SUPERSEDED

This document is no longer current.

806 KAR 17:260.Conversion policy minimum benefits.

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.

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 in 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.

Section 2.

Plan Cost Sharing.

(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:

(a)

$6,000 for a single person; and

(b)

$12,000 for a family.

(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:

(a)

$6,000 for a single person and an out-of-pocket limit of $6,000 after the deductible; and

(b)

$12,000 for a family and an out-of-pocket limit of $12,000 after the deductible.

Section 3.

Minimum Benefits.

(1)

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

(a)

In hospital care:

1.

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

2.

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

a.

Kidney;

b.

Cornea;

c.

Bone marrow;

d.

Heart;

e.

Liver;

f.

Lung;

g.

Heart/lung; and

h.

Pancreas.

(b)

Outpatient care:

1.

Ambulatory outpatient surgery benefits in a maximum copayment amount of $500 per visit;

2.

Provider office visits benefits in a maximum copayment amount of thirty (30) dollars per visit; and

3.

Diagnostic tests benefits in a maximum copayment amount of thirty (30) dollars per testing session.

(c)

Emergency care:

1.

Hospital emergency room benefits in a maximum copayment amount of $150 per visit; and

2.

Ground ambulance benefits in a maximum copayment amount of seventy-five (75) dollars per use.

(d)

Medicare hospice benefit.

(2)

A converted policy issued pursuant to the conversion privilege contained in a group 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/lung; 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 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.

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

806 KAR 17:260.Conversion policy minimum benefits.

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:

Section 1.

Definitions.

(1)

(2)

"FFS" means a fee-for-service product type.

(3)

"Group policy" is defined in 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.

Section 2.

Plan Cost Sharing.

(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:

(a)

$6,000 for a single person; and

(b)

$12,000 for a family.

(2)

(a)

$6,000 for a single person and an out-of-pocket limit of $6,000 after the deductible; and

(b)

$12,000 for a family and an out-of-pocket limit of $12,000 after the deductible.

Section 3.

Minimum Benefits.

(1)

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

(a)

In hospital care:

1.

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

2.

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

a.

Kidney;

b.

Cornea;

c.

Bone marrow;

d.

Heart;

e.

Liver;

f.

Lung;

g.

Heart/lung; and

h.

Pancreas.

(b)

Outpatient care:

1.

Ambulatory outpatient surgery benefits in a maximum copayment amount of $500 per visit;

2.

Provider office visits benefits in a maximum copayment amount of thirty (30) dollars per visit; and

3.

Diagnostic tests benefits in a maximum copayment amount of thirty (30) dollars per testing session.

(c)

Emergency care:

1.

Hospital emergency room benefits in a maximum copayment amount of $150 per visit; and

2.

Ground ambulance benefits in a maximum copayment amount of seventy-five (75) dollars per use.

(d)

Medicare hospice benefit.

(2)

A converted policy issued pursuant to the conversion privilege contained in a group 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/lung; 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 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.

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

Page Generated: 9/19/2024, 12:15:11 PM

Title 806 | Chapter 017 | Regulation 260

806 KAR 17:260.Conversion policy minimum benefits.

RELATES TO:

STATUTORY AUTHORITY:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(3)

(4)

(5)

(6)

Section 2.

(1)

(a)

(b)

(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)

1.

2.

a.

b.

c.

d.

e.

f.

g.

h.

(b)

1.

2.

3.

(c)

1.

2.

(d)

806 KAR 17:260.Conversion policy minimum benefits.

RELATES TO:

STATUTORY AUTHORITY:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(3)

(4)

(5)

(6)

Section 2.

(1)

(a)

(b)

(2)

(a)

(b)

Section 3.

(1)