Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
13B.010,
13B.130,
194A.005(1),
210.370-210.480,
304.1-050(2),
304.1-110(1),
304.9-020(1),
(5),
304.9-040,
304.14-030,
304.17A-005,
304.17A-500(9),
304.17C-010(4),
8
U.S.C. 1101(a)(3),
25
U.S.C. 1603(13), 36B,
151,
5000A,
42 U.S.C.
300gg-15,
300gg-91,
301,
9902(2),
18021,
18022,
18031,
18042,
18054,
18082,
26 C.F.R. 1.36B-1(e), 54.4980B-1, 54.9801-2, 42 C.F.R. Parts 430-456,
435.603(e),
457.10,
45
C.F.R. 144.103,
152.2,
155.20,
155.105,
155.205,
155.210,
155.225,
155.300,
155.310(g),
155.330,
155.335,
155.410,
155.420,
155.430,
155.710,
155.715,
155.1065,
156.140(c),
156.155,
156.200-156.295
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Office of Health Data and Analytics, Division of Health
Benefit Exchange has responsibility to administer the Kentucky Health Benefit
Exchange.
KRS
194A.050(1) requires the
secretary of the cabinet to promulgate administrative regulations necessary to
protect, develop, and maintain the health, personal dignity, integrity, and
sufficiency of the individual citizens of the commonwealth; to operate the
programs and fulfill the responsibilities vested in the cabinet; and to
implement programs mandated by federal law. This administrative regulation
establishes the definitions for 900 KAR Chapter 10.
Section 1. Definitions.
(1) "Actuarial value" means the percentage of
the total allowed costs of benefits paid by a health plan.
(2) "Advance payments of the premium tax
credit" or "APTC" means payment of the tax credits that are:
(a) Authorized by
26
U.S.C. 36B and its implementing regulations;
and
(b) Provided on an advance
basis to an eligible individual enrolled in a qualified health plan through an
exchange in accordance with
42
U.S.C. 18082.
(3) "Adverse witness" means a person who
gives unfavorable evidenc against the part that called him or her as its
witness.
(4) "Agent" is defined by
KRS
304.9-020(1).
(5) "Annual open enrollment period" is
defined by
45 C.F.R.
155.410(e).
(6) "Appeal record" means the official record
of hearing as established by
KRS 13B.130(1) through
(10).
(7) "Appeal request" means a clear
expression, either orally or in writing, by an applicant or enrollee to have an
eligibility determination or redetermination contained in a notice issued in
accordance with
45 C.F.R.
155.310(g) or
45 C.F.R.
155.330(e)(1)(ii).
(8) "Appellant" means the applicant or
enrollee who is requesting an appeal.
(9) "Applicant" is defined by
45
C.F.R. 155.20.
(10) "Application filer" is defined by
45
C.F.R. 155.20.
(11) "Benefit year" means a calendar year for
which a health plan provides coverage for health benefits.
(12) "Business entity" is defined by
KRS
304.9-020(5).
(13) "Cabinet for Health and Family Services"
or "CHFS" is defined by
KRS
194A.005(1).
(14) "Cancellation" is defined by
45 C.F.R.
155.430(e)(2).
(15) "Catastrophic plan" means a health plan
that meets the conditions of
45 C.F.R.
156.155.
(16) "Certificate of authority" is defined by
KRS
304.1-110(1).
(17) "Certification" means a determination
made on the KHBE by the division that a health plan or a stand-alone dental
plan has met the requirements in 900 KAR 10:115.
(18) "Certified application counselor" or
"CAC" means an individual employed by, or volunteer of, an entity designated by
the division to perform the functions described in
45 C.F.R.
155.225.
(19) "Child-only plan" means an individual
health policy that provides coverage to an individual under twenty-one (21)
years of age and meets the requirements of
45 C.F.R.
156.200(c)(2).
(20) "Children's Health Insurance Program" or
"CHIP" is defined by
42 C.F.R.
457.10.
(21) "COBRA" is defined by
26 C.F.R.
54.4980B-1.
(22) "Consultant" is defined by
KRS
304.9-040.
