RELATES TO: KRS 304.17A,
304.18-110,
304.18-114,
304.18-120(2),
29 C.F.R
2590.715-2713(a), 29 C.F.R
2590.715-2713(b)
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
304.2-110(1) authorizes the
Commissioner of Insurance to promulgate administrative regulations necessary
for or as an aid to the effectuation of any provision of the Kentucky Insurance
Code as defined in
KRS
304.1-010.
KRS
304.18-120(2) requires the
department 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.
Section 1.
Definitions.
(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) "FFS" means a fee-for-service product
type.
(3) "Group policy" is defined
by
KRS
304.18-110(1)(a).
(4) "HMO" means a health maintenance
organization product type.
(5)
"POS" means a point-of-service product type.
(6) "PPO" means a preferred provider
organization product type.
(7)
"Preventive Health Service" means the service described by
29 C.F.R
2590.715-2713(a) and
(b).
Section 2. Plan Cost Sharing and Minimum
Benefits.
(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 PPO, FFS, HMO, or POS product
shall be no more than:
(a) $7,000 for a single
person; and
(b) $14,000 for a
family.
(2) A converted
policy issued pursuant to the conversion privilege contained in a group HMO,
POS, FFS, or PPO product shall include the following minimum benefits:
(a) In hospital care:
1. Inpatient hospital room and board benefits
in a maximum coinsurance amount of fifty (50) percent; and
2. Coverage benefits in a maximum coinsurance
amount of fifty (50) percent for transplants, including:
a. Kidney;
b. Cornea;
c. Bone marrow;
d. Heart;
e. Liver;
f. Lung;
g. Heart orlung; and
h. Pancreas.
(b) Outpatient care:
1. Ambulatory outpatient surgery benefits in
a maximum coinsurance amount of fifty (50) percent;
2. Provider office visits benefits in a
maximum coinsurance amount of fifty (50) percent; and
3. Diagnostic tests and Laboratory benefits
in a maximum coinsurance amount of fifty (50) percent;
(c) Emergency care:
1. Hospital emergency room benefits in a
maximum coinsurance amount of fifty (50) percent; and
2. Ground ambulance benefits in a maximum
coinsurance amount of fifty (50) percent.
(d) Medicare hospice benefits.
(e) Prescription drug benefits in a maximum
coinsurance amount of fifty (50) percent.
(f) Maternity Benefits in a maximum
coinsurance amount of fifty (50) percent.
(g) Mental Health and Substance Abuse
Benefits:
1. Inpatient Benefits in a maximum
coinsurance amount of fifty (50) percent; and
2. Outpatient Benefits in a maximum
coinsurance amount of fifty (50) percent.
(h) Rehabilitative and Habilitative Benefits
in a maximum coinsurance amount of fifty (50) percent.
(i) Preventive Health Service shall be
covered at 100 percent.
(j)
Pediatric Benefits in a maximum coinsurance amount of fifty (50)
percent.
