following information to the office[beginning January 1, 2014]:

      (a) Statement of dental coverage written in English consistent with the requirements in KRS 304.12-020 and 806 KAR 12:010;

      (b) Statement of dental coverage written in Spanish with verification that the Spanish language version is a certified translation of the English version;

      (c) The item described in paragraph (a) of this subsection within five (5) calendar days of the date DOI has approved rate and form filings in SERFF; and

      (d) The item described in paragraph (b) of this subsection within fourteen (14) calendar days of the date KHBE has approved the items described in paragraph (a) of this subsection[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 three (3) years of age and up to twenty-one (21) years of age. The KHBE shall ensure that an individual three (3) years of age and 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. Timeframes for Transactions. (1) QHP issuers shall generate a required acknowledgement and process all KHBE initiated transactions within forty-eight (48) hours of receipt of a complete electronic transaction from the KHBE for ninety-five (95) percent of enrollments.

      (2) QHP issuers shall provide effectuation transactions to the KHBE within forty-eight (48) hours of receipt of the initial premium payment and issuer initiated cancellation and termination transactions within forty-eight (48) hours of the cancellation or termination of coverage for ninety-five (95) percent of cancellations and terminations.

 

      Section 20. On-going Compliance. The office shall be responsible for enforcing the requirements referenced in 45 C.F.R. 155.1010(a)(2).

 

      Section 21. Issuer Appeals. (1) An issuer may appeal the office’s decision to:

      (a) Deny certification of a QHP;

      (b) Implement a prohibition against new enrollments by a QHP issuer in a market segment[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 22.[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", May, 2015;

      (b) "Form KHBE-C2, Kentucky Health Benefit Exchange Attestations", May, 2015[revised October, 2013]; and

      (c) "Supplementary Response: Inclusion of Essential Community Providers", May 2015[April 2013 version].

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the[Office of the] Kentucky Office of Health Benefit and Health Information 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.

 

CARRIE BANAHAN, Executive Director

AUDREY TAYSE HAYNES, Secretary

      APPROVED BY AGENCY: May 13, 2015

      FILED WITH LRC: May 14, 2015 at 4 p.m.

      PUBLIC HEARING AND PUBLIC COMMENT PERIOD: A public hearing on this administrative regulation shall, if requested, be held on June 22, 2015, at 9:00 a.m. in the Public Health Auditorium located on the First Floor, 275 East Main Street, Frankfort, Kentucky 40621. Individuals interested in attending this hearing shall notify this agency in writing by June 15, 2015, five (5) workdays prior to the hearing, of their intent to attend. If no notification of intent to attend the hearing is received by that date, the hearing may be canceled. The hearing is open to the public. Any person who attends will be given an opportunity to comment on the proposed administrative regulation. A transcript of the public hearing will not be made unless a written request for a transcript is made. If you do not wish to attend the public hearing, you may submit written comments on the proposed administrative regulation. You may submit written comments regarding this proposed administrative regulation until June 30, 2015. Send written notification of intent to attend the public hearing or written comments on the proposed administrative regulation to:

      CONTACT PERSON: Tricia Orme, Office of Legal Services, 275 East Main Street 5 W-B, Frankfort, Kentucky 40621, phone (502) 564-7905, fax (502) 564-7573, email address tricia.orme@ky.gov.

 

REGULATORY IMPACT ANALYSIS AND TIERING STATEMENT

 

Contact Person: Carrie Banahan

      (1) Provide a brief summary of:

      (a) What this administrative regulation does: This administrative regulation establishes the criteria for certification as a qualified health plan or a qualified dental plan to be offered on the Kentucky Health Benefit Exchange as required by 45 C.F.R. Parts 155 and 156.

      (b) The necessity of this administrative regulation: This administrative regulation is necessary to inform issuers of the requirements for certification of a health plan as a qualified health plan or certification of a dental plan as a qualified dental plan to be offered on the Kentucky Health Benefit Exchange.

      (c) How this administrative regulation conforms to the content of the authorizing statutes: This administrative regulation is necessary so that issuers are aware of the requirements for certification of a health plan as a qualified health plan or dental plan as a qualified dental plan to be offered on the Kentucky Health Benefit Exchange as required by 45 C.F.R. Parts 155 and 156.

      (d) How this administrative regulation currently assists or will assist in the effective administration of the statutes: This administrative regulation provides detailed requirements for certification of a health plan as a qualified health plan or certification of a dental plan as a qualified dental plan to be offered on the Kentucky Health Benefit Exchange to comply with the statute.

      (2) If this is an amendment to an existing administrative regulation, provide a brief summary of:

      (a) How the amendment will change this existing administrative regulation: The amendments to this administrative regulation clarify policy regarding submission of Summary of Benefits and Coverage, Spending Account Fact Sheets, Statement of Dental Coverage, and program attestations by issuers as well as timeframes for processing electronic transactions to or from KHBE. Plans are certified for one (1) year and must complete the certification process no later than twenty-five (25) calendar days prior to the start of annual open enrollment. Issuers failing to meet ongoing compliance requirements may be required to submit a corrective plan and if they continue to fail to meet requirements may face a prohibition of new enrollments on KHBE or the plans may be decertified. Issuers may now offer up to eight (8) plans in each metal level within a market segment.

      (b) The necessity of the amendment to this administrative regulation: The amendment to this administrative regulation is necessary to conform with new federal rules issued and to all issuer to offer more plans on KHBE.

      (c) How the amendment conforms to the content of the authorizing statutes: This amendment conforms to the content of the authorizing statues by providing information regarding the certification process of qualified health plans and stand-alone dental plans for participation on KHBE.

