CABINET FOR HEALTH AND FAMILY SERVICES

Kentucky Office of Health Benefit and Information Exchange

(As Amended at ARRS, July 14, 2015)

 

††††† 900 KAR 10:050. Individual Agent[or Business Entity] Participation with the Kentucky Health Benefit Exchange.

 

††††† RELATES TO: KRS 194A.050(1), 42 U.S.C. 18031, 45 C.F.R. Part 155

††††† STATUTORY AUTHORITY: KRS 194A.050(1)

††††† NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Kentucky Office of[the Kentucky] 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 registration of an[a business entity or] individual agent in accordance with 42 U.S.C. 18031 and 45 C.F.R. Part 155.

 

††††† Section 1. Definitions. (1) "Advance payments[Advanced payment] of premium tax credits" or "APTC" means payment of the tax credits authorized by 26 U.S.C. 36B and its implementing regulations, which are provided on an advance basis to an eligible individual enrolled in a qualified health plan through an exchange in accordance with section 1412 of the Affordable Care Act, 42 U.S.C. 18082.

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

††††† (3) "Business entity" is defined by KRS 304.9-020(5).

††††† (4) "Certified application counselor" or "CAC" means an individual employed by, or a volunteer of, an entity designated by the office and the Department for Medicaid Services.

††††† (5) "Consultant" is defined in KRS 304.9-040.

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

††††† (7)[(6)] "Date of[the] notice" means the date on the notice plus five (5) calendar days.

††††† (8)[(7)] "Department of Insurance" or "DOI" is defined by KRS 304.1-050(2).

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

††††† (10)[(8)] "Individual market" is defined by KRS 304.17A-005(26).

††††† (11)[(9)] "In-person assister" means an entity performing functions described in 45 C.F.R. 155.205 selected by the office[of KHBE].

††††† (12)[(10)] "Insurance affordability program" means one (1) of the following:

††††† (a) A state Medicaid program under title XIX of the Social Security Act, 42 U.S.C. 301 et seq.;

††††† (b) A state children's health insurance program (CHIP) under title XXI of the Social Security Act, 42 U.S.C. 301 et seq.;

††††† (c) A program that makes coverage in a qualified health plan through the exchange with advance payments of the premium tax credit established under section 36B of the Internal Revenue Code, 26 U.S.C. 36B, available to qualified individuals; or

††††† (d) A program that makes available coverage in a qualified health plan through the exchange with cost-sharing reductions established under section 1402 of the Affordable Care Act, 42 U.S.C. 18071.

††††† (13)[(11)] "Issuer" is defined by 45 C.F.R. 144.103.

††††† (14)[(12)] "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 stand-alone dental plan (SADP)[beginning January 1, 2014], that includes an:

††††† (a) Individual exchange; and

††††† (b) Small Business Health Options Program (SHOP).

††††† (15)[(13)] "Kentucky Insurance Code" means KRS Chapter 304 and associated administrative regulations.

††††† (16) "Kentucky Office of Health Benefit and[Health] Information Exchange" or "office" means the office created to administer the Kentucky Health Benefit Exchange.

††††† (17)[(14)] "Kentucky Online Gateway" means the system for authentication services for users requesting access to the KHBE portal.

††††† (18)[(15)] "Kynectors" means CACs, in-person assisters, or navigators.

††††† (19)["Managed care organization" or "MCO" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined in 42 C.F.R. 438.2.

††††† (20)][(16)] "Navigator" means an entity as described in 45 C.F.R. 155.210 selected by the Office of KHBE.

††††† (20)[(21)][(17) "Office of the Kentucky Health Benefit Exchange" or "office" means the office created to administer the Kentucky Health Benefit Exchange.

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

††††† (21)[(22)][(19)] "Qualified employee" means an individual employed by a qualified employer who has been offered health insurance coverage by the qualified employer through the SHOP.

††††† (22)[(23)][(20)] "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 or SADPs in the small group market offered through the SHOP.

††††† (23)[(24)][(21)] "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.

††††† (24)[(25)][(22)] "Qualified individual" means an individual who has been determined eligible to enroll through the KHBE in a QHP or SADP in the individual market.

††††† (25)[(26)] "SHOP" means a Small Business Health Options Program operated by the KHBE through which a qualified employer can provide a qualified employee and the employee's dependents with access to one (1) or more QHPs or SADPs.

††††† (26)[(27)][(23)] "Small group" is defined by KRS 304.17A-005(42) until superseded by 45 C.F.R. 155.20[155.1065].

††††† (27)[(28)] "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.

††††† (28)[(29)][(24)] "Training" means the training established by the office for individual agents and kynectors.

††††† (29)[(30)] "Web broker" means an individual engaged in the activities described in 45 C.F.R. 155.220(c)(3).