(23) "Consumer operated and oriented plan" or
"CO-OP" means a private, non-profit health insurance issuer that:
(a) Is established by
42
U.S.C. 18042; and
(b) Has a certificate of authority.
(24) "Cost sharing" is defined by
45
C.F.R. 155.20.
(25) "Cost sharing reduction" or "CSR" means
a reduction in cost sharing for an eligible individual enrolled in a silver
level plan in the KHBE or for an individual who is an Indian enrolled in a
qualified health plan in the KHBE.
(26) "DAH" means the Division of
Administrative Hearings of the Cabinet for Health and Family
Services.
(27) "Date of notice"
means the date on the notice plus five (5) calendar days.
(28) "Dental insurer" or "stand-alone dental
plan issuer" means an insurer as defined by
KRS
304.17C-010(4) that offers a
limited health service benefit plan for dental services.
(29) "Department of Health and Human
Services" or "HHS" means the U.S. Department of Health and Human
Services.
(30) "Department of
Insurance" or "DOI" means the department defined by
KRS
304.1-050(2).
(31) "Dependent" is defined by
26
C.F.R. 54.9801-2.
(32) "Desk Review" means an administrative
review of:
(a) Information submitted as part
of the application process;
(b) Any
supporting documentation used to determine or redetermine an appellant's
eligibility; and
(c) Any additional
information submitted for consideration as part of the appeal
request.
(33) "Division
of Health Benefit Exchange" or "division" means the division created to
administer the KHBE.
(34)
"Employee" is defined by
42 U.S.C.
300gg-91(d)(5).
(35) "Employer" is defined by
42 U.S.C.
300gg-91(d)(6).
(36) "Enrollee" means an eligible individual
enrolled in a qualified health plan or qualified stand-alone dental
plan.
(37) "Essential community
provider" means either a:
(a) Provider
determined and approved by HHS as an essential community provider for the
Commonwealth of Kentucky; or
(b)
Regional community services program for mental health or individuals with an
intellectual disability established pursuant to
KRS
210.370 through
KRS
210.480, operating in Kentucky, and licensed
pursuant to
902
KAR 20:091.
(38) "Essential community provider category"
means a provider as established in
45 C.F.R.
156.235(a)(2)(ii)(B).
(39) "Essential health benefits" means
benefits as identified by
42 U.S.C.
18022 and approved by the Secretary of HHS
for the Commonwealth of Kentucky.
(40) "Exemption" means an exemption from the
shared responsibility payment.
(41)
"Family size" means the number of individuals in a family for whom a taxpayer
properly claims a deduction for a personal exemption under
26 U.S.C.
151 for the taxable year.
(42) "Federal poverty level" or "FPL" means
the most recently published federal poverty level, updated periodically in the
Federal Register by the Secretary of Health and Human Services under the
authority of
42
U.S.C. 9902(2), as of the
first day of the annual open enrollment period for coverage in a qualified
health plan through the Kentucky Health Benefit Exchange.
(43) "Final order" is defined by
KRS
13B.010(6).
(44) "Formal review request" means a clear
expression, either orally or in writing, by a small business employer to have
any eligibility determination or redetermination contained in a notice issued
in accordance with
45 C.F.R.
155.310(g),
45 C.F.R.
155.330(e)(1)(ii),
45 C.F.R.
155.335(h)(1)(ii), or
45
C.F.R. 155.715(e) or
(f).
(45) "Full-time employee" is defined by
45
C.F.R. 155.20.
(46) "Group participation rate" means the
minimum percentage of all eligible individuals or employees of an employer that
is required to be enrolled
(47)
"Health plan" is defined by
42 U.S.C.
18021(b)(1).
(48) "Health plan form" or "form" means an
application, policy, certificate, contract, rider, endorsement, provider
agreement, or risk sharing arrangement filed in accordance with
806 KAR
14:007 and
806
KAR 17:300.
(49) "Health Reimbursement Arrangement" or
"HRA" means a plan funded solely by employer contributions that reimburses
employees for medical care and other qualified expenses, incurred by the
employee, or his spouse, dependents, and any children who, as of the end of the
taxable year, have not attained age 27, up to a maximum amount for a coverage
period.