      (d) How the amendment will assist in the effective administration of the statutes: This administrative regulation will assist issuers by providing information regarding the certification process of qualified health plans and stand-alone dental plans for participation on KHBE.

      (3) List the type and number of individuals, businesses, organizations, or state and local governments affected by this administrative regulation: This administrative regulation will affect approximately fifteen (15) issuers that may request certification of a health plan as a qualified health plan or certification of a dental plan as a qualified dental plan to be offered on the Kentucky Health Benefit Exchange.

      (4) Provide an analysis of how the entities identified in question (3) will be impacted by either the implementation of this administrative regulation, if new, or by the change, if it is an amendment, including:

      (a) List the actions that each of the regulated entities identified in question (3) will have to take to comply with this administrative regulation or amendment: Each entity will submit information electronically through the SERFF system related to rate and form filings to the Department of Insurance for review by DOI and KHBE.

      (b) In complying with this administrative regulation or amendment, how much will it cost each of the entities identified in question (3): $1,000.

      (c) As a result of compliance, what benefits will accrue to the entities identified in question (3): This administrative regulation will benefit each issuer that may request certification of a health plan as a qualified health plan or certification of a dental plan as a qualified dental plan to be offered on the Kentucky Health Benefit by providing detailed instructions regarding certification of Qualified Health Plans.

      (5) Provide an estimate of how much it will cost the administrative body to implement this administrative regulation:

      (a) Initially: No additional costs will be incurred to implement this administrative regulation.

      (b) On a continuing basis: No additional costs will be incurred.

      (6) What is the source of the funding to be used for the implementation and enforcement of this administrative regulation: The source of funding to be used for the implementation and enforcement of this administrative regulation will be from Kentucky Office of Health Benefit and Health Information Exchange existing budget. No new funding will be needed to implement the provisions of this regulation.

      (7) Provide an assessment of whether an increase in fees or funding will be necessary to implement this administrative regulation, if new, or by the change if it is an amendment: No increase in fees or funding is necessary.

      (8) State whether or not this administrative regulation established any fees or directly or indirectly increased any fees: This administrative regulation does not establish any fees and does not increase any fees either directly or indirectly.

      (9) TIERING: Is tiering applied? Tiering was not appropriate in this administrative regulation because the administrative regulation applies equally to all those individuals or entities regulated by it.

 

FISCAL NOTE ON STATE OR LOCAL GOVERNMENT

 

      (1) What units, parts, or divisions of state or local government (including cities, counties, fire departments, or school districts) will be impacted by this administrative regulation? This administrative regulation affects the Office of the Kentucky Health Benefit Exchange within the Cabinet for Health and Family Services.

      (2) Identify each state or federal statute or federal regulation that requires or authorizes the action taken by the administrative regulation. KRS 194A.050(1), 42 U.S.C. § 18031, and 45 C.F.R. Parts 155 and 156.

      (3) Estimate the effect of this administrative regulation on the expenditures and revenues of a state or local government agency (including cities, counties, fire departments, or school districts) for the first full year the administrative regulation is to be in effect.

      (a) How much revenue will this administrative regulation generate for the state or local government (including cities, counties, fire departments, or school districts) for the first year? This administrative regulation will not generate any revenue.

      (b) How much revenue will this administrative regulation generate for the state or local government (including cities, counties, fire departments, or school districts) for subsequent years? This administrative regulation will not generate any revenue.

      (c) How much will it cost to administer this program for the first year? No additional costs will be incurred to implement this administrative regulation.

      (d) How much will it cost to administer this program for subsequent years? No additional costs will be incurred to implement this administrative regulation on a continuing basis.

      Note: If specific dollar estimates cannot be determined, provide a brief narrative to explain the fiscal impact of the administrative regulation.

      Revenues (+/-):

      Expenditures (+/-):

      Other Explanation:

 

FEDERAL MANDATE ANALYSIS COMPARISON

 

      1. Federal statute or regulation constituting the federal mandate. 42 U.S.C. Section 18031 and 45 C.F.R. Parts 155 and 156.

      2. State compliance standards. 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. Section 18031 and 45 C.F.R. Parts 155 and 156.

      3. Minimum or uniform standards contained in the federal mandate. The Affordable Care Act establishes the creation of the American Health Benefit Exchange as identified in Section 1311(a) of the Affordable Care Act. The "Kentucky Health Benefit Exchange" (KHBE) is the Kentucky state-based exchange conditionally approved by HHS established by 45 C.F.R. 155.105 to offer a QHP in Kentucky beginning January 1, 2014. An Exchange must make qualified health plans available to qualified individuals and qualified employers.  At a minimum, an Exchange must implement procedures for the certification, recertification, and decertification of health plans as qualified health plans. The Affordable Care Act allows for Exchanges to certify health plans as qualified health plans. This certification may be done if: the health plan meets the rules for certification by the U. S. Department of Health and Human Services; and

the Exchange determines that making such health plan available through the Exchange is in the interests of qualified individuals and qualified employers in the state or states in which the Exchange operates. The Exchange must require health plans seeking certification as qualified health plans to submit a justification for any premium increase prior to implementation of the increase. These plans must prominently post such information on their websites.

      4. Will this administrative regulation impose stricter requirements, or additional or different responsibilities or requirements, than those required by the federal mandate? No.

      5. Justification for the imposition of the stricter standard, or additional or different responsibilities or requirements. This administrative regulation does not impose stricter requirements than those required by the federal mandate.