Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO: KRS Chapter 13B, Chapter 304, 304.9-020(1),
304.12-020, 304.14-120, 304.17-380, 304.17A-095, 304.17A-240-304.17A-245,
304.17A.515, 304.17A-590, 304.17C, 20 U.S.C. 36B,
42 U.S.C.
300gg-5,
18022,
18031,
18042,
18054,
18082,
45
C.F.R. 155.706,
45
C.F.R. Part 153, 154.230, Parts 155,
156
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 policies and procedures relating to the certification of a
qualified health plan or a qualified stand-alone dental plan to be offered on
the Kentucky Health Benefit Exchange, pursuant to and in accordance with
42 U.S.C.
18031 and 45 C.F.R. Parts 155 and 156.
Section 1. Participation Standards for
Issuers Offering a Qualified Health Plan. In order to participate on KHBE, an
issuer offering a QHP shall:
(1) Hold a
certificate of authority that would permit the issuer to offer a health benefit
plan and be in good standing with the Kentucky DOI;
(2) Be authorized by the division to
participate on the KHBE;
(3) By
February 1 of each year, submit Form KHBE-C1, Issuer Participation Intent Form,
a nonbinding notice of intent to participate on KHBE during the next calendar
year;
(4) Enter into a
participation agreement with the division;
(5) Offer KHBE certified QHPs in the
individual exchange or SHOP;
(6)
Comply with benefit design standards as defined in
45
C.F.R. 156.20;
(7) Provide coverage of the:
(a) Essential health benefits; or
(b) Essential health benefits excluding
pediatric dental essential health benefits, if a standalone pediatric dental
essential health benefit is offered on the KHBE in accordance with
45 C.F.R.
155.1065;
(8) Comply with applicable standards
established in 45 C.F.R. Part 153 ;
(9) Not discriminate, with respect to a QHP,
on the basis of race, color, national origin, disability, age, sex, gender
identity, or sexual orientation;
(10) Comply with the non-discrimination
requirements in
42 U.S.C.
300gg-5;
(11) Submit verification of issuer compliance
with the requirements of
45 C.F.R.
156.340, including compliance of a delegated
and downstream entity;
(12) Submit
via SERFF:
(a) A quality improvement strategy
plan in compliance with
45 C.F.R.
156.200(b)(5) and
45 C.F.R.
156.1130; and
(b) An attestation that the issuer shall
comply with the quality requirements identified in
45 C.F.R.
156.200(b)(5) including:
1. Collection, disclosure, and report of
information related to health care quality and outcomes in year two (2) of
offering QHPs on the KHBE and annually thereafter; and
2. Implementation of an enrollee satisfaction
survey in year two (2) of offering QHPs on the KHBE and annually
thereafter;
(13) Comply with the provisions of
45 C.F.R.
156.210;
(14) For the individual exchange, offer at
least a:
(a) QHP with a silver metal level of
coverage;
(b) QHP with a gold metal
level of coverage; and
(c)
Child-only plan;
(15)
For SHOP, offer at least a:
(a) QHP with a
silver metal level of coverage; and
(b) QHP with a gold metal level of
coverage;
(16) Make its
provider directory for a QHP available:
(a) To
a potential enrollee in hard copy upon request; and
(b) In accordance with
45 C.F.R.
156.230;
(17) If participating in the small group
market, comply with KHBE processes, procedures, and requirements established in
accordance with
45
C.F.R. 155.706 and 900 KAR 10:120 for the
small group;
(18) Allow a
registered participating agent to enroll qualified individuals on KHBE in
accordance with the requirements of 900 KAR 10:125;
(19)
(a)
Offer a QHP in a statewide service area; or
(b) Offer a QHP in a service area less than
statewide if:
1. The issuer's service area
includes one (1) or more counties;
2. The issuer's service area is approved by
the DOI; and
3. The issuer's
service area is established in a nondiscriminatory manner with regard to:
a. Race;
b. Ethnicity;
c. Language;
d. Health status of an individual in a
service area; or
e. A factor that
excludes a high utilizing, high cost, or medically-underserved
population;
(20) Comply with the requirements of
KRS
304.12-020,
304.14-120,
304.17-380,
304.17A-095,
304.17A-240-304.17A-245, 304.17A.515,
304.17A-590,
and KRS Chapter 304;
(21) Have the
option to offer QHPs to include benefits in excess of the essential health
benefits if the issuer also offers at least one (1) QHP on the exchange at the
same metal level of coverage that is limited to the essential health benefits;
and
(22) Have the option to offer a
catastrophic plan on the individual exchange.
