RELATES TO:

KRS 304.17A, 304.18-110, 304.18-120(2)

STATUTORY AUTHORITY:

KRS 304.2-110(1), 304.18-120(2)

NECESSITY, FUNCTION, AND CONFORMITY:

KRS 304.2-110(1) provides that the executive director may make reasonable administrative regulations necessary for or as an aid to the effectuation of any provision of the Kentucky Insurance Code. KRS 304.18-120(2) requires the office to promulgate administrative regulations to establish minimum benefits for a conversion policy issued pursuant to the conversion privilege contained in a group health policy. This administrative regulation establishes those requirements.

1. Section 1. Definitions.

   1. (1) "Conversion policy" means an individual health policy issued to an insured person pursuant to a conversion privilege contained in a group health policy upon termination of the insured person's coverage under the group policy.
   2. (2) "FFS" means a fee-for-service product type.
   3. (3) "Group policy" is defined in KRS 304.18-110(1)(a).
   4. (4) "HMO" means a health maintenance organization product type.
   5. (5) "POS" means a point-of-service product type.
   6. (6) "PPO" means a preferred provider organization product type.

2. Section 2. Plan Cost Sharing.

   1. (1) The out-of-pocket limit for covered expenses incurred during a plan year for a converted policy issued pursuant to a conversion privilege contained in a HMO or POS product shall be no more than:

      1. (a) $6,000 for a single person; and
      2. (b) $12,000 for a family.

   2. (2) The deductible and out-of-pocket limit for covered expenses incurred during a plan year for a converted policy issued pursuant to the conversion privilege contained in a group FFS or PPO product shall be no more than:

      1. (a) $6,000 for a single person and an out-of-pocket limit of $6,000 after the deductible; and
      2. (b) $12,000 for a family and an out-of-pocket limit of $12,000 after the deductible.

3. Section 3. Minimum Benefits.

   1. (1) A converted policy issued pursuant to the conversion privilege contained in a HMO or POS product shall include the following minimum benefits:

      1. (a) In hospital care:

         1. 1. Inpatient hospital room and board benefits in a maximum copayment amount of $1,000 per admission; and

         2. 2. Coverage benefits in a maximum copayment amount of $1,000 per admission for transplants, including:

            1. a. Kidney;
            2. b. Cornea;
            3. c. Bone marrow;
            4. d. Heart;
            5. e. Liver;
            6. f. Lung;
            7. g. Heart/lung; and
            8. h. Pancreas.

      2. (b) Outpatient care:

         1. 1. Ambulatory outpatient surgery benefits in a maximum copayment amount of $500 per visit;
         2. 2. Provider office visits benefits in a maximum copayment amount of thirty (30) dollars per visit; and
         3. 3. Diagnostic tests benefits in a maximum copayment amount of thirty (30) dollars per testing session.

      3. (c) Emergency care:

         1. 1. Hospital emergency room benefits in a maximum copayment amount of $150 per visit; and
         2. 2. Ground ambulance benefits in a maximum copayment amount of seventy-five (75) dollars per use.
      4. (d) Medicare hospice benefit.

   2. (2) A converted policy issued pursuant to the conversion privilege contained in a group FFS or PPO product shall include the following minimum benefits:

      1. (a) In hospital care:

         1. 1. Inpatient hospital room and board benefits in a maximum coinsurance amount of fifty (50) percent; and

         2. 2. Coverage benefits in a maximum coinsurance amount of fifty (50) percent for transplants, including:

            1. a. Kidney;
            2. b. Cornea;
            3. c. Bone marrow;
            4. d. Heart;
            5. e. Liver;
            6. f. Lung;
            7. g. Heart/lung; and
            8. h. Pancreas.

      2. (b) Outpatient care:

         1. 1. Ambulatory outpatient surgery benefits in a maximum coinsurance amount of fifty (50) percent;
         2. 2. Provider office visits benefits in a maximum coinsurance amount of fifty (50) percent; and
         3. 3. Diagnostic tests benefits in a maximum coinsurance amount of fifty (50) percent;

      3. (c) Emergency care:

         1. 1. Hospital emergency room benefits in a maximum coinsurance amount of fifty (50) percent; and
         2. 2. Ground ambulance benefits in a maximum coinsurance amount of fifty (50) percent.
      4. (d) Medicare hospice benefits.

History

(27 Ky.R. 1696; eff. 2-15-2001; TAm eff. 8-9-2007; Crt eff. 2-26-2020.)