(50) "Hearing" is defined
by
KRS
13B.010(2).
(51) "Hearing officer" means a hearing
officer employed by DAH.
(52)
"Household income" is defined by 26 C.F.R. 1.36B-1(e).
(53) "Indian" is defined by
25
U.S.C. 1603(13).
(54) "Individual exchange" means the Kentucky
Health Benefit Exchange that serves the individual health insurance
market.
(55) "Individual market" is
defined by
KRS
304.17A-005(28).
(56) "Insurance affordability program" means
one (1) of the following:
(a) A state
Medicaid program under title XIX of the Social Security Act,
42 U.S.C.
301 et seq.;
(b) A state children's health insurance
program (CHIP) under title XXI of the Social Security Act,
42 U.S.C.
301 et seq.;
(c) A program that makes coverage in a
qualified health plan through the exchange with advance payments of the premium
tax credit available to qualified individuals; or
(d) A program that makes coverage in a
qualified health plan through the exchange with CSRs available to qualified
individuals.
(57)
"Issuer" is defined by
45
C.F.R. 144.103.
(58) "Issuer application assister" means an
employee, contractor, or agent of a QHP issuer who is not licensed as an agent,
broker, or producer under state law and who assists individuals in the
individual market with applying for a determination or redetermination of
eligibility for coverage through the KHBE or for insurance affordability
programs.
(59) "Judicial review"
means a court's review of factual or legal findings of an administrative
body.
(60) "Kentucky Children's
Health Insurance Program" or "KCHIP" means the separate child health program
established by the commonwealth of Kentucky to administer CHIP.
(61) "Kentucky Health Benefit Exchange" or
"KHBE" or "Exchange" means the Kentucky state-based exchange approved by HHS
pursuant to
45 C.F.R.
155.105 to offer a QHP or SADP that utilizes
the state provided information technology infrastructure known as kynect to
provide for eligibility determinations and consumer enrollment in qualified
health plans and stand-alone dental plans and that includes:
(a) An individual exchange; and
(b) SHOP.
(62) "Kentucky online gateway" or "KOG" means
the system for identity authentication services used by the division to
register a kynector or agent.
(63)
"kynector" means a CAC or navigator.
(64) "Lawfully present" is defined by
45
C.F.R. 152.2.
(65) "MAGI-based income" is defined by
42 C.F.R.
435.603(e).
(66) "Managed care plan" is defined by
KRS
304.17A-500(9).
(67) "Medicaid" means the program established
pursuant to 42 C.F.R. parts 430 through 456.
(68) "Metal level of coverage" means health
care coverage provided within the variation established in
45 C.F.R.
156.140(c) of the full
actuarial value as follows:
(a) Bronze level
with an actuarial value of sixty (60) percent;
(b) Silver level with an actuarial value of
seventy (70) percent;
(c) Gold
level with an actuarial value of eighty (80) percent; and
(d) Platinum level with an actuarial value of
ninety (90) percent.
(69) "Minimum essential coverage" or "MEC" is
defined by
26 U.S.C.
5000A(f).
(70) "Multi-state plan" means a health plan
that is offered under a contract with the U.S. Office of Personnel Management
in accordance with
42 U.S.C.
18054.
(71) "Navigator" means an entity that is
selected by the division and shall comply with the requirements of
42 U.S.C.
18031(i),
45 C.F.R.
155.205(d)-(e), and
45 C.F.R.
155.210.
(72) "Non-citizen" means "alien" as defined
by 8
U.S.C. 1101(a)(3).
(73) "Organization" means an entity as
follows:
(a) Community health
center;
(b) Hospital;
(c) Health care provider;
(d) Indian health service provider;
(e) Ryan White HIV/AIDS provider;
(f) Behavioral or mental health provider;
or
(g) An agency with experience
providing social services, nutrition assistance, energy assistance, legal
services, or tax assistance that is a:
1.
Non-federal government entity;
2.
501(c) organization; or
3. Local
government agency.
(74) "Participating agent" means an agent who
has been registered with the division on KHBE through KOG.
(75) "Participation agreement" means an
agreement between the division and the issuer to offer a QHP or stand-alone
dental plan on the KHBE.
