Title 806 | Chapter 017 | Regulation 260
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806 KAR 17:260.Conversion policy minimum benefits.
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; and2.
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; andh.
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; and3.
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; and2.
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; and2.
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.HISTORY: (27 Ky.R. 1696; eff. 2-15-2001; TAm eff. 8-9-2007; Crt eff. 2-26-2020; 48 Ky.R. 188, 1164; eff. 1-4-2022.)
CONTACT PERSON: Abigail Gall, Executive Administrative Secretary, 500 Mero Street, Frankfort, Kentucky 40601, phone (502) 564-6026, fax (502) 564-1453, email abigail.gall@ky.gov.
806 KAR 17:260.Conversion policy minimum benefits.
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(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(b)
$14,000(2)
(a)
(b)
Section 3.
(1)
(a)
1.
2.
a.
b.
c.
d.
e.
f.
g.
h.
(b)
1.
2.
3.
(c)
1.
2.
(d)
(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; and2.
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 orh.
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; and3.
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; and2.
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; and2.
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.HISTORY: (27 Ky.R. 1696; eff. 2-15-2001; TAm eff. 8-9-2007; Crt eff. 2-26-2020; 48 Ky.R. 188, 1164; eff. 1-4-2022.)
CONTACT PERSON: Abigail Gall, Executive Administrative Secretary, 500 Mero Street, Frankfort, Kentucky 40601, phone (502) 564-6026, fax (502) 564-1453, email abigail.gall@ky.gov.