Title XXV, Business and Financial Institutions

(1) Health insurance on a franchise plan is that issued to: (a) Five (5) or more employees of a common employer; or (b) Ten (10) or more members of any bona fide association or labor union, which association or union was formed and exists for purposes other than that of obtaining…

providing for utilization review of benefits. (1) Every health insurer proposing to issue or deliver in this state a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital benefits and the utilization review of those…

If an individually marketed health insurance policy is canceled, the insurer shall return promptly the unearned portion of any premium paid beyond the month in which the cancellation is effective.

As used in this subtitle, unless the context requires otherwise: (1) "Association" means an entity, other than an employer-organized association, that has been organized and is maintained in good faith for purposes other than that of obtaining insurance for its members and that h…

(1) As used in this section, "otherwise specifically indicated or provided" means that the section or another section of the Kentucky Revised Statutes: (a) Expressly states that the section is applicable to; and (b) Specifically refers to; a type of insurance, coverage, or benefi…

Expenses and supplies. (1) There is hereby created and established a Health Insurance Advisory Council whose duties shall be to review and discuss with the commissioner any issues which impact the provision of health insurance in the state. The advisory council shall consist of t…

Commissioner's approval -- Policy forms -- Administrative regulations -- Hearing. (1) (a) Notwithstanding any other provisions of this chapter to the contrary, each insurer that issues, delivers, or renews any health benefit plan to any market segment other than a large group sha…

plans. Premium rates for a health benefit plan issued or renewed to an individual, a small group, or an association on or after April 10, 1998, shall be subject to the following provisions: (1) The premium rates charged during a rating period to an individual with similar case ch…

(1) Notwithstanding any other provision of this chapter, the amount or rate of premiums for an employer-organized association health plan may be determined, subject to the restrictions of subsection (2) of this section, based upon the experience or projected experience of the emp…

association markets -- Required coverage -- Exclusions from coverage. (1) An insurer authorized to engage in the business of insurance in the Commonwealth of Kentucky may offer one (1) or more basic health benefit plans in the individual, small group, and employer-organized assoc…

An insurer that offers a basic health benefit plan shall disclose to all individuals, small employer groups and employer-organized associations prior to the issuance of a policy that the basic health benefit plan: (1) Provides limited coverage; (2) Includes federally mandated ben…

improvement program. (1) An insurer issuing a group or individual health benefit plan may offer a voluntary wellness or health improvement program that allows for rewards or incentives to encourage participation or to reward members for participation, including but not limited to…

payments under federal law to defray the cost of application of provision of chapter -- Administrative regulations. (1) As used in this section, "qualified health plan" has the same meaning as in 42 U.S.C. sec. 18021(a)(1), as amended. (2) Notwithstanding any other provision of t…

Denial letter -- Network adequacy -- Reports. (Effective January 1, 2027) (1) As used in this section, "health benefit plan" has the same meaning as in KRS 304.17A-005, except for purposes of this section, the term includes student health insurance offered by a Kentucky-licensed …

(1) As used in this section: (a) "Habilitative services" means health care services that help a person keep, learn, or improve skills and functioning for daily living; (b) "Habilitative speech therapy" means speech therapy that helps a person keep, learn, or improve skills and fu…

All health benefit plans shall provide coverage for cochlear implants for persons diagnosed with profound hearing impairment.

(1) As used in this section: (a) "Hearing aid" means any wearable, nondisposable instrument or device designed to aid or compensate for impaired human hearing and any parts, attachments, or accessories, including earmolds, but excluding batteries and cords; and (b) "Related servi…

requirements for covered diagnostic breast examinations or supplemental breast examinations. Health benefit plans shall comply with KRS 304.17-316.

mastectomy, diagnosis and treatment of endometrioses and endometritis, and bone density testing -- Requirements for health benefit plan. (1) A health benefit plan shall make available and offer to the purchaser coverage for: (a) The following, if a health benefit plan provides me…

(1) Health benefit plans which provide benefits for treatment of breast cancer by chemotherapy shall also provide coverage for treatment of breast cancer by high- dose chemotherapy with autologous bone marrow transplantation or stem cell transplantation. (2) The administration of…

(1) As used in this section, unless the context requires otherwise: (a) "Cancer clinical trial" means a clinical trial that: 1. Is approved by: a. The National Institutes of Health, or any institutional review board recognized by the National Institutes of Health; b. The United S…

benefit plan -- Reimbursement for rural health clinics, federally qualified health centers, and federally qualified health center look-alikes -- Benefits subject to deductible, copayment, or coinsurance -- Payment subject to provider network arrangements -- Audio-only encounters …

moment of birth and to include inherited metabolic diseases -- Requirement for notification and payment of premium -- Coverage for milk fortifiers to prevent enterocolitis. (1) A health benefit plan that provides coverage for a family or dependent shall provide coverage of a newl…

All health benefit plans issued or renewed on or after July 15, 1995, which provide coverage for a family member of the insured shall provide that the health plan benefits applicable for children shall be payable with respect to legally-adopted children of the insured or any chil…