Section 2. QHP Rate and Benefit Information.
(1) A QHP issuer shall:
(a) Comply with the provisions of
45 C.F.R.
156.210 and
KRS
304.17A-095;
(b) Submit to DOI through the SERFF system:
1. Form filings in compliance with
KRS
304.14-120;
2. Rate filings in compliance with
KRS
304.17A-095; and
3. Plan management data templates;
and
(c)
1. Receive approval from DOI for a rate
filing prior to implementation of the approved rate; and
2. For a rate increase that meets the
criteria in
45
C.F.R. 154.230, post the justification
prominently on the QHP issuer's Web site.
(2) A CO-OP, multi-state plan, and a
qualified SADP shall comply with the requirements established in subsection (1)
of this section.
(3) A QHP issuer
shall comply with the maintenance of records standards pursuant to
45
C.F.R. 156.705.
(4) To be certified as a QHP, a health plan
shall provide coverage of the:
(a) Essential
health benefits; or
(b) Essential
health benefits excluding pediatric dental benefits if there is at least one
(1) SADP offered in each county through the KHBE.
Section 3. QHP Certification
Timeframes.
(1) The division shall take final
action on a request for certification no later than twenty-five (25) calendar
days prior to the start of the annual open enrollment period for the following
plan year.
(2) A QHP not certified
by twenty-five (25) calendar days prior to the start of the annual open
enrollment period shall not be offered on the KHBE at any time during the
following calendar year.
Section
4. Transparency in Coverage.
(1)
A QHP issuer shall provide the following information to the KHBE in accordance
with the standards established in subsection (2) of this section:
(a) Data as identified in
45 C.F.R.
155.1050(a),
156.220,
and
156.230;
(b) An SBC written in English for each CSR
level in a QHP with the exception of zero cost sharing level for an
Indian;
(c) An SBC written in
Spanish for each CSR level in a QHP with the exception of zero cost sharing
level for an Indian, with verification that the Spanish language version is a
certified translation of the English version;
(d) If the plan includes a health
reimbursement account, flexible spending account, or health savings account, a
spending account fact sheet written in English for each CSR level in a QHP
consistent with the requirements in
KRS
304.12-020 and
806 KAR
12:010;
(e) If the plan includes a health
reimbursement account, flexible spending account, or health savings account, a
spending account fact sheet written in Spanish for each CSR level in a QHP with
verification that the Spanish language version is a certified translation of
the English version; and
(f)
Information on patient responsibility for out-of-network coverage.
(2) A QHP issuer shall:
(a) Submit in an accurate and timely manner,
to be determined by HHS, the information established in subsection (1)(a) and
(f) of this section to the KHBE;
(b) Provide public access to the information
established in subsection (1) of this section;
(c) Provide the items established in
subsection (1)(b) and (d) of this section to KHBE within five (5) calendar days
of the date DOI has approved rate and form filings in SERFF; and
(d) Provide the items established in
subsection (1)(c) and (e) of this section to KHBE within fourteen (14) calendar
days of the date KHBE has approved the items established in paragraph (c) of
this subsection.
(3) A
QHP issuer shall ensure that the information submitted under subsection (1) of
this section is provided in plain language as the term is defined by
45
C.F.R. 155.20.
(4)
(a) A
QHP issuer shall make available, in a timely manner, information about the
amount of enrollee cost sharing under the enrollee's plan or coverage relating
to provision of a specific item or service by a participating provider upon the
request of the enrollee.
(b) The
information shall be made available to an enrollee through:
1. The internet; and
2. Other means if the enrollee does not have
access to the internet.
