Title XXV, Business and Financial Institutions

Catchline at repeal: Definitions for KRS 304.17A-141, 304.17A-142, and 304.17A-143.

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…

Catchline at repeal: Coverage for treatment of autism in the individual and small group market -- Limitation -- Definitions.

(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…

Catchline at repeal: Standard health benefit plans -- Written agreement required before provider may be represented as participating.

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…

Terms and conditions. (1) Any insurer issuing or renewing a health benefit plan issued or renewed on or after July 12, 2006, which provides coverage for services rendered by a physician or osteopath duly licensed under KRS Chapter 311 that are within the scope of practice of an o…

services rendered by chiropractor or optometrist. An insurer shall not impose a copayment or coinsurance amount charged to the insured for services rendered by a chiropractor licensed under KRS Chapter 312 or an optometrist licensed under KRS Chapter 320 that is greater than the …

services rendered by occupational or physical therapist -- Insurer to clearly state coverage. (1) An insurer shall not impose a copayment or coinsurance amount charged to the insured for services rendered for each date of service by an occupational therapist licensed under KRS Ch…

group, large group, or association markets -- Limitation on premium -- Participation rules -- Effect of denial of coverage -- Disclosure. (1) An insurer that offers health benefit plan coverage in the small group, large group, or association market may not establish rules for eli…

Catchline at repeal: Guaranteed-issue basis of individual market plans -- Guidelines -- Exceptions.

section. (1) All group health plans and insurers offering group health insurance coverage in the Commonwealth shall comply with the provisions of this section. (2) Subject to subsection (8) of this section, a group health plan, and a health insurance insurer offering group health…

against use of genetic information -- Administrative regulations. (1) A health insurer offering individual health benefit plan coverage in the individual market in the Commonwealth shall not impose any pre-existing conditions exclusions as to any eligible individual. (2) Each hea…

with participating provider. (1) As used in this section, unless the context requires otherwise: (a) "Material change" means a change to a contract, the occurrence and timing of which is not otherwise clearly identified in the contract, that decreases the health care provider's p…

discontinuance. (1) Except as provided in this section, an insurer shall renew or continue in force a health benefit plan at the option of the insured. (2) An insurer may nonrenew, cancel, or discontinue a health benefit plan based only on one (1) or more of the following: (a) Th…

If premium is not paid by the premium due date, an insurer shall allow for a thirty (30) day grace period for which payments shall be paid by the policyholder or contract holder prior to termination of the policy.

premium. (1) Except as provided in subsection (2) of this section, an insurer delivering or issuing a health benefit plan subject to this subtitle shall give the policyholder or contract holder at least thirty (30) days' advance written notice of cancellation. The notice shall be…

Writing requirement for provider participation -- Time limit for rate quote -- Notice of denial of coverage. (1) The commissioner shall, by administrative regulations promulgated under KRS Chapter 13A, define one (1) standard health benefit plan. After July 15, 2004, insurers may…

enacted after issuance. (1) Notwithstanding any other provision of law to the contrary, an insurer that issues or renews a health benefit plan on or after January 1, 2005, and before December 31, 2007, shall not be required to include any additional state mandated benefit beyond …

An insurer that offers a health benefit plan that is not a managed care plan but provides financial incentives for a covered person to access a network of providers shall: (1) Notify the covered person, in writing, of the availability of a printed document, in a manner consistent…

specified federal programs on behalf of an insured count toward insured's premium and cost-sharing requirement -- Payments made by any person on behalf of insured permissible -- Exceptions -- Insured's responsibility towards premium payments. (1) As used in this section: (a) "Cos…

Disclaimer. (1) All group health benefit plans which provide dependent benefits shall offer the master policyholder the following two (2) options to purchase coverage for an unmarried dependent child: (a) Coverage until age nineteen (19) and coverage to unmarried children from ni…

examinations and laboratory tests. (1) A health benefit plan shall provide coverage for all colorectal cancer examinations and laboratory tests specified in the most recent version of the American Cancer Society guidelines for individuals referenced in paragraph (b)1. of this sub…

supplements, low-protein modified food products, and amino acid-based elemental formula. (1) For purposes of this section: (a) "Therapeutic food, formulas, and supplements" means products intended for the dietary treatment of inborn errors of metabolism or genetic conditions, inc…

(1) As used in this section, "genetic test for cancer risk" means a blood, saliva, or tissue typing test that reliably determines the presence or absence of an inherited genetic characteristic that is generally accepted in the medical or scientific community as being associated w…

Catchline at repeal: Approval to reenter state for insurer that ceased doing business after July 15, 1995, and before April 10, 1998.

preservation services. (1) As used in this section: (a) "Health benefit plan" has the same meaning as in KRS 304.17A-005, except that for purposes of this section, the term includes student health insurance offered by a Kentucky-licensed insurer under written contract with a univ…

urological cancers. (1) All insurers issuing or renewing a health insurance policy, certificate, plan, or contract, including but not limited to a health benefit plan, that provides coverage for orchiectomy or orchidectomy as treatment for testicular or other urological cancer sh…

(1) As used in this section: (a) "Biomarker": 1. Means a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug inte…

procedure. (1) As used in this section: (a) "Cancer screening, test, or procedure" means any preventive screening, test, or procedure performed for the purpose of detecting cancer, including but not limited to lung, breast, cervical, prostate, and colorectal cancer; and (b) "Heal…

mental health facility -- Exceptions -- Requirements for assignment -- Construction. (1) As used in this section: (a) "Health insurance policy": 1. Includes any health insurance policy, certificate, plan, or contract or managed care plan, as defined in KRS 304.17A-500, regardless…