Utilization review -- Reimbursement not required. (1) As used in this section unless the context requires otherwise: (a) "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to prod…

(1) An insurer offering a health benefit plan that provides benefits for the treatment of autism spectrum disorders shall make available to members a liaison to facilitate communication between the member and the insurer. (2) The responsibilities of the liaison shall include but …

inpatient care for mothers and newly born children -- Exemption. (1) As used in this section: (a) "Health benefit plan" has the same meaning as in KRS 304.17A-005, except for purposes of this section, the term: 1. Includes student health insurance offered by a Kentucky-licensed i…

Notwithstanding any provision of law, a health plan issued or renewed on or after July 15, 2000, that provides coverage for surgical first assisting benefits or services shall be construed as providing coverage for a registered nurse first assistant who performs services that are…

include services performed by certified surgical assistant. Notwithstanding any provision of law, a health plan issued or renewed on or after July 15, 2000, that provides coverage for surgical first assisting or intraoperative surgical care benefits or services shall be construed…

include services performed by certified surgical assistant or physician assistant. Notwithstanding any provision of law, a health benefit plan issued or renewed on or after July 15, 2001, that provides coverage for surgical first assisting or intraoperative surgical care benefits…

(1) All health benefit plans issued or renewed on or after January 1, 2022, shall provide coverage for equipment, supplies, outpatient self-management training and education, including medical nutrition therapy, and all medications necessary for the treatment of insulin-dependent…

procedures for certain patients. All health benefit plans issued or renewed on or after July 15, 2002, that provide coverage for general anesthesia and hospitalization services to a covered person shall provide coverage for payment of anesthesia and hospital or facility charges f…

(1) On and after July 15, 1995, it is an unfair trade practice for an insurer, agent, broker, or any other person in the business of marketing and selling health plans, to commit or perform any of the following acts: (a) Encourage individuals or groups to refrain from filing an a…

(1) No health benefit plan shall deny coverage, refuse to issue or renew, cancel or otherwise terminate, restrict, or exclude any person from any health benefit plan issued or renewed on or after July 15, 1998, on the basis of the applicant's or insured's status as a victim of do…

304.17A-165. As used in this section and KRS 304.17A-162, 304.17A-163, and 304.17A-165 unless the context requires otherwise: (1) "Contracted pharmacy" or "pharmacy" means a pharmacy located in Kentucky participating in the network of a pharmacy benefit manager through a direct c…

reimbursement -- Process to appeal disputes over maximum allowable cost pricing -- Adjustment of maximum allowable cost and drug product reimbursement -- Duties of pharmacy benefit manager. (1) A pharmacy benefit manager shall: (a) Identify to contracted pharmacies the sources us…

of clinical review criteria -- Override of restrictions on medication sequence in step therapy or fail-first protocol. (1) As used in this section and KRS 304.17A-1631, unless the context requires otherwise: (a) "Clinical practice guidelines" means a systematically developed stat…

commissioner. (1) Notwithstanding any other law to the contrary, the commissioner shall promulgate any administrative regulations necessary to enforce this section and KRS 304.17A- 163. (2) Annually, an insurer, health plan, pharmacy benefit manager, or private review agent shall…

cost-sharing for prescription drugs -- Exceptions. (1) As used in this section: (a) "Cost sharing" means the cost to an insured under a health plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of- pocket expense requirements imposed by the pla…

for refills of covered drugs -- Limitations and exclusions -- Program for synchronization of medications. (1) Any health benefit plan that provides benefits for prescription drugs shall include an exceptions policy or an override policy that provides coverage for the refill of a …

if conditions met. (1) As used in this section, "practitioner" has the same meaning as in KRS 217.015. (2) Any health benefit plan issued or renewed on or after January 1, 2015, that provides coverage for prescription eye drops shall not deny coverage for a refill of a prescripti…

authorization of drugs for ongoing medication therapy -- Requirements -- Time span of authorization -- Exemptions. (1) On or before January 1, 2020, an insurer offering a health benefit plan shall develop, coordinate, or adopt a process for electronically requesting and transmitt…

(1) Notwithstanding any provision of law to the contrary, a health benefit plan shall, at a minimum, provide coverage for all United States Food and Drug Administration- approved tobacco cessation medications, all forms of tobacco cessation services recommended by the United Stat…

As used in this section and KRS 304.17A-171, unless the context requires otherwise: (1) "Health benefit plan" has the meaning provided in KRS 304.17A-005. (2) "Primary chiropractic provider" means a chiropractor licensed pursuant to KRS Chapter 312 who has been selected by a pers…

benefits. A health benefit plan that includes chiropractic benefits shall: (1) Include all primary chiropractic providers who are selected by covered persons of the plan for the provision of all chiropractic benefits provided by the plan which fall within the statutory scope of p…

medications that are injected or intravenously administered by a health care provider and patient-administered anticancer medications. (1) For purposes of this section: (a) "Anticancer medications" means drugs and biologics that are used to kill, slow, or prevent the growth of ca…