(5) A QHP issuer may provide the following
information to KHBE in accordance with the standards established by subsection
(2) of this section:
(a) An SBC written in
English for each zero cost sharing level for an Indian in a QHP; and
(b) An SBC written in Spanish for each zero
cost sharing level for an Indian in a QHP, with verification that the Spanish
language version is a certified translation of the English version.
Section 5. Marketing
and Benefit Design of QHPs. A QHP issuer and its officials, employees, agents,
and representatives shall:
(1) Comply with
issuer marketing practices provided under KRS Chapter 304.17A and
806 KAR 12:010;
and
(2) Not employ marketing
practices or benefit designs that will have the effect of discouraging the
enrollment of individuals with complex health care needs in QHPs.
Section 6. Network Adequacy
Standards.
(1) A QHP issuer shall ensure that
the provider network of a QHP:
(a) Is
available to all enrollees within the QHP service area;
(b) Includes essential community providers in
the QHP provider network in accordance with
45 C.F.R.
156.235 and meets the network adequacy
standards for essential community providers as established in Section 7 of this
administrative regulation;
(c)
Maintains a network that is sufficient in number and types of providers,
including providers that specialize in mental health and substance use disorder
services, to assure that all services will be provided in a timely manner;
and
(d)
1. If a managed care plan, meets the
reasonable network adequacy provisions of
45 C.F.R.
156.230 and
KRS
304.17A-515; or
2. If not a managed care plan, meets the
reasonable network adequacy provisions of
45 C.F.R.
156.230 and
KRS
304.17A-515.
(2) A QHP issuer shall make its provider
directory for a QHP available:
(a) To the KHBE
for online publication;
(b) To
potential enrollees in hard copy upon request; and
(c) In accordance with
KRS
304.17A-590.
(3) A QHP issuer shall identify in the QHP
provider directory a provider that is not accepting new patients.
Section 7. Network Adequacy
Standards for Essential Community Providers. A QHP issuer shall:
(1)
(a)
Demonstrate a provider network, which includes at least the minimum percentage
of available essential community providers in the QHP service area who
participate in the issuer's provider network as required by
45 C.F.R.
156.235(a)(2)(i);
and
(b) Offer a contract to:
1. At least one (1) essential community
provider in each essential community provider category in each county in the
service area where an essential community provider in that category is
available; and
2. Available Indian
health service providers in the service area; or
(2) If unable to comply with the
requirements in subsection (1) of this section, submit a supplementary response
via SERFF.
Section 8.
Health Plan Notices. A QHP issuer shall provide notices to enrollees pursuant
to standards established in
45 C.F.R.
155.230.
Section 9. Consistency of Premium Rates
Inside and Outside the KHBE for the Same QHP. A QHP issuer shall charge the
same premium rate without regard to whether the plan is offered:
(1) Through the KHBE;
(2) By an issuer outside the KHBE;
or
(3) Through a participating
agent.
Section 10.
Enrollment Periods for Qualified Individuals.
(1) A QHP issuer participating in the
individual market shall accept an enrollment during the open enrollment period
or SEP for a qualified individual participating in the individual market with
effective dates of coverage established by the division in accordance with
45 C.F.R.
155.410(f)(2) and
45 C.F.R.
155.420.
(2) A QHP issuer shall notify a qualified
individual of the effective date of coverage.
(3) Except for renewal transactions prior to
open enrollment, premium invoices shall be generated to a qualified individual
within five (5) business days from receipt of KHBE enrollment
transactions.
(4) A QHP issuer
shall allow a qualified individual a minimum of thirty (30) days from the date
of the initial invoice to submit premium payment before coverage can be
cancelled.
(5) A QHP issuer shall
allow a qualified individual a minimum of thirty (30) days from the date of a
corrected invoice to submit premium payment before coverage can be
terminated.
(6) Notwithstanding the
requirements of this section, coverage shall not be effective until premium
payment is received by the issuer.
(7) The issuer shall provide proof of
coverage, including insurance identification cards, to enrollees within ten
(10) calendar days of receipt of initial premium payment for ninety-nine (99)
percent of enrollments.