(76)
"Pediatric dental essential health benefit" means the pediatric dental services
required by
42 U.S.C.
18022(b)(1)(J) and provided
to an individual under the age of twenty-one (21) years.
(77) "Personal exemption deduction" means an
amount that can be deducted from taxable income based on the exemption given to
any tax filer who cannot be claimed as a dependent by another tax
filer.
(78) "Personally
identifiable information" means any data about an individual that could
potentially identify that individual.
(79) "Plan management data template" means
the data collection templates that are:
(a)
Used to facilitate data submission through SERFF for certification of qualified
health plan issuers, qualified health plans, qualified stand-alone dental plan
issuers, and qualified standalone dental plans as established in CMS Form
Number CMS-10433, as amended; and
(80) "Plan year" means a
consecutive twelve (12) month period during which a health plan provides
coverage for health benefits.
(81)
"Premium" is defined by
KRS
304.14-030.
(82) "Provider network" is defined by
KRS
304.17A-005(38).
(83) "Qualified employer" means an employer
that elects to make, at a minimum, all full-time employees of the employer
eligible for one (1) or more QHPs or SADPs in the small group market offered
through the SHOP.
(84) "Qualified
health plan" or "QHP" means a health plan that meets the standards established
in 45 C.F.R. 156 Subpart C, 156.200-156.295, and that has in effect a
certification issued by the division on the KHBE.
(85) "Qualified individual" means an
individual who has been determined eligible to enroll through the KHBE in a QHP
or SADP in the individual market.
(86) "Qualified small employer health
reimbursement arrangement" or "QSEHRA" means an HRA for use by small
employers.
(87) "Qualifying
coverage in an eligible employer-sponsored plan" means coverage in an eligible
employer-sponsored plan that meets the affordability and minimum value
standards established by
26
U.S.C.
36B(c)(2)(C).
(88) "Qualifying event" means an event that
triggers a SEP for an individual to enroll in health insurance
coverage.
(89) "Recommended order"
is defined by
KRS
13B.010(5).
(90) "Service area" means a geographical area
in which an issuer may offer a QHP.
(91) "Shared responsibility payment" means a
penalty imposed for failing to meet the requirement to maintain minimum
essential coverage in accordance with
26 U.S.C.
5000A.
(92) "SHOP" means a Small Business Health
Options Program operated by the Kentucky Health Benefit Exchange through which
small employers that meet the standards established in
45 C.F.R.
155.710 may obtain an eligibility
determination from KHBE that allows the small employer to purchase one (1) or
more QHPs or SADPs that have been certified by KHBE through either:
(a) A participating agent; or
(b) An issuer offering QHPs or SADPs on the
KHBE.
(93) "Silver
level" is defined by
42 U.S.C.
18022(d)(1)(B).
(94) "Small employer" is defined by
KRS
304.17A-005(44).
(95) "Small group" is defined by
KRS
304.17A-005(45).
(96) "Special enrollment period" or "SEP"
means a period, as described in
45 C.F.R.
155.420, during which a qualified individual
or enrollee who experiences certain qualifying events may enroll in, or change
enrollment in, a QHP through the KHBE outside the annual open enrollment
period.
(97) "Stand-alone dental
plan" or "SADP" means a dental plan as established by
45 C.F.R.
155.1065 that has been certified by the
division on the KHBE to provide dental benefits, including a pediatric dental
essential health benefit.
(98)
"Summary of Benefits and Coverage" or "SBC" means a standard format, created in
accordance with
42
U.S.C. 300gg-15, for providing information to
consumers about a health plan's coverage and benefits.
(99) "System for Electronic Rate and Form
Filing" or "SERFF" means an online system established and maintained by the
National Association of Insurance Commissioners (NAIC) that enables an issuer
to send and a state to receive, comment on, and approve or reject rate and form
filings.
(100) "Tax filer" is
defined by
45
C.F.R. 155.300.
(101) "Termination" is defined by
45 C.F.R.
155.430(e)(1).
(102) "Training" means the training
established by the division for agents and kynectors.
(103) "Vacate" means to set aside a previous
action.