 

††††† Section 2. Requirements to be a Participating Individual Agent[or Business Entity].[(1)] An individual agent seeking to be a participating agent shall:

††††† (1)[(a)] Be licensed by DOI with a health line of authority;

††††† (2)[(b)] Complete the office approved agent training in accordance with 45 C.F.R. 155.220(d)(2);

††††† (3)[(c)] Sign an individual agent participation agreement;

††††† (4)[(d)] Comply with the privacy and security standards of 45 C.F.R. 155.260;

††††† (5)[(e) 1.] Except for an employee of an issuer or an individual agent directly contracted with an issuer:

††††† (a) Maintain an appointment with at least two (2) QHP or SADP issuers participating on the KHBE; or

††††† (b)[2.] Maintain a designation with a business entity having an appointment with at least two (2) QHP or SADP issuers participating on the KHBE;[and]

††††† (6)[(f)] Register with the KHBE through the Kentucky Online Gateway; and

††††† (7) Not serve as a web broker or consultant while assisting individuals with the activities described in Section 3 of this administrative regulation[(2) A business entity licensed as an agent with a health line of authority seeking to participate with the KHBE shall:

††††† (a) Select an individual to serve as the participating business entity representative who shall:

††††† 1. Register with KHBE through the Kentucky Online Gateway as the individual authorized by the business entity;

††††† 2. Serve as a primary contact for the office;

††††† 3. Ensure that the business entity signs a participation agreement with the office; and

††††† 4. Be responsible for ensuring that only an active Kentucky licensed agent designated with the business entity is provided access to the KHBE through the Kentucky Online Gateway;

††††† (b) Designate the individual agents who shall participate on the KHBE through the participating business entity and who shall:

††††† 1. Complete the agent training provided by the office or an approved party;

††††† 2. Sign an agent participation agreement;

††††† 3. Comply with the privacy and security standards of 45 C.F.R. 155.260; and

††††† 4. Register with the KHBE through the Kentucky Online Gateway; and

††††† (c) Maintain an appointment with at least two (2) QHP issuers participating on the KHBE].

 

††††† Section 3. Permitted Activities of a Participating Individual Agent[or Business Entity]. (1) Upon completion of the registration requirements as set forth in Section 2 of this administrative regulation, a participating individual agent[or business entity] may:

††††† (a) Enroll a qualified individual in any QHP or SADP offered by an issuer with which the individual agent has the appropriate designation or appointment as established[defined] in Section 2(5) of this administrative regulation through the KHBE in the individual market;

††††† (b) Assist qualified employers in selecting a QHP or SADP and enroll qualified employees in a QHP or SADP offered by an issuer with which the individual agent has the appropriate designation or appointment as established[defined] in Section 2(5) of this administrative regulation through the KHBE in the small group market; or

††††† (c) Assist an individual in applying for advance payments of the premium tax credit and cost-sharing reductions.

††††† (2) A qualified individual may be enrolled in a QHP or SADP through the KHBE by a participating individual agent[or business entity] if the participating individual agent[or business entity] ensures the applicantís completion of an application as described in 42 C.F.R. 155.405.

††††† (3) A participating individual agent[or business entity] shall:

††††† (a) Disclose to potential applicants any relationships the individual agent[or business entity] has with QHP or SADP issuers, insurance affordability programs, or other potential conflicts of interest identified by the office; and

††††† (b) Not:

††††† 1. Impose any charge or fee on an applicant for assistance in completing an application for, or enrolling in, a QHP, an SADP, or an insurance affordability program[or enrolling in a QHP];

††††† 2. Provide compensation or a referral fee to a kynector; and

††††† 3. Enter into an exclusive referral agreement with a kynector.

††††† (4) If the office finds noncompliance with the terms and conditions of the individual agent participation agreement[, business entity participation agreement,] or an administrative regulation within 900 KAR Chapter 10[of the office], the office shall withdraw an agentís[or business entityís] registration and participation with the KHBE after:

††††† (a) Giving notice to the participating individual agent[or participating business entity]; and

††††† (b) An opportunity to respond in accordance with Section 5 of this administrative regulation.

 

††††† Section 4. Renewal of Participation and Registration with the office. To maintain registration with the office, a participating individual agent[or participating business entity] shall:

††††† (1) Comply with annual training prescribed by the office;

††††† (2) Sign an agent[or business entity] participation agreement;[and]

††††† (3) Maintain licensure, appointments, and designations as identified in Section 2 of this administrative regulation;

††††† (4) Comply with the requirements of 45 C.F.R. 155.220; and

††††† (5) Comply with 900 KAR Chapter 10.

 

††††† Section 5. Withdrawal of Registration and Appeals. (1)(a) Except as provided in subsection (2) of this section, if the office finds noncompliance with the terms and conditions of an individual agent participation agreement[, a business entity participation agreement,] or an administrative regulation within 900 KAR Chapter 10[of the office], the office shall:

††††† 1. Provide the participating individual agent[or the participating business entity] with notice that the applicable registration shall be withdrawn as of the date of notice;

††††† 2. Allow the participating individual agent[or participating business entity] an opportunity to submit evidence of compliance or additional information within ten (10) business days;

††††† 3. Review any information submitted by the participating individual agent[or participating business entity]; and

††††† 4. Based on a review of the information provided, issue a decision to uphold the withdrawal or reinstate the applicable registration of a participating individual agent[or participating business entity].

††††† (b) A participating individual agent[or participating business entity] shall have the right to appeal a decision to withdraw registration in accordance with paragraph (a) of this subsection through the office.

††††† (2)(a) If the health line of authority or licensure of an agent[or business entity] is suspended, revoked, or expired, the registration of the agent[or business entity] shall be withdrawn by the office based on DOIís administrative action.

††††† (b) Any appeal or request of an action by DOI pursuant to paragraph (a) of this subsection shall be made to DOI in accordance with the Kentucky Insurance Code.

††††† (3) After one (1) year following a decision to withdraw the registration of a participating individual agent[or participating business entity], the individual agent[or business entity] may reapply in accordance with Section 2 of this administrative regulation.

 

CARRIE BANAHAN, Executive Director

AUDREY TAYSE HAYNES, Secretary

††††† APPROVED BY AGENCY: May 13, 2015

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

††††† 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.