Section
11. Enrollment Process for Qualified Individuals. A QHP issuer
shall process enrollment of an individual in accordance with this section.
(1) A QHP issuer participating in the
individual market shall enroll a qualified individual if the KHBE:
(a) Notifies the QHP issuer that the
individual is a qualified individual; and
(b) Transmits information to the QHP issuer
in accordance with
45 C.F.R.
155.400(a).
(2) If an applicant initiates
enrollment directly with the QHP issuer for enrollment in a plan offered
through the KHBE, the QHP issuer shall either:
(a) Direct the individual to file an
application with the KHBE in accordance with
45 C.F.R.
155.310; or
(b) Ensure the applicant received an
eligibility determination for coverage through the KHBE.
(3) A QHP issuer shall accept enrollment
information in accordance with the privacy and security requirements pursuant
to
45
C.F.R. 155.260 in an electronic format that
meets the requirements pursuant to
45
C.F.R. 155.270.
(4) A QHP issuer shall follow the premium
payment process in accordance with
45 C.F.R.
155.240.
(5) A QHP issuer shall provide new enrollees
with an enrollment information package that complies with the accessibility and
readability requirements established by
45 C.F.R.
155.230(b).
(6) A QHP issuer shall reconcile enrollment
files with the KHBE no less than once a month in accordance with
45 C.F.R.
155.400(d).
(7) A QHP issuer shall acknowledge receipt of
enrollment information transmitted from the KHBE in accordance with
45 C.F.R.
155.400(b)(2).
Section 12. Termination or
Cancellation of Coverage for Qualified Individuals.
(1) A QHP issuer may terminate coverage of an
enrollee in accordance with
45 C.F.R.
155.430(b)(2).
(2) If an enrollee's coverage in a QHP is
terminated by the issuer, the QHP issuer shall:
(a) Provide the enrollee with a notice of
termination of coverage that includes the reason for termination at least
thirty (30) days prior to the final day of coverage, in accordance with the
effective date established pursuant to
45 C.F.R.
155.430(d);
(b) If the termination is the result of death
or termination by the issuer for non-payment of premium as established in
subsections (3) through (8) of this section, provide the enrollee with a notice
of termination of coverage within at least thirty (30) days of the action to
terminate that includes the reason for termination, in accordance with the
effective date established pursuant to
45 C.F.R.
155.430(d);
(c) Notify the KHBE of the termination
effective date and reason for termination; and
(d) Comply with the requirements of
KRS
304.17A-240 to
304.17A-245.
(3) Termination of coverage of
enrollees due to non-payment of premium in accordance with
45 C.F.R.
155.430(b)(2)(ii) shall:
(a) Include the grace period for enrollees
receiving APTC as established in
45
C.F.R. 156.270(d);
and
(b) Be applied uniformly to
enrollees in similar circumstances.
(4) Prior to termination of coverage, a QHP
issuer shall provide a grace period of three (3) consecutive months if an
enrollee receiving APTC has previously paid at least one (1) full month's
premium during the benefit year.
(5) During the grace period, the QHP issuer:
(a)
1. Shall
pay claims for services provided to the enrollee in the first month of the
grace period; and
2. May suspend
payment of claims for services provided to the enrollee in the second and third
months of the grace period;
(b) Shall notify the KHBE of the non-payment
of the premium due; and
(c) Shall
notify providers of the possibility for denied claims for services provided to
an enrol-lee in the second and third months of the grace period.
(6) For the three (3) month grace
period established in subsection (4) of this section, a QHP issuer shall:
(a) Continue to collect APTC on behalf of the
enrollee from the U.S. Department of the Treasury; and
(b) Return APTC paid on behalf of the
enrollee for the second and third months of the grace period if the enrollee
exhausts the grace period as established in subsection (8) of this
section.
(7) If an
enrollee is delinquent on premium payment, the QHP issuer shall provide the
enrol-lee with a notice of the payment delinquency.
(8) If an enrollee receiving APTC exhausts
the three (3) month grace period in subsection (4) of this section without
paying the outstanding premiums, the QHP issuer shall terminate the enrollee's
coverage on the effective date of termination established in
45 C.F.R.
155.430(d)(4).
(9) A QHP issuer shall maintain records
pursuant to
45 C.F.R.
155.430(c).
(10) A QHP issuer shall comply with the
termination of coverage effective dates as established in
45 C.F.R.
155.430(d).
(11) A QHP issuer may cancel coverage of an
enrollee in accordance with
45 C.F.R.
155.430(b)(2) and
(e).
(12) If an enrollee's coverage in a QHP is
cancelled by the issuer for any reason, the QHP issuer shall:
(a) Provide the enrollee with a notice of
cancellation of coverage that includes the reason for cancellation within at
least thirty (30) days of the action to cancel coverage, in accordance with the
effective date established pursuant to
45 C.F.R.
155.430(d);
(b) Notify the KHBE of the cancellation
effective date and reason for cancellation; and
(c) Comply with the requirements of
KRS
304.17A-240 to
304.17A-245.
(13) Cancellation of coverage of
enrollees due to non-payment of premium in accordance with
45 C.F.R.
155.430(b)(2)(ii) shall be
applied uniformly to enrollees in similar circumstances.
(14) A QHP issuer shall comply with the
cancellation of coverage effective dates as established in
45 C.F.R.
155.430(d).
(15) If coverage of an enrollee is terminated
or cancelled by the KHBE for any reason, the QHP issuer shall provide the
enrollee a notice of the termination or cancellation within fifteen (15) days
of processing the termination or cancellation transaction from the KHBE or upon
the expiration of the grace period, whichever occurs first.
Section 13. Accreditation of QHP
Issuers.
(1) A QHP issuer shall:
(a) Be accredited on the basis of local
performance of a QHP by an accrediting entity recognized by HHS in categories
identified by
45 C.F.R.
156.275(a)(1); and
(b) Pursuant to
45 C.F.R.
156.275(a)(2), authorize the
accrediting entity that accredits the QHP issuer to release to the KHBE and
HHS:
1. A copy of the most recent
accreditation survey; and
2.
Accreditation survey-related information that HHS may require, including
corrective action plans and summaries of findings.
(2) A QHP issuer shall be
accredited prior to the fourth year of QHP certification and in every
subsequent year of certification thereafter in accordance with the requirements
and timeline identified under
45 C.F.R.
155.1045.
(3) A QHP issuer that has not received
accreditation shall submit an attestation to the division that the issuer shall
obtain accreditation in accordance with subsection (1)(a) of this
section.
(4) The QHP issuer shall
maintain accreditation so long as the QHP issuer offers QHPs.
Section 14. Decertification of
QHPs.
(1) If a QHP is decertified by the
division pursuant to
45 C.F.R.
155.1080 or withdrawn by the issuer after
certification, the QHP issuer shall terminate coverage of enrollees only after:
(a) The KHBE has provided notification as
required by
45 C.F.R.
155.1080(e);
(b) Enrollees have an opportunity to enroll
in other coverage; and
(c) The QHP
issuer has complied with the requirements of
KRS
304.17A-240 to
304.17A-245,
as applicable.
(2) If a
QHP issuer fails to meet ongoing compliance requirements of Section 18 of this
administrative regulation, the division may require the issuer to:
(a) Submit a corrective action plan to
address deficiencies to ongoing compliance requirements within thirty (30) days
of notification of the deficiency; and
(b) Submit evidence of compliance with the
corrective action plan within the timeframes established in the division
approved corrective plan.
(3) If the division finds that the QHP issuer
failed to meet the requirements of subsection (2) of this section, the division
may implement a prohibition against new enrollments on KHBE for the QHP issuer
and market segment out of compliance or may decertify all plans offered by the
QHP issuer within the market segment.
Section 15. General Requirements for a
Stand-alone Dental Plan.
(1) In order for a
dental insurer to participate in the KHBE and offer a stand-alone dental plan,
the dental insurer shall:
(a) Hold a
certificate of authority that would permit the issuer to offer dental plans and
be in good standing with the DOI;
(b) Be authorized by the division to
participate on the KHBE;
(c) By
February 1 of each year, submit Form KHBE-C1, Issuer Participation Intent Form,
a nonbinding notice of intent to participate on KHBE during the next calendar
year;
(d) Enter into a
participation agreement with the division;
(e) Offer a dental plan certified on the KHBE
in accordance with this administrative regulation in the individual exchange or
SHOP that shall comply with the requirements of KRS Chapter 304 Subtitle
17C;
(f) Submit to DOI through the
SERFF system:
1. Form filings in compliance
with KRS Chapter 304;
2. Rate
filings in compliance with
KRS 304.17-380;
and
3. Dental plan management data
templates;
(g) Offer a
SADP that shall:
1. Provide the pediatric
dental essential health benefits required by
42 U.S.C.
18022(b)(1)(J) for
individuals up to twenty-one (21) years of age; and
2. Have an annual limitation on cost sharing
for a SADP covering the pediatric dental essential health benefits at or below
the limits permitted by
45
C.F.R. 156.150;
(h) Comply with the:
1. Provider network adequacy requirements
identified by
KRS
304.17C-040 and maintain a network that is
sufficient in number and types of dental providers to assure that all dental
services will be accessible without unreasonable delay in accordance with
45 C.F.R.
156.230;
2. Requirements for a SADP referenced in 45
C.F.R. 156 Subpart E; and
3.
Essential community provider requirements in
45 C.F.R.
156.235;
(i) Not discriminate, with respect to a
pediatric dental plan, on the basis of race, color, national origin,
disability, age, sex, gender identity, or sexual orientation; and
(j) Make its provider directory for a SADP
available:
1. To the KHBE for online
publication;
2. To potential
enrollees in hard copy upon request; and
3. In accordance with
KRS
304.17A-590.
(2) A dental insurer offering a stand-alone
dental plan participating in the KHBE shall provide the following information
to the division on the KHBE:
(a) Statement of
dental coverage that is:
1. Written in English
consistent with the requirements in
KRS
304.12-020 and
806 KAR 12:010;
and
2. Submitted within five (5)
calendar days of the date DOI has approved rate and form filings in SERFF;
and
(b) Statement of
dental coverage that is:
1. Written in Spanish
with verification that the Spanish language version is a certified translation
of the English version; and
2.
Submitted within fourteen (14) calendar days of the date KHBE has approved the
item described in paragraph (a) of this subsection.
Section 16. Enforcement
by DOI. The DOI shall be responsible for enforcing the requirements of KRS
Chapter 304 and any administrative regulations promulgated thereunder against
any issuer.
Section 17. Timeframes
for Transactions.
(1) A QHP issuer shall
generate a required acknowledgement and process all KHBE initiated transactions
within forty-eight (48) hours of receipt of a complete electronic transaction
from the KHBE for ninety-five (95) percent of enrollments.
(2) A QHP issuer shall provide effectuation
transactions to the KHBE within seventy-two (72) hours of receipt of the
initial premium payment and issuer initiated cancellation and termination
transactions within forty-eight (48) hours of the cancellation or termination
of coverage for ninety-five (95) percent of cancellations and
terminations.
Section
18. On-going Compliance. The division shall be responsible for
enforcing the requirements referenced in
45 C.F.R.
155.1010(a)(2).
Section 19. Issuer Appeals.
(1) An issuer may appeal the division's
decision to:
(a) Deny certification of a
QHP;
(b) Implement a prohibition
against new enrollments by a QHP issuer in a market segment; or
(c) Decertify a QHP.
(2) An issuer appeal identified in subsection
(1) of this section shall be made to the division in accordance with KRS
Chapter 13B.
Section 20.
Incorporation by Reference.
(1) Form KHBE-C1,
"Issuer Participation Intent Form", Rev. March, 2021, is incorporated by
reference.
(2) This material may be
inspected, copied, or obtained, subject to applicable copyright law, at the
Division of Health Benefit Exchange, 275 East Main Street 4WE, Frankfort,
Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m., or at
www.khbe.ky.gov.
STATUTORY AUTHORITY:
KRS
194A.050(1)